Intestinal cystic pneumatosis is a rare condition characterised by the presence of gaseous cysts in the intestinal wall that can affect the entire digestive tract, with a predilection for the small intestine and colon. It is diagnosed by CT scan and surgery can be avoided if there are no complications. The authors report a rare case of cystic pneumatosis of the colon leading to abdominal pain requiring surgery

Abdessamad, Majd

Aziz, Moussahim

Elbakouri, Abdelilah

Ichrak, Bouali

Khadija, Kamal

Khalid, El Hattabi

Mounir, Bouali

English

European Journal of Medical and Health Research

      Pneumatosis Intestinal Cystic: A Case Report   Bouali Mounir Department of General Surgery, Hospital Center Ibn Rochd, Casablanca, Morocco; University of Hassan II, Casablanca, Morocco Bouali Ichrak  Department of General Surgery, Hospital Center Ibn Rochd, Casablanca, Morocco; University of Hassan II, Casablanca, Morocco Moussahim Aziz Department of General Surgery, Hospital Center Ibn Rochd, Casablanca, Morocco; University of Hassan II, Casablanca, Morocco Kamal Khadija Department of General Surgery, Hospital Center Ibn Rochd, Casablanca, Morocco; University of Hassan II, Casablanca, Morocco Majd Abdessamad Department of General Surgery, Hospital Center Ibn Rochd, Casablanca, Morocco; University of Hassan II, Casablanca, Morocco Abdelilah Elbakouri Department of General Surgery, Hospital Center Ibn Rochd, Casablanca, Morocco; University of Hassan II, Casablanca, Morocco El Hattabi Khalid Department of General Surgery, Hospital Center Ibn Rochd, Casablanca, Morocco; University of Hassan II, Casablanca, Morocco  Abstract Intestinal cystic pneumatosis is a rare condition characterised by the presence of gaseous cysts in the intestinal wall that can affect the entire digestive tract, with a predilection for the small intestine and colon. It is diagnosed by CT scan and surgery can be avoided if there are no complications. The authors report a rare case of cystic pneumatosis of the colon leading to abdominal pain requiring surgery.  Introduction Intestinal cystic pneumatosis (ICP) is a rare entity, defined by the presence of gas-containing cysts in the intestinal wall [1], which remains poorly understood, posing diagnostic and therapeutic problems [1, 2]. It may be primary or secondary, associated with multiple gastrointestinal or other pathologies. The authors report a case of PKI secondary to gastric thickening, revealed by acute peritonitis. Patient and Observation This is a 65-year-old patient with the following medical history: Surgery 12 years ago for gastric pathology (undocumented), chronic smoker of 20 cigarettes a day, weaned 2 months ago, who has presented for 5 days with diffuse abdominal pain associated with vomiting of food, without transit disorders or externalised digestive bleeding, all developing in a context of apyrexia and preservation of general condition. Clinical examination: presence of haemodynamic instability, median laparotomy scar, distended, tympanic abdomen with generalised abdominal guarding, on rectal palpation: presence of marisci, good sphincter tone, no palpable mass. Abdomino-pelvic CT: large pneumoperitoneum with cystic intestinal pneumatosis (pneumatosis coli), distension of some of the loop gullies of the NHA seat, with no clearly visible transition zone: probably functional origin, large peritoneal effusion. Biological tests revealed hyperleukocytosis and hyponatremia.  Given the hemodynamic instability and generalized abdominal defensiveness, the patient was referred to the operating room. Surgical exploration revealed a gastric stasis in front of a non-stenotic pyloric thickening of about 2 cm, cystic parietal pneumatosis in the right colon, sigmoid colon and small intestine. A transmesocolic omega loop More Information How to cite this article: Mounir B, Ichrak B, Aziz M, Khadija K, Abdessamad M, Elbakouri A, Khalid EH. Pneumatosis Intestinal Cystic: A Case Report. Eur J Med Health Res, 2025;3(2):143-6. DOI: 10.59324/ejmhr.2025.3(2).14 Keywords: pneumatosis, cystic, Intestinal.     