Pneumoperitoneum secondary to benign pneumatosis coli

Case contributed by Mohamed Saber


Acute abdominal pain mainly at the right iliac fossa. The patient gave a history of recurrent attacks.

Patient Data

Age: 30 years
Gender: Male

CT study shows pneumoperitoneum with free intraperitoneal gas seen at the upper abdomen, perihepatic region, falciform ligament, right iliac fossa, and left hypochondria.

The cecum and proximal right colon show prominent intramural gas (pneumatosis coli) forming gas bubbles (cystoides) seen predominantly involving the lateral antimesenteric colonic wall.

No evidence of free intraperitoneal fluid collection.

No peritoneal fat blurring.

No oral contrast leakage.

Case Discussion

Pneumoperitoneum is not always a serious finding, it is occasionally caused by benign conditions like pneumatosis coli. The absence of radiological signs of peritonitis like peritoneal fat blurring and free fluid should direct towards searching for benign causes of pneumoperitoneum. Communication with the physician and knowing more about the patient’s clinical status are also very important. This patient presented with acute abdominal pain of mild severity that is recurrent and his abdomen was lax. This clinical presentation is totally different in cases of bowel perforation or bowel ischemia.   

Pneumatosis coli is rare, idiopathic, and usually benign especially if the gas adopts bubbles (ie cystoides) rather than lines.  These gas cysts can rupture and cause repeated episodes of pneumoperitoneum without peritonitis as there is no spill of bowel content. 

The patient followed a conservative treatment with complete relief of symptoms within two days. Right hemicolectomy was advised.

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