Case Report
Copyright ©The Author(s) 2016. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Aug 28, 2016; 22(32): 7383-7388
Published online Aug 28, 2016. doi: 10.3748/wjg.v22.i32.7383
Does massive intraabdominal free gas require surgical intervention?
Tadashi Furihata, Makoto Furihata, Kunibumi Ishikawa, Masato Kosaka, Naoki Satoh, Keiichi Kubota
Tadashi Furihata, Makoto Furihata, Kunibumi Ishikawa, Masato Kosaka, Naoki Satoh, Department of General Surgery, Kyouwa Chuo Hospital, Chikusei-shi, Ibaraki 309-1195, Japan
Tadashi Furihata, Keiichi Kubota, Department of Gastroenterological Surgery, Dokkyo Medical University, Shimotsuga-gun, Tochigi 321-0293, Japan
Author contributions: Furihata T served as an attending doctor for the patient, designed the report, and wrote the manuscript; Furihata M contributed equally to this manuscript; Ishikawa K, Kosaka M and Satoh N clinically managed the present case; and Kubota K comprehensively revised the manuscript.
Institutional review board statement: This manuscript was reviewed and approved by the institutional review board of Kyouwa Chuo Hospital.
Informed consent statement: Written informed consent was obtained from the patient for publication of the case report and the accompanying images.
Conflict-of-interest statement: The authors declare no conflicts of interest.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Correspondence to: Tadashi Furihata, MD, PhD, Department of General Surgery, Kyouwa Chuo Hospital, 1676-1 Kadoi, Chikusei-shi, Ibaraki 309-1195, Japan.
Telephone: +81-296-576131 Fax: 81-296-574676
Received: March 26, 2016
Peer-review started: March 27, 2016
First decision: May 12, 2016
Revised: May 24, 2016
Accepted: June 15, 2016
Article in press: June 15, 2016
Published online: August 28, 2016

We describe a rare case of an 81-year-old man who presented with severe epigastralgia. A chest radiograph showed massive free gas bilaterally in the diaphragmatic spaces. Computed tomography (CT) scan also showed massive free gas in the peritoneal cavity with portal venous gas. We used a wait-and-see approach and carefully considered surgery again when the time was appropriate. The patient received conservative therapy with fasting, an intravenous infusion of antibiotics, and nasogastric intubation. The patient soon recovered and was able to start eating meals 4 d after treatment; thus, surgical intervention was avoided. Thereafter, colonoscopy examination showed pneumatosis cystoides intestinalis in the ascending colon. On retrospective review, CT scan demonstrated sporadic air-filled cysts in the ascending colon. The present case taught us a lesson: the presence of massive intraabdominal free gas with portal venous gas does not necessarily require surgical intervention. Pneumatosis cystoides intestinalis should be considered as a potential causative factor of free gas with portal venous gas when making the differential diagnosis.

Keywords: Case reports, Portal vein, Pneumatosis cystoides intestinalis, Colonoscopy, General surgery

Core tip: We describe a rare case of an 81-year-old man with pneumatosis cystoides intestinalis (PCI). PCI is characterized by free gas in the submucosal or subserosal layer of the gastrointestinal tract, and its etiology is unknown. The patient presented with massive intraabdominal free gas and portal venous gas (PVG) due to PCI, and he was successfully treated without surgical intervention. When clinicians encounter free gas with PVG, PCI should be considered.