Incidental pneumoperitoneum due to pneumatosis intestinalis: A rare case of benign pneumoperitoneum

Abstract

Introduction and significance

Pneumatosis intestinalis (PI), the presence of gas within the intestinal wall, is a rare but significant gastrointestinal condition. It may be associated with underlying gastrointestinal disorders or detected incidentally, posing diagnostic challenges. This article emphasizes the importance of recognizing and managing this condition conservatively when appropriate.

Case presentation

A previously healthy 40-year-old Caucasian female patient presented with left lumbar fossa pain, initially suggestive of renal colic. Physical examination revealed stable vital signs and a soft abdomen. Laboratory tests showed no signs of inflammation or renal abnormalities. Abdominal CT scan ruled out urinary lithiasis but identified pericolonic pneumoperitoneum on the left side. Due to the absence of peritonitis signs, surgical intervention was deferred. Over 72 h of close monitoring, the patient remained stable without clinical deterioration. Subsequent CT scans confirmed pneumatosis intestinalis. The patient remained asymptomatic and underwent a confirming colonoscopy.

Clinical discussion

Pneumatosis intestinalis can manifest with varying severity and is often linked to underlying gastrointestinal conditions. It can mimic life-threatening conditions like bowel perforation, necessitating careful differentiation. Non-surgical pneumoperitoneum, exemplified in this case, may result from benign causes like PI, warranting meticulous evaluation to prevent unnecessary surgery.

Conclusion

This case highlights the need to recognize and manage asymptomatic PI. A multidisciplinary approach and CT imaging play pivotal roles in ensuring optimal patient outcomes. Vigilance among healthcare professionals is essential to consider PI in asymptomatic patients, mitigating the risk of undue surgical interventions, and facilitating timely diagnosis and intervention when necessary.

Highlights

• •Pneumatosis intestinalis (PI) is a condition with a 0.3% incidence, characterized by gas in the bowel wall and varying degrees of severity.
• •PI poses diagnostic challenges as it can mimic bowel perforation, causing confusion in cases of uncertain septic shock origin, and distinguishing between surgical and non-surgical pneumoperitoneum is crucial for proper management.
• •PI is defined by gas-filled cystic spaces in the intestinal wall, and its enigmatic nature is evident in cases where no clear association with underlying gastrointestinal issues is apparent.
• •CT imaging plays a pivotal role in diagnosing PI by providing detailed visualization of gas within the intestinal wall, aiding in differentiation from surgical pneumoperitoneum.
• •In managing asymptomatic PI cases, a conservative approach is favored, involving regular clinical follow-up and imaging, with surgical intervention considered based on an algorithm considering factors like incidental findings, characteristic features, and clinical examinations.

1. Introduction

Pneumatosis intestinalis (PI) is a rare and intriguing gastrointestinal condition characterized by the presence of gas within the intestinal wall [1]. It is most commonly associated with underlying gastrointestinal disorders, such as bowel ischemia, inflammatory bowel disease, or bowel obstruction. However, PI can also manifest as an incidental finding in patients with no prior medical history, often discovered during routine imaging studies [2]. In this case report, we present the clinical course of a patient who was diagnosed with PI following the discovery of pneumoperitoneum during a routine CT scan.

This work has been reported in line with the SCARE criteria [3].

2. Case report

We present a case report of a 40-year-old Caucasian female patient with no significant medical history who presented to the emergency department with left lumbar fossa pain radiating to the pubis, suggestive of renal colic. Upon examination, she was afebrile, with stable hemodynamic parameters and a soft abdomen. Laboratory tests revealed no signs of inflammatory syndrome, electrolyte disturbances, or renal insufficiency. An abdominal CT scan ruled out urinary lithiasis but revealed a low-volume pericolonic pneumoperitoneum on the left side (air bubbles) (Fig. 1).

Fig. 1.

The patient did not exhibit any clinical or laboratory signs of gastrointestinal perforation or peritonitis. Given the absence of peritonitis signs, we decided not to operate. Instead, the patient was closely monitored for 48 to 72 h, with a plan to initiate surgical intervention promptly in case of any deterioration. She was admitted for observation and maintained afebrile status for 72 h, with a normal physical examination. A follow-up laboratory evaluation after 72 h showed no abnormalities. A subsequent CT scan demonstrated air within the wall of the left colonic flexure, but no intraperitoneal fluid collection, digestive thickening, perforation, or mesenteric ischemia were observed (Fig. 2). The diagnosis of idiopathic colonic pneumocystosis without signs of complication was established. The patient was discharged and remained asymptomatic during the 6-month follow-up period. The colonoscopy revealed cysts in the colonic wall with a healthy mucosa, confirming colonic pneumocystosis (Fig. 3).

