Pneumatosis cystoides intestinalis in a trauma patient presenting with pneumoperitoneum: a case report

Background Pneumatosis cystoides intestinalis is a rare and usually benign condition in which multiple thin-walled cysts develop in the submucosa or subserosa of the gastrointestinal tract. While usually asymptomatic, severe cases can result in pneumoperitoneum, which can be managed surgically or medically depending on circumstances. We present a case of a patient with pneumatosis cystoides intestinalis, which presented as pneumoperitoneum following trauma. To our knowledge, there are no other published cases in which a trauma patient with pneumoperitoneum was found to have radiologic evidence of pneumatosis cystoides intestinalis. Case presentation We present the case of a 37-year-old Hispanic male admitted to the hospital after being involved in a motorcycle accident. Computed tomography imaging of the abdomen and pelvis with oral and intravenous contrast demonstrated trace pneumoperitoneum, possibly originating from the splenic flexure of the colon without evidence of extravasation of oral contrast. Laparoscopy with conversion to exploratory laparotomy revealed bowel abnormalities at the distal transverse colon and splenic flexure, which were identified as pneumatosis cystoides intestinalis by pathology. There was no evidence of bowel perforation. A panel of abdominal radiologists attended the computed tomography interpretation to note that incidental atraumatic or traumatic rupture of the cysts could have caused the pneumoperitoneum. The patient had an uncomplicated postoperative course and was transferred to another facility per insurance request. Conclusions When presenting in the context of trauma, pneumatosis cystoides intestinalis can lead to difficult management decisions. To our knowledge, there are no existing evidence-based guidelines for the scenario of concurrent pneumatosis cystoides intestinalis, blunt abdominal trauma, and pneumoperitoneum in a patient with a benign abdominal exam. This patient’s pneumoperitoneum was likely caused by rupture of preexisting cysts rather than frank bowel perforation. Patients who are asymptomatic, lack signs of clinically worrisome disease, and have a low pretest probability will likely not benefit from surgery and can be medically managed. Thorough discussion between surgeons and radiologists can be helpful when evaluating the clinical significance of a patient’s pneumatosis cystoides intestinalis and aid in the decision to perform surgery.

796 Chronic Pneumoperitoneum: Cause or Consequence of Pneumatosis Cystoides Intestinalis

Pneumatosis cystoides intestinalis (PCI), ‘gas cysts’ in the wall of the bowel, is a rare sign that can be found as a result of many different conditions, ranging from benign and asymptomatic, to life threatening. Its pathogenesis is not yet fully understood, and patients found to have PCI are treated in a heterogeneous manner. Pneumoperitoneum, however, is much more commonly seen by the General Surgeons, and most often occurs as a result of a perforated viscus; usually necessitating an emergent surgical intervention. Spontaneous pneumoperitoneum occurs very rarely, although it is seen more frequently with small bowel PCI, compared to large bowel PCI. We present here an unusual case of a patient with acute-on-chronic pneumoperitoneum and subsequently subacute small bowel obstruction associated with small bowel pneumatosis cystoides intestinalis. The patient also had extensive pan colonic and jejunal diverticulosis, although the area of perforation and PCI was discrete and located in the mid-ileum. It is unclear whether the patient had chronic pneumoperitoneum secondary to perforated PCI, or if the PCI developed secondary to an ileum perforation of unknown origin (fitting with the bacterial or mechanical theory of pathogenesis). The patient went onto to have an emergency laparotomy and small bowel resection 28 months after initial presentation and a trial of conservative management.