INTRODUCTION

In patients with blunt trauma, free air on abdominal computed tomography (CT) typically indicates a hollow viscus injury and necessitates surgical intervention [1,2]. In rare circumstances, however, such as in pneumatosis cystoides intestinalis (PCI) or an incidental finding after blunt trauma, conservative nonoperative management may be appropriate [3]. In conscious patients, treatment decisions are generally guided by a comprehensive evaluation of clinical features, including abdominal physical examinations and laboratory data [4]. By contrast, in patients with impaired consciousness, physical examinations are unreliable, making observation alone difficult and often leading to a decision for laparotomy. Here, we report our experience with surgical treatment for PCI in a patient with severe traumatic brain injury.

CASE REPORT

A 57-year-old man presented to the emergency department in an altered mental state after falling from a height of 2.5 m. The initial Glasgow Coma Scale score was 4 (E1V1M2). Initial vital signs included a blood pressure of 141/96 mmHg, pulse rate of 112 beats per minute, respiratory rate of 23 breaths per minute, and body temperature of 38.8 °C. Laboratory results showed a hemoglobin level of 13.7 g/dL, white blood cell count of 12,800/μL, and lactate level of 37.8 mg/dL. The abdomen was soft and flat; however, due to impaired consciousness, it was difficult to reliably assess tenderness or rebound tenderness.

Brain CT revealed a subarachnoid hemorrhage, subdural hemorrhage, and multiple skull fractures. Chest CT showed fractures of the left 10th and 11th ribs. Abdominopelvic CT demonstrated extraluminal and retroperitoneal air collection in the right retroperitoneal space adjacent to the distal ascending colon (Fig. 1). PCI was considered a possible diagnosis, but bowel microperforation could not be excluded. Because the patient was comatose, tenderness and guarding could not be adequately assessed. In addition, the elevated white blood cell count and fever heightened the clinical suspicion for peritonitis. Therefore, an exploratory laparotomy was performed to rule out colonic perforation.

During surgery, no dirty fluid or food material was found in the abdominal cavity. Severe adhesions were present between the colon and the omentum. Adhesiolysis revealed PCI in the retroperitoneal space adjacent to the hepatic flexure of the colon (Fig. 2). Because microperforation could not be completely excluded, a right hemicolectomy with anastomosis was performed.

Postoperatively, the patient was managed in the neurosurgery department for traumatic brain injury. However, his intracranial condition worsened due to progressive cerebral edema, and he ultimately died.

Ethics statement

This study was approved by the Institutional Review Board of Wonkwang University Hospital, with a waiver of informed consent (No. WKUH 2024-12-039). All personally identifiable information was collected anonymously and all study procedures complied with the Declaration of Helsinki.

DISCUSSION

PCI is characterized by multiple gas-filled cysts located in the subserosal or submucosal layers of the gastrointestinal tract [3,5,6]. Although relatively rare, the number of reported cases is increasing [5,7]. PCI is most often discovered incidentally during radiographic or endoscopic examinations [7,8]. While PCI is usually benign, it can sometimes present with acute, life-threatening complications requiring urgent surgical management [6,9]. The exact etiology of PCI remains uncertain; however, several hypotheses have been proposed. These are broadly categorized into the mechanical theory and the bacterial theory. The mechanical theory suggests that gas enters the bowel wall through one or more mechanisms, including gastrointestinal surgeries, colonoscopies, pulmonary action, trauma, mucosal injury, obstruction, or anastomoses. By contrast, the bacterial theory is supported by cyst gas analyses showing that the proportion of hydrogen in PCI cysts is significantly higher than in normal luminal gas. This observation suggests that PCI may be attributed to the activity of hydrogen-producing bacteria. In adults, PCI is generally considered benign and is classified as either primary or secondary, with secondary PCI accounting for up to 85% of cases [3,5]. When detected on contrast-enhanced CT, antibiotic therapy may be guided by laboratory findings, and surgery can often be avoided if complications such as obstruction, strangulation, or stricture are absent. PCI, particularly when found incidentally and not in association with trauma, usually follows a benign clinical course and can be managed conservatively [3,9]. However, there are currently no evidence-based guidelines for managing PCI in the context of blunt abdominal trauma, which is generally considered benign [6].

