Indian Journal of Medical Sciences Medknow Publications on behalf of Indian Journal of Medical Sciences Trust ISSN: 0019-5359 EISSN: 1998-3654 Vol. 61, Num. 5, 2007, pp. 288-289

Indian Journal of Medical Sciences, Vol. 61, No. 5, May, 2007, pp. 288-289

Letter To Editor

Pnematosis intestinalis of the small bowel in an adult associated with gastric perforation

Utpal De, Khamrui Tapas

Department of Surgery, Calcutta Medical College, Kolkata

Correspondence Address:L-4/9, Phase - III, Dankuni Housing Complex, Dankuni, Hooghly - 711 224
utpalde@vsnl.net

Code Number: 07041

Sir,
A 42-year-old male patient was admitted with history of sudden acute epigastric pain and vomiting since 3 days. The patient had past history of irregular treatment for peptic ulcer disease. There was no history of intake of nonsteroidal anti-inflammatory drugs (NSAIDS).

On admission, the patient was found to be dehydrated and had fever and tachycardia; his blood pressure was 100/80 mmHg. Inspection revealed abdominal distension. On palpation, abdominal tenderness with board-like rigidity, obliterated liver dullness and absent bowel sounds was noted. Base-line hematological examinations were within normal limits excepting mildly raised blood urea (36 mg%, n - 16-28 mg/%) and serum creatinine (1.4 mg %, n - 0.5-1.1 mg/%). Abdominal skiagram showed ground-glass appearance with evidence of free gas in the peritoneal cavity. A diagnosis of perforative peritonitis was made.

On exploration, 1 cm x 0.5 cm perforation was noted in the anterior wall of the stomach. The peritoneal cavity was filled with purulent fluid, food debris and flakes. A striking feature noted was the presence of numerous gas cysts studded along the whole length of second, third and fourth part of duodenum, jejunum and proximal ileum [Figure - 1]. Other abdominal organs appeared healthy. A biopsy was taken, followed by repair of perforation. Abdomen was closed after thorough peritoneal lavage.

The postoperative period was uneventful. Stitches were removed on the 10 ^th postoperative day and the patient was discharged after 2 weeks′ observation. Histopathology did not reveal any evidence of malignancy or infection with H. pylori. The patient is well after 6 months of follow-up.
PI associated with peptic ulcer disease (PUD) involves the small gut in 55% of the cases. ^[1] Cases of duodenal ulcer, peptic perforation and gastric carcinoma associated with PI have been reported, but PI associated with benign gastric ulcer perforation is unique. ^[2],[3],[4]

Of the pathogenic theories proposed about PI, the mechanical theory and the bacterial theory are the most acceptable. ^[4]
PI due to PUD is found in the third or fourth decade of life. ^[1],[4] Presentations include diarrhea, constipation, flatulence, abdominal distension and, occasionally, bleeding. Rarely intestinal obstruction or volvulus due to the cysts has been reported. ^[1],[2],[5] It may present asymptomatically with benign or tension pneumoperitoneum or with features of perforative peritonitis. ^[3]

Radiographically, PI presents with free gas under diaphragm, along with linear, circumferential or mixed appearance of gas within the bowel wall. ^[2],[3],[4] CT with a lung window is more sensitive in diagnosing the extent and possible complications of PI. ^[4] PI can also be diagnosed by endoscopy, magnetic resonance imaging and laparoscopy. ^[2],[4],[5]

Managing patients with PI can be challenging because urgent surgery is required in high-risk patients with presence of portal venous gas, malignant gastrointestinal tumors, bowel infarction and perforation. ^[2],[5] Small bowel cysts secondary to surgically correctable lesions follow a benign course and regress spontaneously. ^[5] Radiographically detected PI without associated clinical evidence of intra-abdominal pathology may be treated conservatively and followed up with USG and UGI endoscopy to note resolution of the cysts. ^[5]

References

Copyright 2007 - Indian Journal of Medical Sciences

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