A rare cause of spontaneous pneumoperitoneum and surgical management of idiopatic pneumatosis intestinalis

G. Cito, T. Ambrosetti, P. Richard, S. Aellen

Introduction

Pneumatosis intestinalis (PI) is defined as the presence of gas in the bowel wall and is often associated with severe disease or clinical conditions. The overall incidence of idiopathic PI in the general population has been reported to be as low as 0.03% based on autopsy series. Rarely, no cause is found, making the diagnosis idiopathic. Patients are usually asymptomatic but some might present with mild abdominal discomfort, which is usually related to the underlying associated medical condition. It may be complicated by obstruction or bleeding. Physical examination is rarely abnormal unless peritoneal signs from gross intestinal perforation are present, as seen in cases of pneumatosis due to life-threatening conditions.

Method

We report herein the case of a 79-years-old man complaining of a 7-day history of upper abdominal pain, vomiting, diarrhea and fever. On presentation at hospital, patient was confused with a distended swollen and diffusely sensitive abdomen without tenderness or muscular guarding. Abdominal Computed Tomography-scan (Fig. 1 - 2) showed intra-abdominal free-air with the presence of gas bubbles, which extend along the wall of several small intestinal loops and mesentery.

Figure 1
Figure 2
Figure 3

Results

Clinical presentation and radiologic images were highly suggestive of pneumoperitoneum due to intestinal pneumatosis and perforation. Exploratory laparoscopy confirmed pneumatosis of an intestinal segment without free liquid or contamination (Fig. 3). A small laparotomy was performed for a 20 cm-resection of the proximal emphysematous jejunum with an end-to-end jejuno-jejunal anastomosis (Fig. 4). Histopathological analysis revealed the presence of multiple gas-filled cysts in the submucosa and the subserosa with a final diagnosis of idiopatic pneumatosis intestinalis (Fig. 5). The clinical course was uneventful, and the patient was discharged seven days postoperatively.

Figure 4
Figure 5

Conclusion

Conservative therapy is generally recommended for most patients with idiopathic PI. In more severe cases with guarding, fever and severe peritonitic and systemic signs, a more aggressive, surgical management is mandatory.

References

P. N. Khalil, S. Huber-Wagner, R. Ladurner, A. Kleespies, M. Siebeck, W. Mutschler, K. Hallfeldt, K.-G. Kanz Natural history , clinical pattern, and surgical consideretions of pneumatosis intestinalis. Eur J Med Res. 2009; 14: 231-39. PMid: 19541582

M. Kitagawa, N.Yamoka, K. Imura, M. Sakita, M. Kato, K. Toda, E. Otsuji: Recurrent extensive idiopathic pneumatosis intestinalis of the small intestine with pneumoperitoneum: Effective treatment with the surgical intervention J Biomedical graphics and Computing June 2012 Vol2 N1

Y. Vogel, NJ Buchner, M.Szpakowski, A.Tannapfel and B. F Henning: Pneumatosis cystoides intestinalis of the ascending colon related to acarbose treatment: a case report