Occlusive syndrome in intestinal cystic pneumatosis, medical treatment or surgery

Occlusive syndrome in intestinal cystic pneumatosis, medical treatment or surgery

Mohamed Ghassane Rachid^1,&, Taoufik Sadok¹, Youssef Narjis¹, Ridouan Benomar Benelkhaiat¹

¹General Surgery Department, Surgical Hospital Ibn Tofail, University Hospital Center Mohamed VI, Marrakech, Morocco

^&Corresponding author
Mohamed Ghassane Rachid, General Surgery Department, Surgical Hospital Ibn Tofail, University Hospital Center Mohamed VI, Marrakech, Morocco

Introduction    

Intestinal cystic pneumatosis is a rare pathology, its causes still not clearly established, occlusive syndrome is not common manifestation of this pathology. Computed tomography led to diagnosis. The treatment is principally medical, containing symptomatic measures, for the majority of cases; surgical abord is reserved for complicated cases.

Patient and observation     

Observation 1: a 43 years old man with abdominal trauma a week ago presented for vomiting with abdominal distension and stopping of materials and gases (SMG) for 3 days. Examination found abdominal distention, generalized abdominal pain, leukocytosis at 20.103 elements/mm³, a correct ionogram, the standard abdominal X rays: small bowel hydroaeric levels (HAL), abdominal computed tomography(CT): huge hail distention and cystic formations suggestive of parietal pneumatosis (Figure 1). The patient benefited from the establishment of a nasogastric tube (NGT) with medical treatment (metronidazole and anti spasmodic) In front of the exacerbation of clinical signs and the onset of fever, the patient was operated on. Surgical exploration found a hailic distension with diffuse hail pneumatosis (Figure 2). The gesture consisted in an enterovidange of the healthy small bowel segment with pneumatose bleb biopsies. The operative follow-ups were simple. The pathological examination concluded to ICP.

Obervation 2: a 40 years old woman followed for gastric ulcer with Helicobacter pylori + under treatment and in gynecology for infertility with irregular menstrual cycles. She was admitted to the emergency department for generalized abdominal pain with SMG for 2 days, preceded by episodes of diarrhea and vomiting, in a context of fever at 38 ^OC. The clinical examination found abdominal distention with generalized sensitivity, leukocytosis at 17.103 elements/mm³, CRP at 170 mg/l; abdominal X rays has objectified small bowel HAL; abdominal ultrasound: peritoneal effusion slide with multi-cystic ovaries. Abdominal CT: small bowel distention without obvious obstacle with multiple cystic formations at the level of the intestinal wall and diffuse localization realizing a grape bunch appearance evoking ICP (Figure 3). The treatment consisted in a conditioning of the patient with implementation of NGT. Treatment with C3G antibiotics and metronidazole was instituted in addition to antispasmodic and antipyretic. The evolution was marked by the resumption of transit and the disappearance of the fever at the end of 24h. The patient was declared outgoing on D3 of hospitalization.

Discussion     

The ICP affects the man between 40 and 50 years and is secondary to other pathologies: chronic inflammatory bowel disease, gastroduodenal ulcer [1], pulmonary diseases and auto-immune pathlogies such as scleroderma and dermatomyositis [2,3]. Taking certain medications such as alpha-glucosidase inhibitors, anti-psychotics, chemotherapy and occupational exposure to trichlorethylene. The mechanism of formation of gaseous cysts is multifactorial: loss of mucosal integrity, elevation of endoluminal pressure, changes in bacterial flora and hyperproduction of intestinal gas [4]. ICP is usually paucisymptomatic, revealed by nonspecific signs in 30% of cases such as diarrhea, bloody or glairy stools, meteorism, vomiting, constipation and tenesmus. Intestinal obstruction is a rare complication related to the number and size of cysts that can reduce the intestinal lumen and lead to occlusive syndrome. Other complications related to cystic volume have been described: volvulus, intussusception, perforation and haemorrhage [5]. Computed tomography has a good diagnostic accuracy. It reveals images of gaseous density in the digestive wall, better visible in the lung window [6]. The association with asymptomatic pneumoperitoneum is almost pathognomonic [7]. An important diagnostic criterion to rule out acute intestinal pneumatosis is the absence of an aeroport for CT [8]. Endoscopic examinations confirm submucosal cysts. To properly manage patients; treatment of benign ICP is medical, surgical treatment is for complications [9], It is a risk-benefit decision [10]. In the first case, the patient is operated on the exacerbation of clinical symptomatology, the onset of fever and severity of the occlusive syndrome, unlike and given the clinical improvement, the second case was treated medically.

Conclusion     

Intestinal cystic penumatosis is a rare condition, often asymptomatic. It is a rare cause of bowel obstruction, whose diagnosis is based on CT; surgical treatment is reserved for complicated forms.

Competing interests     

The authors declare no competing interests.

Authors' contributions     

All the authors have read and agreed to the final manuscript.

Acknowledgements     

To the co-authors: professors and doctors.

Figures     

Figure 1: patient 1, huge hail distention and cystic formations suggestive of parietal pneumatosis

Figure 2: diffuse cystic pneumatosis

Figure 3: patient 2, multiple cystic formations at the level of the intestinal wall and diffuse localization realizing a grape bunch appearance evoking ICP

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