Background <p>Pleuroperitoneal communication (PPC) is a serious complication that may necessitate the discontinuation of peritoneal dialysis. Accurate identification of the communication site is essential for successful thoracoscopic surgery. In this report, we introduce a novel approach that combines contrast-enhanced ultrasonography (CEUS) with pneumoperitoneum, providing a safe and effective alternative for diagnosing and localizing PPC. This innovative combination has not been previously reported in literature, highlighting its potential to improve patient outcomes.</p> Case presentation <p>A 53-year-old man with an iodine allergy undergoing peritoneal dialysis for end-stage renal disease due to autosomal dominant polycystic kidney disease presented with a cough and right pleural effusion. CEUS revealed contrast medium flowing from a bleb on the diaphragm into the thoracic cavity, confirming the diagnosis and pinpointing the bleb as the communication site. Video-assisted thoracic surgery was performed, and intraoperative pneumoperitoneum confirmed air leakage from the bleb. The bleb was excised, and tissue sealant was applied. Peritoneal dialysis was resumed on postoperative day 7 without recurrence.</p> Conclusions <p>This report introduces a novel approach combining CEUS and pneumoperitoneum, which provides an effective and widely applicable method for diagnosing and treating PPC in patients on peritoneal dialysis. This innovative combination enhances diagnostic accuracy and broadens therapeutic options for all PPC cases, with particular utility in patients for whom traditional contrast agents are contraindicated. Our findings demonstrate that this methodology facilitates successful surgical interventions and supports the continuation of peritoneal dialysis without recurrence.</p>