We present an 88-year-old man who was reviewed in a regional hospital with nausea, vomiting, generalized abdominal distension and vague pain for 3 days. Computed tomography (CT) was performed, and this was reported as perforated viscus with intramural gas and pneumoperitoneum (Figs 1,2). The patient was urgently transferred to a tertiary referral hospital for an urgent laparotomy.He was assessed in the emergency department following transfer and clinically had a soft, slightly tender and distended abdomen but with no clinical signs of peritonism. However, based on the radiological findings of intramural gas, pneumoperitoneum and suggestions of a partial small bowel obstruction without a transition point, a decision was made to perform a laparotomy. There was no evidence of necrotizing enterocolitis at laparotomy. There was a small bowel obstruction without any ischaemic segment, and careful adhesiolysis was performed. Incidentally, there were numerous segments of jejunal and ileal air-filled cysts and large jejunal diverticula and several small bowel cystic lesions were excised for histology.Post-operatively, the pathologist confirmed the diagnosis of pneumatosis cystoides intestinalis (PCI) (Fig. 3). The cysts ranged in size from 1 to 20 mm in diameter. Microscopically, the specimens consisted of cystic spaces lined by histiocytes and multinucleated foreign body giant cells on a background of dilated and congested blood vessels.PCI is a rare benign condition that has a similar CT appearance to perforated viscus. In the literature, there have been a number of case reports and series on PCI. Most are found incidentally during laparoscopy or laparotomy for other conditions. Fig. 2. Computed tomographic findings suggestive of free locules of gas and pneumoperitoneum.Fig. 3. Intra-operative finding of lobulated cystic structures within small bowel mesentery and attached to jejunum and ileum.Fig. 1. Computed tomographic finding suggestive of pneumatosis intestinalis highly suspicious for necrotizing enterocolitis.

HighlightsSmall bowel obstruction in a virgin abdomen can be caused by food bezoar such as rehydrated fruits.Dried apple has a potential to reabsorb fluid and expand up to 35% of its initial size within 72 h.The most common site of small bowel obstruction is proximal to ileocecal valve.

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