Case Report of a Challenging Cystic Intestinal Pneumatosis of the Small Gut Associated With Ulcer Perforation

Abstract

Introduction:-Cystic Intestinal Pneumatosis represents a challenging clinical condition with various clinical onsets and complications. Altogether, CIP is prone to misdiagnosis and or mistreatment due to delayed management. The aim of our study is to report the challenging diagnosis of a pneumatosis intestinalis clinical case, the therapeutic strategy we chose to adopt and the outcome. Material and Methods:-Forty-five-year-old manwith no past medical and surgical history who presented aggravated acute abdominal pain and absence of bowel movement associated with vomitus in the last 5 days earlier. Physical examination unveiled unstable patient with cardiovascular choc syndrome and generalized abdominal contraction. Prompt medical care was started with abundant IV fluids repletion and antibiotics. Abdominal X-ray without barium showed the presence of air in the abdominal cavity. Diagnosis of pneumoperitoneum was confirmed, and due to the unstable condition, we decided to undergo surgical assessment first without abdominal CT scan. Therefore, laparotomy was carried on. We found perforated anterior duodenal ulcer associated with cystic bubbles filled with air along the gut wall. We decided to preserve the affected segment with cystic pneumatosis as there was no significant signs of inflammation, perforation nor ischemia. Post-operative course was uneventful, and the patient was discharged on day 5. Long-term follow-up at 4 months was uneventful. Discussion:-The abstract underlined the misleading radiology imaging of CIP, highly like the one of pneumoperitoneum. The etiology behind Pneumatosis intestinalis is yet to be understood. Multiple theories have been described, including mechanical disruption of mucosa, the spread of intraparietal gas to operate via lymphatic drainage, pulmonary pathogenesis and bowel necrosis, or finally idiopathic. Although it is a benign condition there arepotentially associated complications requiring both adequate diagnosis and management. Conclusion:-To the best of our knowledge, we report the third case in literature of associated cystic intestinal pneumatosis with perforated duodenal ulcer.Intestinal preservation in cystic intestinal pneumatosis seems to be the best suited approach, both in an elective setting and emergency setting. Though more clinical data and extend follow-ups on this matter should be held in order to affirm the safety of this approach.