Cystic pneumatosis intestinalis: causes, symptoms, diagnosis, treatment

Cystic pneumatosis of the intestine is very rare. According to A. A. Rusanov, by 1960 only 250 similar observations of pneumatosis of the small intestine, which is the most common, were described in the literature. In the large intestine, pneumatosis occurs less often, and even less often in the stomach. However, air cysts are found much less often in the parietal peritoneum, mesenteric lymph nodes of the retroperitoneal tissue, in the wall of the urinary bladder, and vagina. In some cases, intestinal pneumatosis can be combined with bronchial asthma and pulmonary emphysema.

Pneumatosis was first described in 1754 by Duvernoy. The disease is characterized by the appearance in the intestinal wall of numerous dense bubbles containing gas similar in composition to atmospheric air.

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Causes cystic pneumatosis intestinalis

The etiology and pathogenesis of the disease are unclear. According to one point of view, pneumatosis is caused by gas penetration from the intestinal lumen through intertissue gaps with increased intraintestinal pressure (spastic contractions of the intestine, increased pressure of intestinal contents in the suprastenotic region, with intestinal obstruction, etc.). According to A. A. Rusanov (1960), there are known cases when pneumatosis disappeared after the elimination of intestinal obstruction. According to other authors, the appearance of gas bubbles is caused by the activity of microorganisms that have penetrated the intestinal wall and are capable of producing gas. However, it is noted that ruptures of gas bubbles usually do not contribute to the development of an inflammatory process. There is also an assumption that anomalies in the development of the lymphatic vessels of the intestinal wall play a certain role in the occurrence of pneumatosis.

Pathogenesis

The most typical is the presence of cystic cavities in the intestinal wall containing gas. The sizes of gas bubbles vary, their diameter from 1-2 mm to 1.0-1.5 cm. As a rule, they are located under the serous or mucous membrane, less often - in the muscular membrane. Their wall is formed by connective tissue usually without elements of the epithelial or endothelial membrane. Inflammatory infiltrates containing eosinophilic, and in some cases - giant cells are often observed around the cysts.

Usually, gas bubbles in the wall of the small intestine are multiple, forming conglomerates similar to soap foam, crepitating when palpated, or evenly distributed over a certain section, and sometimes the entire small intestine, in the intestinal mesentery.

Symptoms cystic pneumatosis intestinalis

The clinical picture in most cases is asymptomatic [according to A. A. Rusanov (1960), intestinal pneumatosis itself does not give typical manifestations] and is detected only by chance during operations. However, according to observations of other authors, the disease can manifest itself as abdominal pain of an indefinite nature, flatulence, bowel disorder (constipation or, conversely, diarrhea).

Complications and consequences

Since pneumatosis is often combined with other, more severe diseases, they often determine not only the clinical picture, but also the prognosis. Significant conglomerates of gas bubbles, especially those located circularly around some section of the intestine, can themselves cause a narrowing of its lumen and disruption of the intestinal contents. Spontaneous ruptures of large gas bubbles can cause pneumoperitoneum. I. T. Abasov (1977) described 4 patients with cystic pneumatosis of the small intestine; in 1 case, a large accumulation of fluid and free gas in the abdominal cavity was observed.

Diagnostics cystic pneumatosis intestinalis

As a rule, it is impossible to palpate pneumatic cysts. However, if they are located subserously, they can be detected in the stomach and duodenum during gastroduodenoscopy. In this case, the endoscopist usually tries to determine the prevalence of the process, and if it is possible to pass the endoscope into the initial sections of the jejunum, then pneumatosis of this section of the intestine can be detected. In some cases, large bubbles of small intestinal pneumatosis can also be suspected by changes in the relief of its mucous membrane during targeted X-ray examination of the small intestine. Subserous pneumatosis of the small and large intestine can be suspected during plain fluoroscopy only in the presence of large air bubbles or their conglomerates. Subserous pneumatosis of the intestine can be detected during laparoscopy, submucous pneumatosis of the colon - during colonoscopy.