This study presents a case of
pneumatosis cystoides intestinalis affecting the terminal ileum in a 25-year
old male patient, discovered accidentally during laparotomy for acute abdomen
which was proved to be due to perforated duodenal ulcer, Pneumatosis cystoides intestinalis
is characterized by the presence of subserosal or submucosal gas filled cysts
in the wall of gastrointestinal tract, this condition is rarely seen in the
surgical practice.
Key words: Pneumatosis cystoides
intestinalis, Pneumoperitonium.
JRMS
December 2011; 18(4): 55-57
Case Report
A 25-year
old male presented to the Emergency Department at Prince Rashid Bin Al-Hasan
Hospital on 22th June 2008 with recent history of severe,
generalized abdominal pain that started suddenly. It was associated with nausea
and vomiting. On admission his pulse was 80/min, blood pressure was 120/70mm
Hg, body temperature 37c◦ and WBC was 14800/mm3. Abdominal
examination revealed board –like rigidity, his chest X-ray showed air under diaphragm
bilaterally as shown in Fig. 1. Our impression was perforated viscous mostly
perforated duodenal ulcer as demonstrated in Fig. 1.
He
was resuscitated with intravenous fluids and antibiotics, laparotomy was performed and revealed 2x1cm duodenal
perforation affecting the anterior aspect of the first part of duodenum and
multiple air filled subserosal cysts
over 90cm of the terminal ileum with normal colour and viable bowel as illustrated in Figures 2
and 3.
Billroth
1 procedure was performed because the perforation was big with friable edges,
and the gas filled cysts was treated conservatively post operatively with O2
mask 4 liters/min and antibiotics including metronidazole. The post operative
course was uneventful, and without complications. Seven days later the patient
was discharged in a good condition.
Discussion
Pneumatosis
Cystoides Intestinalis (PCI) is an uncommon condition not often seen in
surgical practice; it is characterized by multiple gas filled cysts. It is
found in the subserosa or submucosa of the gastrointestinal tract from the
oesophagus to the rectum also the mesentry, peritoneum and falciform ligament
may be involved, the cysts are translucent, thin walled of variable sizes
containing gas mainly nitrogen, carbon
dioxide and hydrogen.(1-3)
PCI
could be primary in 15% of cases without obvious cause or secondary to other
pathology in 85% of cases like: Mesenteric vascular disease, necrotizing
entercolitis, inflammatory bowel disease and connective tissue disorder as
scleroderma, another cause is drug therapy as immunosuppressive and
chemotherapeutic drugs. Also PCI can result as a complication of segmoidoscopy,
colonoscopy and post surgical anastomosis, furthermore cases have been reported
secondary to obstructive pulmonary diseases and artificial ventilation.(1,3-5)
Two theories were suggested for PCI, the mechanical and the bacterial theory,
the mechanical theory suggests that PCI arises when gas is forced into the
bowel wall as a result of trauma, obstruction, increased intraluminal pressure
or increased peristalsis in the presence of mucosal alteration or injury that
provide a pathway for gas and bacteria
to enter the intestinal wall, the bacterial theory was suggested because of abnormally high levels of hydrogen in the cysts which is mainly produced by bacteria and this was proved in the laboratory animals by injecting bacteria in their intestinal wall to produce PCI.(3,5-9) PCI can lead to certain complications like intestinal obstruction, tension pneumoperitoneum, rectal bleeding and cyst – induced volvulous.(1,4) PCI can not be definitely diagnosed based on clinical and laboratory findings but plain abdominal radiographs or CT scan can suggest the diagnosis.(5,6) The treatment of PCI is according to the underlying cause and when discovered incidentally during laparatomy and the affected bowel is healthy and not in obstruction only post operative oxygen therapy and metronidazole usually beneficial, as we did in our case, but when life-threatening cause is present we should deal with it, especially among patients with increased inflammatory parameters in laboratory findings or signs of sepsis, peritonitis or bowel perforation.(3,4,8,10)
Conclusion
PCI
is a rare condition usually benign, discovered accidentally during laparotomy
for another disease, but could lead to surgical emergency that need
interference in the presence of complications.
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