Case Report: Pneumatosis cystoides intestinalis in patients with diverse comorbidities: a case series highlighting multifactorial management

Background Pneumatosis cystoides intestinalis (PCI), the cystic form of pneumatosis intestinalis, is a rare condition characterized by gas-filled cysts within the bowel wall. It is frequently misdiagnosed as acute gastrointestinal perforation because of intra-abdominal free gas, which may prompt surgery before the benign nature of the condition is recognized. Case presentation We report three PCI patients with distinct risk factors. The first was a 55-year-old female with PCI during acarbose exposure. She had minimal free gas and a benign clinical course, but a suspicious right-colon lesion that could not be characterized led to right hemicolectomy. The second was a 43-year-old female with autoimmune disease on immunosuppressive therapy and extensive pneumoperitoneum, who achieved full recovery with conservative treatment. The third was a 75-year-old male with combined metabolic and mechanical risk factors; 48-hour observation combined with endoscopy, which identified no overt luminal perforation, small-bowel perforation being considered unlikely on clinical grounds, avoided surgery. All patients presented evidence of radiological–clinical dissociation. Conclusion Our observations suggest that, in PCI, radiological severity does not reliably reflect clinical risk. We propose, as an unvalidated hypothesis rather than a clinical decision rule, that initial management be guided by recognition of the radiological–clinical dissociation rather than by imaging severity alone, provided that strict safety criteria are met. Mechanism-based strategies, including withdrawal of the offending drug when PCI is drug-associated, close observation of clinically stable patients, and surgery reserved for definite complications, may reduce morbidity. Prospective validation of this framework and derivation of evidence-based escalation thresholds are warranted.