June 09-41-2.indd - Kma.org.kw

June 2009KUWAIT MEDICAL JOURNAL 143Case ReportPneumatosis Intestinalis of Small Bowelin an Adult: A Case ReportRajan Arora 1 , Amany Abd El-Hameed 1 , Obaid Al Harbi 21Department of Pathology and 2 Department of Surgery, Al Farwaniya Hospital, KuwaitABSTRACTKuwait Medical Journal 2009; 41 (2): 143-145Pneumatosis Intestinalis (PI) is rare in adults although itcan be seen in the pediatric population as a complicationof necrotizing enterocolitis. We report a case of PI affectingthe small bowel in a 27-year-old patient who presentedwith signs and symptoms of acute abdomen due toperforated duodenal ulcer. Histopathologic findings aredemonstrated and the pathogenesis is discussed with theobjective of highlighting that PI is not a diagnosis but afinding which needs further evaluation and managementin view of the underlying etiology.KEY WORDS: gastrointestinal, necrotizing enterocolitis, small bowelINTRODUCTIONPneumatosis intestinalis (PI) defined as gaswithin the wall of gastrointestinal (GI) tract, isnot a diagnosis but a physical or radiologicalfinding. It is secondary to an underlying diseaseprocess in 85% of cases which include obstructivepulmonary disease [1] , cystic fibrosis [2] , obstructiveGI disease (e.g., volvulus [3] and intussusception [4] ),gastroduodenal ulcer, ulcerative colitis, necrotizingenterocolitis [5,6] , acquired immunodeficiencysyndrome, and trauma [7] . Secondary form typicallyinvolves the small bowel but may occur throughoutthe GI tract. Since the etiology is so varied, the courseand outcome varies from benign self resolving tofatal depending on the underlying disease process.The primary form which accounts for 15%of cases is a benign idiopathic condition usuallyaffecting the colon [8] . Histopathologic findingsin both are usually the same but pathogenesisis complex depending on interaction of manyfactors like mucosal integrity [5] , intraluminalpressure [7] , bacterial flora [9] , and intraluminalgas [10] . Management depends on treating theunderlying cause and surgery is indicated whenacute complications appear such as perforationand peritonitis.CASE REPORTClinical findingsA 27-year-old male was admitted to surgicalcasualty with signs and symptoms of acuteabdomen. Radiological investigations revealed gasunder the diaphragm (indicative of perforation)as well as air in relation to bowel wall on plainradiograph. Computerized tomographic scan couldnot be done due to the nature of the emergency, andlaparotomy was performed.Operative findingsA perforated duodenal ulcer was found whichwas closed by patch omentoplasty. The terminal180 cm of the small bowel all the way to theileocecal junction showed multiple thin walled,tense, air filled cysts on the serosal surface (fewwere perforated and collapsed). The cecum andcolon were not involved. The small bowel proximalto the involved portion was distended. A limitedright colectomy and resection of the involvedsmall bowel was done. After resection, the patientwas managed in the intensive care unit and wasdischarged from the hospital after 10 days. He is onfollow up and is in good health till date.Pathological findingsGross features: The specimen (comprising ofterminal ileum, cecum with appendix, and partof ascending colon) was received in 10% neutralbuffered formalin. It was floating in the containerdue to buoyancy of the air. Outer surface of wholelength of small bowel (180 cm) showed congestionand multiple cysts in grape like manner (Fig. 1).On cut section, the mucosa showed cobblestoneAddress correspondence to:Dr. Rajan Arora, Senior Registrar, Department of Pathology, Farwaniya Hospital, PO Box : 18373, Farwaniya 81004, Kuwait. (F) 00965-4893078, E-mail: arorarajan73@rediffmail.com, drrajarora@yahoo.com