A Case Report on Pneumatosis Intestinalis Complicated by Pneumoperitoneum

Background: Pneumatosis intestinalis (PI) is a rare radiological finding characterized by gas within the bowel wall, often linked to conditions such as ischemia, infection, or inflammation. When complicated by pneumoperitoneum, it suggests a potentially life-threatening condition, such as bowel perforation, and may necessitate surgical intervention.

Case Summary: A 43-year-old male patient presented with 5 days of diffuse abdominal pain, distention, and vomiting of gastric contents. He had a remote history of peptic ulcer disease. On physical examination, he appeared sick, dehydrated, and cachexic. His vital signs were stable, but his BMI was low (16.2 kg/m2). His abdomen was distended with diffused tenderness and had no guarding or bowel sounds. There was a radiological evidence of pneumoperitoneum, pneumatosis intestinalis, and free fluid concerning hollow viscus perforation. However, small bowel biopsy showed polypoid, grape-like lesions with cystic spaces lined by multinucleated giant cells and surrounded by inflammatory cells and hemosiderin pigment. Findings were consistent with Pneumatosis Cystoides Intestinalis, with no atypia or malignancy. Following fluid resuscitation, the patient underwent laparotomy exploration which did not demonstrate any bowel injury but scarred the 1st part of the duodenum. The pneumoperitoneum was attributed to the rupture of gas-filled cysts located along the bowel wall but not within it. He had an uncomplicated postoperative course. The endoscopy was done on follow-up, revealing a small Forest III pre-pyloric ulcer with a stenotic pyloric ring managed by balloon dilatation and PPI.

Conclusion: Pneumatosis intestinalis is a rare finding and its significance cannot be determined outside of a clinical contest. Surgery may be performed occasionally when pneumoperitoneum is present, raising concerns about the risk of hollow viscus injury.