This work is licensed under a Creative Commons Attribution 4.0 International License. The license permits unrestricted use, distribution, and reproduction in any medium, on the condition that users give exact credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if they made any changes.  EUR J MED HEALTH RES                                          Volume 3 | Number 2 | March-April 2025   144 gastrojejunal bypass was performed. Postoperative management was uneventful.    Figure1: CT Image of Cystic Intestinal Pneumatosis and Pneumoperitoneum   Figure2: Intraoperative Image of Cystic Intestinal Pneumatosis  Discussion Intestinal cystic pneumatosis (ICP) is a rare condition characterized by the presence of gaseous cysts in the intestinal wall. It can be found in various segments of the digestive tract, from the esophagus to the rectum [8, 9]. The small intestine seems to be more affected than the colon, and the association of colonic and gallbladder involvement by PKI is possible in 20% of cases [10, 11]. This condition must be clearly distinguished from “acute intestinal pneumatosis”, a symptom of diffuse pneumatosis or intestinal emphysema, observed in severe ischemic and/or infectious conditions, in which it constitutes a very poor prognosis, prompting EUR J MED HEALTH RES                                          Volume 3 | Number 2 | March-April 2025   145 emergency surgery [1,3]. Pathologically, cystic formations are mostly found in the submucosa, particularly in colonic disease, and/or in the subserosa, particularly in the small intestine. These cystic formations may extend into the mesentery, the subperitoneal cellulograins of the retroperitoneum and the abdominal walls, and may lead to benign pneumoperitoneum or retropneumoperitoneum [2]. PKI occurs preferentially in men between 40 and 50 years of age, and is primary in 15% of cases, although it is often associated with other pathologies [10, 12-15]. Primary forms are uncommon [3]. The situations most frequently described in association with PKI are ulcerative stenosis of the bulb, which occurs in 1/3 of all PKI cases and in 50% of PKI of the small bowel [8], gastric ulcer [10], organ transplantation, scleroderma, Steinert's disease [9], and certain bronchopulmonary conditions, particularly obstructive ones [8], ischemic, inflammatory, infectious or tumoral diseases of the colon (adenocarcinoma of the colon), especially when accompanied by intestinal obstruction [8, 11, 13, 16], mesenteric and intestinal metastases, certain drugs such as phenprocoumon and prolonged exposure to trichloroethylene [13, 14]. Two cases of appendicitis have been reported in association with PKI. PKI predominantly affects males, with a peak in frequency between the ages of 40 and 60 [10, 11, 14]. In our patient, given the presence of a stasis stomach upstream of a non-stenosing pyloric thickening, we concluded that it was a cystic pneumatosis secondary to a gastric tumor. The mechanism by which gas cysts are formed and maintained is multifactorial, involving in variable parts several components: loss of mucosal integrity (infectious or inflammatory damage), increased endoluminal pressure, changes in the bacterial flora, constitutional and/or acquired, and hyperproduction of intestinal gases with disruption of their degradation mechanisms [4]. PKI is generally pauci-symptomatic. In 30% of cases, it may be revealed by non-specific signs: diarrhoea, bloody or mucous stools, meteorism, vomiting, constipation, tenesmus. Intestinal obstruction is a rare complication linked to the number and size of the cysts, which can reduce the intestinal lumen, leading to an occlusive syndrome [5]. Other complications linked to cystic volume have been described: volvulus, invagination, perforation, haemorrhage [5]. CT is the most sensitive examination for the diagnosis of PKI [10, 13, 16]. It reveals images of gas density in the digestive wall, best seen in the pulmonary window [6]. Multi-planar