Presentation
History of amyotrophic lateral sclerosis (ALS) and PEG tube, presents with fever, abdominal distension, constipation and dark gastric contents discharging from the nose.
Patient Data
Contrast-enhanced abdominal CT scan is performed showing multiple well-circumscribed gas-filled cysts within the colonic wall with a honeycomb pattern. The affected walls are not thickened and pericolic fat stranding is not seen. Lung window helps in the recognition of the cysts, so it is attached. A small volume of pneumoperitoneum and a small quantity of perihepatic free fluid are also present. The PEG is well-positioned.
Additionally, there is diffuse hepatic steatosis and multiple calculi in the right kidney and inside the renal pelvis.
A month later, a control CT scan shows resolution of the pneumoperitoneum. The air cysts in the colonic wall are circumscribed to the transverse colon.
Case Discussion
Pneumatosis cystoides intestinalis (PCI) is a benign and infrequent form of pneumatosis intestinalis that can be associated with the presence of gas in the peritoneal cavity. Pneumoperitoneum usually suggests bowel perforation. However, the patient did not present peritoneal irritation signs or analytical changes that justify an urgent intervention. This is an example of a "benign" form of pneumoperitoneum, caused by the rupture of the cysts to the peritoneal cavity, that does not require surgical treatment.
This condition may be associated with a variety of diseases. This is the case of a bedridden patient with a history of motor neuron disease and polypharmacy, e.g. corticosteroids.
CT imaging is the gold standard technique for the diagnosis. It allows the detection of 'red flag' findings that may suggest an underlying life-threatening pathology. PCI can mimic conditions like intestinal ischemia. The patient had a CT scan that found no evidence of wall thickening, ascites, bowel dilatation, fat stranding, gas in the portal venous system, altered contrast enhancement or linear pneumatosis intestinalis that suggested intestinal ischemia.
This patient was treated conservatively. Follow up CT showed resolution of the pneumoperitoneum.
Images courtesy of Dr Marta Rausell and Dr Alberto Cuñat.
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