In patients with blunt abdominal trauma, detection of pneumoperitoneum or extraluminal air on CT typically raises suspicion of bowel perforation and frequently necessitates exploratory surgery [1,2]. Delay in treating peritonitis can result in severe complications, including sepsis, which may be fatal. Nevertheless, if the abdominal examination is unremarkable and vital signs and temperature are stable, close observation may be appropriate. However, if diagnostic uncertainty persists or clinical judgment is impaired, surgical intervention becomes necessary [3,5]. In hemodynamically stable patients with equivocal CT findings, diagnostic laparoscopy can serve as a less invasive option before proceeding to laparotomy. Laparoscopy is feasible and safe in stable blunt trauma patients, and in recent years has been applied for both diagnostic and therapeutic purposes. However, in patients with multiple intra-abdominal injuries, laparoscopic procedures can be technically challenging and require advanced surgical expertise. Moreover, in cases with concomitant extra-abdominal injuries, the feasibility of laparoscopy may be significantly restricted [10,11].

In our case, the patient sustained multiple traumatic injuries, including severe head trauma, leading to coma and precluding adequate abdominal examination. Abdominal CT performed as part of trauma evaluation revealed extraluminal and retroperitoneal air, along with elevated white blood cell count, elevated lactate level, and fever of unknown origin. Had the patient been conscious, serial physical examinations could have guided clinical decision-making. Unfortunately, the comatose state rendered abdominal evaluation unreliable. Furthermore, it was not possible to distinguish on CT whether the air around the ascending colon was due to primary PCI or traumatic intestinal perforation. For this reason, exploratory surgery was deemed unavoidable. Laparoscopy was not initially considered because the large volume of air around the ascending colon strongly suggested perforation, and the surgical team anticipated the potential need for bowel resection. Thus, an exploratory laparotomy was performed. Intraoperatively, the peritoneal cavity was unexpectedly clean, with no contaminated fluid or gross inflammatory changes, raising doubt about the necessity of resection. Nevertheless, microperforation could not be entirely ruled out, and reliance on postoperative clinical monitoring was impossible in a comatose patient. Missing even a small perforation could have delayed diagnosis of peritonitis, resulting in potentially fatal sepsis. Therefore, we determined that the benefits of right hemicolectomy outweighed the risks, given the diagnostic uncertainty and inability to rely on clinical monitoring. Histopathological evaluation confirmed PCI, demonstrating submucosal air bubbles surrounded by multinucleated giant cells (Fig. 3) [12].

Laparotomy remains the standard treatment for trauma patients with suspected intestinal perforation. However, in very rare cases, PCI may follow a benign course and improve with nonoperative management. It is important to balance the risk of overtreatment against the risk of missed perforation. In alert trauma patients with suspected PCI who present without abdominal pain, maintain stable vital signs, and show normal laboratory results, careful observation may prevent unnecessary surgery, including bowel resection. Close follow-up with repeated physical examinations, hemodynamic monitoring, and repeated imaging and laboratory review is essential. Signs of peritonitis or suspicion of bowel perforation indicate the need for urgent surgical treatment [3,5,6].

In blunt abdominal trauma, pneumoperitoneum detected on CT generally raises suspicion of bowel perforation and often leads to surgical intervention. However, when air collections are caused by PCI, a condition usually benign, conservative management may suffice, and surgery can sometimes be avoided. If PCI is suspected, management should involve careful serial evaluations, including repeated abdominal examinations, monitoring of vital signs, laboratory testing, and assessment of abdominal symptoms. In trauma patients with impaired consciousness, however, determining the necessity of surgery remains particularly challenging. We hope that our case experience will aid other clinicians in making treatment decisions in similarly complex situations.

ARTICLE INFORMATION

Author contributions

Conceptualization: CYP; Investigation: all authors; Methodology: all authors; Writing–original draft: SRA, CYP; Writing–review & editing: all authors. All authors read and approved the final manuscript.

Conflicts of interest

Chan Yong Park is an editorial board member of this journal, but was not involved in the peer reviewer selection, evaluation, or decision process of this article. The authors have no other conflicts of interest to declare.

Funding

The authors received no financial support for this study.

Data availability

Data sharing is not applicable as no new data were created or analyzed in this study.

Fig. 1.

Initial abdominopelvic computed tomography revealed multiple extraluminal air foci (arrows) in the retroperitoneal space surrounding the ascending colon, without associated fluid collections. (A) Axial view. (B) Coronal view.

Fig. 2.

Examination of the resected right colon. Multiple air-filled cysts are shown within (A) the subserosa (arrow) and (B) submucosa (arrowhead), without any lesions suggestive of intestinal perforation.

Fig. 3.

Pathological examination revealed a submucosal cyst surrounded by multinucleated giant cells (CD68-positive) in the submucosa of the ascending colon. (A) Hematoxylin and eosin (H&E), ×40. (B) H&E, ×100. (C) CD68 immunohistochemical stain, ×40. (D) CD68 immunohistochemical stain, ×100.

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