IMAGES IN CLINICAL MEDICINE

Pneumatosis Cystoides Intestinalis with Pneumoperitoneum

Francesco Pata, and Salomone Di Saverio

N Engl J Med 2019; 380:e17
DOI: 10.1056/NEJMicm1808960

A 61-year-old woman presented to the emergency department with acute onset of diffuse abdominal pain and a 1-week history of diarrhea and vomiting. Her medical history included chronic obstructive pulmonary disease, which was being treated with an inhaled glucocorticoid and a long-acting β-agonist. On examination, the abdomen was distended and diffusely tender, with guarding. Computed tomography of the abdomen revealed large amounts of free air (Panel A, arrow) and extraluminal gas in the wall of the small bowel (Panel B, arrow). Emergency laparotomy was performed, and gas-filled, thin-walled, cystlike structures were seen throughout most of the small bowel (Panel C). Examination of the bowel ruled out a perforation, and the bowel was not resected. The pathophysiology of pneumatosis cystoides intestinalis is poorly understood. Cyst rupture can produce pneumoperitoneum and peritoneal irritation. Radiographic findings of pneumoperitoneum and gas within the bowel wall can be associated with a number of conditions, ranging from non–life-threatening causes, as in this case, to surgical emergencies such as ischemic bowel, depending on the clinical scenario. Within 15 months after presentation, the patient returned with a similar episode of abdominal pain, which was treated nonoperatively. At follow-up 2 years after surgery, the patient remained well.

一名61岁女性患者因腹泻呕吐一周伴突发弥漫性腹痛到急诊就诊。患者既往史包括COPD（使用吸入激素及长效β受体激动剂）。体格检查发现，患者腹胀，弥漫性压痛伴肌卫。腹部CT显示大量游离气体（图A，箭头），小肠肠壁内气体（图B，箭头）。急诊剖腹探查手术发现，多数小肠呈充气薄壁囊样结构（图C）。小肠检查排除穿孔，遂未行切除。肠壁囊样积气的病理生理尚不清楚。囊壁破裂可导致气腹及腹膜刺激。在多种情况下，影像学检查可发现气腹及肠壁内气体，包括非致命性因素（如本例）或外科急症（如肠缺血）。就诊后15个月，患者因相似情况再度就诊，仍然接受非手术治疗。手术后随访2年，患者一般情况良好。