Pneumatosis cystoides intestinalis and ketoacidosis in a diabetic patient: A case report and literature review

Abstract

Rationale: Pneumatosis cystoides intestinalis (PCI) is a rare disease characterized by gas accumulation in the intestinal wall, and is usually treated conservatively. Patients with diabetic ketoacidosis (DKA) sometimes present with severe abdominal pain as the first symptom, which may be misdiagnosed. We report a case of PCI in a patient with diabetes mellitus (DM) misdiagnosed as gastrointestinal perforation and underwent exploratory laparotomy.

Patient concerns: A 41-year-old woman with a history of DM treated with miglitol, an α-glucosidase inhibitors (αGI), was admitted to the emergency department with severe abdominal pain. Computed tomography revealed thickening of the ascending colon wall and scattered free gas around it, and the possibility of tumor perforation was considered.

Diagnosis: The patient was diagnosed with gastrointestinal perforation and DM but was revised to PCI and DKA after surgery.

Interventions: The patient underwent exploratory laparotomy; however, no signs of digestive perforation were found. The patient developed DKA after surgery and received conservative treatment, including antibiotics, insulin, fluid support, oxygen therapy, and cessation of miglitol.

Outcomes: Ketoacidosis was controlled, and the abdominal pain resolved with conservative treatment. She was discharged 16 days later and no longer required αGI therapy. She did not develop gastrointestinal symptoms or any signs of PCI on computed tomography imaging within 3 months.

Lessons: PCI is a rare disease with great heterogeneity in etiology, treatment and prognosis and comorbidities like diabetes may increase the chances of misdiagnosis. Surgeons should pay attention to the patient's medical history and examination and carefully identify the real disease that triggers the symptoms to avoid misdiagnosis.

Keywords: diabetes mellitus; ketoacidosis; misdiagnose; pneumatosis cystoides intestinalis; α glucosidase inhibitors.

Figure 1.

The black arrow indicates PCI. (A) Thickened bowel wall (bidirectional arrow) (B) PCI on the opposite side of the mesentery (C) PCI at the mesangial border like free gas black arrow. PCI = pneumatosis cystoides intestinalis.