Pneumatosis cystoides intestinalis mimicking hollow viscus perforation: a case report

Pneumatosis cystoides intestinalis (PCI) is a rare condition characterized by gas-filled cysts within the bowel wall, with an estimated incidence of 0.03%. Its nonspecific clinical manifestations and radiological findings, which may mimic hollow viscus perforation, pose a significant diagnostic challenge for surgeons. A 37-year-old male presented with intermittent epigastric pain for one year, with an acute exacerbation for one day. An upright abdominal radiograph revealed intraperitoneal free air and small bowel gaseous distension, suggesting hollow viscus perforation and incomplete intestinal obstruction; subsequent contrast-enhanced whole-abdominal computed tomography (CT) confirmed pneumoperitoneum with pericolonic gas-density foci, peritoneal effusion, and mesenteric haziness with tiny nodules. Despite mild physical findings and unremarkable laboratory parameters, diagnostic laparoscopy was performed because of persistent symptoms and alarming radiological findings. Intraoperatively, extensive grape-like translucent cystic lesions were observed on the liver surface, abdominal wall, falciform ligament, and multiple small intestinal serosal surfaces, together with approximately 200 mL of dark brown hemorrhagic fluid in the peritoneal cavity. No perforation, necrosis, or complete obstruction was identified, and histopathological examination confirmed PCI. The intraperitoneal free air and hemorrhagic fluid were presumed to result from spontaneous rupture of subserosal gas cysts rather than visceral perforation. The patient recovered uneventfully following conservative management with drainage and was discharged on hospital day 10; he was subsequently lost to follow-up. This case highlights the critical importance of distinguishing benign PCI with cyst rupture from true hollow viscus perforation. Comprehensive preoperative assessment integrating clinical, laboratory, and imaging findings is essential and may help avoid unnecessary major surgical intervention. In equivocal cases, laparoscopic exploration can serve as both a diagnostic and a therapeutic modality.