Images in Clinical Medicine: Pneumatosis Cystoides Intestinalis with Pneumoperitoneum

Summary

  • 61 F
  • C/C
    • diffuse abd pain
    • 1w diarrhea / vimiting
  • PMHx
    • COPD
      • INH glucocorticoid, LABA
  • PEx
    • abd distened tender w/ guarding
  • Ex
    • CT
      • free air
  • Dx
    • Pneumatosis cystoides intestinalis (腸管嚢腫様気腫症)

Original

Fig

A 61-year-old woman presented to the emergency department with acute onset of diffuse abdominal pain and a 1-week history of diarrhea and vomiting. Her medical history included chronic obstructive pulmonary disease, which was being treated with an inhaled glucocorticoid and a long-acting β-agonist. On examination, the abdomen was distended and diffusely tender, with guarding. Computed tomography of the abdomen revealed large amounts of free air (Panel A, arrow) and extraluminal gas in the wall of the small bowel (Panel B, arrow). Emergency laparotomy was performed, and gas-filled, thin-walled, cystlike structures were seen throughout most of the small bowel (Panel C). Examination of the bowel ruled out a perforation, and the bowel was not resected. The pathophysiology of pneumatosis cystoides intestinalis is poorly understood. Cyst rupture can produce pneumoperitoneum and peritoneal irritation. Radiographic findings of pneumoperitoneum and gas within the bowel wall can be associated with a number of conditions, ranging from non–life-threatening causes, as in this case, to surgical emergencies such as ischemic bowel, depending on the clinical scenario. Within 15 months after presentation, the patient returned with a similar episode of abdominal pain, which was treated nonoperatively. At follow-up 2 years after surgery, the patient remained well.