Fig. 2.

CT scan with low-level water opacification showing the cysts in the colon wall.

Fig. 3.

Colonoscopy showing the air-filled cysts.

3. Discussion

Pneumatosis intestinalis, also known by various aliases such as intramural gas, pseudopneumatosis, intestinal emphysema, and bullous emphysema of the intestine, is a condition characterized by the presence of gas within the bowel wall. Its overall incidence, as indicated by the increasing use of CT scans, stands at 0.3 % [2]. This condition can manifest with varying degrees of severity, ranging from asymptomatic to potentially life-threatening, particularly when associated with bowel infarction. It is noteworthy that pneumatosis intestinalis may mimic bowel perforation, thereby causing pneumoperitoneum, potentially leading to diagnostic confusion, especially in cases where the origin of septic shock is uncertain [4].

Pneumoperitoneum, defined as the presence of free air within the peritoneal cavity, can be categorized into two distinct types: surgical and non-surgical [5]. Surgical pneumoperitoneum is typically linked to critical situations, such as a perforated bowel, necessitating immediate surgical intervention. On the contrary, non-surgical pneumoperitoneum can result from benign causes, including recent abdominal surgery, medical procedures, barotrauma, and even conditions like pneumatosis intestinalis (as observed in this case) [6]. Distinguishing between these two categories is essential to guide appropriate management decisions.

Pneumatosis intestinalis, characterized by intramural gas within the gastrointestinal tract, primarily within the submucosal or subserosal layers of the intestines, presents as a distinctive pattern of cystic spaces filled with gas within the intestinal wall. It is pertinent to note that pneumatosis intestinalis may manifest without any underlying gastrointestinal pathology, and its precise etiology can be challenging to elucidate.

This enigmatic nature of PI, where no clear association with underlying gastrointestinal issues is evident, is further exemplified by cases like the one under consideration, where a patient with no previous medical history was unexpectedly diagnosed with PI following the incidental discovery of pneumoperitoneum during a routine CT scan [7]. The remarkable aspect of this case is that the patient remained entirely asymptomatic throughout the diagnostic process.

CT imaging plays an indispensable role in diagnosing PI and distinguishing it from other causes of pneumoperitoneum. It offers detailed visualization of the gas within the intestinal wall, aiding in ruling out surgical pneumoperitoneum and identifying the characteristic features of PI [2].

In the management of asymptomatic PI cases, a conservative approach is typically favored. This approach involves vigilant clinical follow-up and periodic imaging studies to monitor the condition's progression or potential spontaneous resolution. The decision to avoid surgical intervention is contingent on the absence of complications or concerning findings such as peritonitis or evidence of bowel ischemia [8].

Ceska et al. have proposed an algorithm for guiding surgical indications when confronted with pneumoperitoneum [9]. This algorithm takes into account factors such as the incidental nature of the pneumoperitoneum finding, the presence or absence of features characteristic of non-surgical pneumoperitoneum, the results of physical examinations, and the presence or absence of free fluid in the abdomen.

4. Conclusion

Pneumatosis intestinalis, a condition marked by gas within the bowel wall, presents a diagnostic challenge, especially when discovered incidentally in asymptomatic patients. Recognition of this condition's distinctive features is vital for guiding appropriate clinical management and avoiding unnecessary surgical interventions. The role of CT imaging in differentiation, coupled with a conservative approach for asymptomatic cases, underscores the importance of a multidisciplinary approach to ensure optimal patient outcomes.

Consent for publication

Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.

Availability of supporting data

Not applicable.

Ethics approval and consent to participate

Not applicable. Our institutions requires no ethical approval for case reports.

Funding

Not applicable.

All authors read and approved the final manuscript.

Author contribution

Souhaib Atri: conceptualization, data curation, redaction, project manager.

Mahdi Hammami: conceptualization, data curation, redaction, project manager.

Amine Sebai: conceptualization, redaction.

Aida Zaiem: resources, visualization.

Anis Haddad: supervision, validation, visualization.

Montassar Kacem: supervision, validation, visualization.

Guarantor

Mahdi Hammami.

Registration of research studies

Not applicable.

Declaration of competing interest

All authors declare that they have no conflicts of interest.