Pneumatosis intestinalis with pneumoperitoneum: Not always a surgical emergency

Abstract

Pneumatosis intestinalis (PI) and pneumoperitoneum are commonly recognized as severe signs of gastrointestinal diseases that require emergency surgery. However, these symptoms can also be caused by benign conditions. We describe 4 cases of benign PI and pneumoperitoneum that were detected in different clinical situations (accidental discovery in bilan of aortic dissection (case #1), bilateral pulmonary embolism (case #2), overflow diarrhea due to fecal impaction (case #3), and in follow-up postbiliary digestive anastomosis surgery (case #4), which were addressed with exploratory surgery (case #1) or conservative treatment (the remaining cases), with favorable outcomes. Because PI and pneumoperitoneum can be associated with both life-threatening causes and benign conditions, treatment decisions should be based on the correspondence between clinical and paraclinical features, rather than imaging alone .

Pneumatosis cystoides intestinalis with pneumoperitoneum in an 87-years-old male patient: a case report

“…There are four main theories for its pathogenesis. The bacterial hypothesis: presence of aerogenic bacteria inside the intestinal wall that produces gas; the mechanical hypothesis: increased intraluminal pressure with epithelial damage that allows passage of gas from the lumen to the intestinal wall; the biochemical hypothesis: increased hydrogen gas production from carbohydrate fermentation exerts pressure within the intestinal lumen and is forced through the mucosa; the pulmonary hypothesis: pulmonary disease such as chronic obstructive pulmonary disease (COPD) and interstitial pneumonia may cause alveolar rupture with the release of gas that follows the path of the vessels reaching the mesentery [ 2 , 3 , 5–7 , 12 , 13 ]. Coughing causes abrupt changes in intra-abdominal pressure and may be a contributory factor [ 2 , 3 ].…”

Pneumatosis intestinalis: Not always bowel ischemia

“…Benign causes can be divided into idiopathic, or secondary to various diseases. These include respiratory disease, inflammatory bowel disease, autoimmune disease, immunosuppression, chemotherapy and post-operative sequelae [8 , 9] .…”

“…Elevated intra-abdominal pressures in these patients, may also cause intraluminal gas to track intramurally. Factors which compromise the intestinal mucosa, such as corticosteroid therapy, or damage the mucosa, due to ischemia, inflammation, trauma, surgery and ulcers can also cause intraluminal gas to diffuse intramurally [1 , 8] . Constipation can damage the bowel mucosa causing gas-forming bacteria to invade the intestinal wall, which may be the mechanism of PI in our patient [9 , 10] .…”

“…However, these signs can be non-specific and should be interpreted with caution. Pneumoperitoneum may be due to extravasation of intramural gas to the peritoneal cavity from benign PI rather than a perforated viscus [8 , 10] . More specific findings for ischemia include absent bowel wall enhancement, solid organ infarctions and signs of arterial or venous mesenteric occlusion [1] .…”

Asymptomatic pneumoperitoneum or pneumatosis cystoides intestinalis? Easy to make a mistake

“…However, due to difficulties in distinguishing PCI from perforated viscus and necrotizing enterocolitis, a large percentage of patients still unnecessarily receive operative intervention. Surgery should be instead reserved for management of pneumatosis intestinalis secondary to life-threatening conditions that account for about 3% of all cases [ 9 , 12 ]. To date there has been no randomized controlled trial and only few systematic reviews that specifically analyze PCI [ 5 , 11 ].…”