Small Bowel Perforation and Subsequent Pleural Effusion Following Operative Hysteroscopy: A Case Report

A 59-year-old woman developed severe and persistent abdominal pain following a hysteroscopy, which was performed the previous day.Initial differential diagnoses included postoperative infection, ovarian pathology, and uterine perforation.The patient remained haemodynamically stable despite severe abdominal tenderness and signs of peritonism.CT imaging of the abdomen and pelvis demonstrated a pneumoperitoneum with marked small-bowel abnormalities and mesenteric inflammatory change.This finding prompted recognition of small-bowel perforation and the need for emergency surgical intervention.Laparoscopy was converted to laparotomy, where a 7 mm small-bowel perforation was identified and primarily repaired.The postoperative course was complicated by a significant right-sided pleural effusion.Thoracic ultrasound demonstrated marked septations, raising concern for possible empyema.Pleural fluid analysis was nondiagnostic, with a pH of 7.31 and glucose of 4.6 mmol/L, and microbiological analysis identified no organisms.The effusion was ultimately considered clinically to represent a parapneumonic effusion, although a reactive postoperative effusion related to the recent intra-abdominal pathology remained a consideration.The patient improved clinically with antibiotics and conservative management and was discharged with appropriate respiratory follow-up.This case highlights the need to consider intra-abdominal visceral injury in patients presenting with severe or persistent abdominal pain and peritonism following operative hysteroscopy, even in the absence of early haemodynamic instability.It also illustrates the diagnostic complexity that can arise when a pleural effusion develops following intra-abdominal pathology, as reactive and infective causes may have overlapping clinical and radiological features.