reconstructions enable precise study of the topography, volume and extent of cysts. The association with asymptomatic pneumoperitoneum is almost pathognomonic [1]. Ultrasound examination is non-specific, and may suspect the diagnosis by showing thinning of the intestinal wall and echoes with acoustic shadowing, producing the “aurora sign” [6,7], and the visualization of echogenic bubbles around the circumference of the digestive lumen, itself echogenic, producing the “circle sign” [15]. Colonoscopy, sometimes carried out to investigate PKI or, on the contrary, to search for another diagnosis, reveals aerial cysts with the appearance of translucent polyploid formations. Their walls are thin and covered by normal mucosa [10, 18]. Sub-mucosal cysts produce a characteristic popping sound when collapsed by the biopsy forceps. An important diagnostic criterion for differential diagnosis with acute intestinal pneumatosis or intestinal gangrene is the absence of aeroportia on CT or ultrasound [6]. Treatment is still poorly codified, and most often involves medical therapy aimed at reducing or eliminating cysts by reducing the anaerobic bacteria that cause them. This involves hygienic dietary measures, anti-anaerobic antibiotic therapy with metronidazole [7, 3] and hyperbaric oxygen therapy. Surgical treatment is indicated in the event of complications, in the event of symptoms resistant to medical treatment, and in the event of associated surgical pathology. It consists of resecting the affected intestinal segment by laparotomy, or even better, by laparoscopy [7]. The laparoscopic approach appears to be the technique of choice [20]. In our case, the patient underwent surgery in view of the acute peritonitis and the voluminous, stenosing appearance of the cysts on imaging. He underwent transmesocolic omega loop gastro-jejunal diversion. Conclusion Intestinal cystic pneumatosis is an uncommon, often asymptomatic and benign condition. Its recognition is important to avoid abusive therapeutic attitudes. It is a rare cause of intestinal obstruction, the diagnosis of which relies mainly on CT. Conflicts of Interest The authors declare having no conflicts of interest for this article  References [1] Goel A, Tiwari B, Kujur S, Ganguly PK. Pneumatosis cystoides intestinalis. World J Gastroenterol. 2011;17(44):4932-4936.  [2] Behnoush B, Bazmi B, Mohammadi F, Bazmi E, Dorvashi GA. Pneumatosis Intestinalis : Autopsy Finding. Acta Medica Iranica. 2009;47(5):415-417.  [3] Serraj I, El kihal N, Mohcine R, Essaid A. Pneumatose kystique intestinale avec ascite: association exceptionnelle. Acta Endoscopica. 2006;36(3):357-362.  [4] Rivera Vaquerizo PA, Caramuto Martins A, Lorente García1 MA, Blasco Colmenarejo M and Pérez Flores R. Pneumatosis cystoides intestinalis. Rev Esp Enferm Dig. 2006;98(12):959- 961.  EUR J MED HEALTH RES                                          Volume 3 | Number 2 | March-April 2025   146 [5] Lê P, Benazzouz A, Fritsch L. Une pneumatose kystique colique révélée par un syndrome pseudo occlusif. Ann Chir. 2003;128(2):117-120.  [6] Braham R, Said M, Rehaiem A, Jerbi Omezzine S, Memmi F, Bouabid Z, et all. Imagerie de la pneumatose kystique intestinale. J Chir. 2004;14(3):201- 204.  [7] El Bouhaddouti H, Ousadden A, Benjelloun B, Mazaz K,et Aït Taleb K. Pneumatose kystique iléale révélée par un volvulus du grêle [8] Danse EM, Vanbeers BE, Gilles A, Jacquet I. Sonographic detection of intestinal pneumatosis. Eur J ultrasound 2000;11:201-203.  [9] Rybacj LD, Shopiro RS, Carano K, Halton KP. Massive pneumatosis intestinalis : CT diagnosis. Comput Med Imaging Graph 1999;23:165-168. [10] Xavier JL, Boscangi G, Claudel N et al. La pneumatose kystique intestinale. Ann Radiol 1991;34:401-406.  [11] Kaassis M, Ben bouali A, Arnaud JP. 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Pneumatosis Intestinal Cystic: A Case Report

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Pneumatosis Intestinal Cystic: A Case Report

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