An Acute-on-Chronic Presentation of Pneumatosis Cystoides Intestinalis: A Case Report.

Pneumatosis cystoides intestinalis (PCI) is a rare manifestation of pneumatosis intestinalis (PI), characterized by intramural gas cysts within the gastrointestinal tract. While frequently benign and many times idiopathic, PCI can also be associated with underlying critical conditions. Radiographically, benign cases of PCI can mimic life-threatening abdominal pathology, creating diagnostic uncertainty and challenging operative decision-making. We report a case of a 71-year-old male with a three-year history of progressive abdominal bloating, early satiety, postprandial pain and significant weight loss who presented acutely with worsening abdominal symptoms following a mechanical fall. Computed tomography (CT) revealed extensive small bowel pneumatosis with associated pneumoperitoneum. Despite concerning imaging findings, the patient lacked peritoneal signs, laboratory abnormalities, or evidence of mesenteric ischemia on computed tomography angiography (CTA). Given persistent symptoms and worsening radiologic appearance, an exploratory laparotomy was pursued. Intraoperative findings demonstrated a segment of dilated, atonic small bowel containing diffuse intramural air cysts without evidence of ischemia, perforation, obstruction, or purulent peritonitis. Small bowel resection with primary anastomosis was performed. The patient recovered uneventfully and experienced complete resolution of chronic gastrointestinal symptoms at postoperative follow-up. This case highlights the importance of integrating clinical presentation with laboratory and radiologic findings when evaluating pneumatosis intestinalis. Although small bowel involvement is often associated with pathologic etiologies, PCI may present as an acute exacerbation of chronic disease. Selective surgical intervention can be both diagnostic and therapeutic in symptomatic patients.