Prolonged ileus with pneumatosis cystoides intestinalis.

A 40-year-old woman with rectal cancer visited our emergency department for abdominal pain and vomiting. She had received operation and chemoradiotherapy 6 months ago with subsequent lymph node recurrence and obstructive uropathy. Ureteral stenting and pecutaneous nephrostomy were performed for relief then. Her abdominal symptoms were attributed to ileus, and consulting surgeon recommended against re-operation owing to poor performance status. Her ileus fluctuated in severity, with recurrent bacteremia. An abdominal film 3 weeks later revealed radiolucent areas surrounding the entire bowel contour (Fig. 1). Abdominal computed tomography demonstrated prominent pneumatosis cystoides intestinalis involving colon and small bowel (Fig. 1). Hypotension and profound metabolic acidosis ensued with consciousness loss, and a family decision was made not to resuscitate her. She passed away 1 day later. Pneumatosis cystoides intestinalis presents as air collection in bowel wall layers, and can be innocent as in idiopathic or post-endoscopic cases. Other causes could be life-threatening. The main aetiologies include mesenteric vascular diseases with bowel ischaemia, followed by inflammatory bowel diseases and intestinal obstruction/infection. Small intestine and right side colon are the most common sites involved. Our patient presumably suffered from Correspondence to: C.-T. Chao, Department of Internal Medicine, National Taiwan University Hospital Jin-Shan Branch, No. 51, Nan-Shih, Jin-Shan District, New Taipei City, Taiwan. Email: b88401084@gmail.com Figure 1 (Left) Abominal plain film disclosed clear contour of the, while colonic segments from right (curved arrow), transverse to left colon (straight arrow) as contrasted from radiolucent bowel wall gas. Small bowel wall pneumatosis was also identified. (Right) Computed tomography demonstrated the extensive bowel gas over small bowel and colon.