Convulsions and Catastrophe: Status Epilepticus Complicated by Massive Pneumoperitoneum and Bowel Perforation: A Case Report

Abstract

We report the case of a sixteen-year-old female with a known history of epilepsy who presented to the emergency department following prolonged generalized tonic-clonic seizures at home, consistent with status epilepticus, after recent noncompliance with her antiepileptic regimen. She had experienced multiple convulsive episodes over twenty minutes without full recovery between seizures, prompting urgent ambulance transport. On arrival, she remained confused, drowsy, and tachycardic, with stable oxygenation on supplemental oxygen. Initial examination revealed subtle postictal features including tongue biting, but no focal neurological deficits were detected. Unexpectedly, progressive abdominal distension was noted, with the abdomen tense and tympanic on percussion, raising concern for an acute intra-abdominal process. Urgent chest radiography demonstrated massive bilateral subdiaphragmatic free air, confirmed by contrast-enhanced CT of the abdomen, which revealed focal distal ileal perforation with surrounding inflammation and small amounts of free fluid, consistent with pneumoperitoneum secondary to bowel perforation. Laboratory studies demonstrated mild leukocytosis, elevated creatine kinase, and metabolic acidosis, reflecting physiological stress from prolonged seizures. The patient underwent multidisciplinary management, including intravenous anticonvulsants for seizure control, supportive care with fluids and oxygen, broad-spectrum antibiotics, and urgent surgical intervention with resection of the perforated ileal segment and primary anastomosis. Postoperatively, she was monitored in the intensive care unit, with gradual neurological recovery, resolution of abdominal distension, and restoration of bowel function. This case illustrates the rare but serious occurrence of seizure-induced gastrointestinal perforation, emphasizing the importance of vigilant clinical assessment, early imaging, and coordinated multidisciplinary care in adolescents with status epilepticus to identify and manage life-threatening complications promptly.