An Obscure Source of Pneumomediastinum

Ziv Talemi^1*, Daniel Fischer¹ , Svetlana Davidov¹ & Zvi Perry^1,2

¹Department of Surgery A Ward, Soroka University Medical Center, Beer Sheva, Israel
²Faculty of Health Sciences, Ben Gurion University of the Negev, Beer Sheva, Israel

*Correspondence to: Dr. Ziv Talemi, Department of Surgery A Ward, Soroka University Medical Center, Beer Sheva, Israel.

Copyright © 2022 Dr. Ziv Talemi, et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Case
A 62-year-old male arrived at the emergency department complaining of one week of abdominal distension without pain. Patient history included Crohn’s disease complicated by intestinal perforation 10 months prior to the current presentation and cardiac transplantation in 2001 due to non-ischemic cardiomyopathy with continued immunosuppressant therapy. A physical exam revealed a distended abdomen without peritoneal signs. Crepitations were auscultated in the neck, right shoulder, and groin. Total body computed tomography (CT) showed pneumoperitoneum, pneumomediastinum, and subcutaneous emphysema in the neck [Figure A]. A review of imaging from six months prior to the current presentation showed pneumatosis intestinalis (PI), which was determined to be the most likely source of the patient’s peritoneal, mediastinal, and subcutaneous free air [Figure B]. The patient was admitted to the surgical ward and managed conservatively with nil per os (NPO), intravenous fluids, and antibiotics. His clinical condition improved with this treatment and he was discharged home on day 6.

Pneumatosis intestinalis is defined as gas within the submucosa or subserosa of the bowel wall. It may be idiopathic or secondary to a variety of gastrointestinal or non-gastrointestinal pathologies. Our patient’s history of Crohn’s disease and intestinal perforation put him at risk for PI, however, some cases of PI do not come to clinical attention unless discovered incidentally on imaging or during surgery [1]. Symptomatic PI may have a variable presentation depending on the involved segment of the bowel. Vomiting, abdominal distension and discomfort, and weight loss are seen with involvement of the small intestine, while diarrhea and hematochezia are more common with large intestine involvement [2]. The presence of pneumoperitoneum, as in our patient, may be seen in up to 9% of patients, due to rupture of subserous cysts [3] [Galandiuk, 1986]. The additional findings in this patient of pneumomediastinum and subcutaneous emphysema are rare manifestations of this condition. Finally, this case illustrates the importance of careful evaluation of the clinical setting following the discovery of free abdominal air.

Significant pneumoperitoneum, though most commonly is due to abdominal organ perforation, may be managed conservatively when occurring secondary to pneumatosis intestinalis, as in our case. In fact, laparotomy in this setting may be unnecessary and non-therapeutic [4].

Learning Points/Take Home Messages (2-3 Bullet Points)
• Most cases of free abdominal air occur secondary to abdominal organ perforation, however, in the appropriate clinical setting, other causes should be investigated to determine appropriate treatment
• Even in the presence of significant pneumoperitoneum, uncomplicated pneumatosis intestinalis may be managed conservatively; In these cases, laparotomy may be unnecessary and ultimately non-therapeutic [2].
• Just like in love and war, in medicine nothing is always or never true, and one should always take into consideration the clinical status of the patient.

Bibliography

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3. Galandiuk, S. & Fazio, V. W. (1986). Pneumatosis cystoides intestinalis. A review of the literature. Dis Colon Rectum., 29(5), 358-363.
4. Hsueh, K. C., Tsou, S. S. & Tan, K. T. (2011). Pneumatosis intestinalis and pneumoperitoneum on computed tomography: Beware of non-therapeutic laparotomy. World J Gastrointest Surg., 3(6), 86-88.