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Peptic Ulcer Kamal Mansour, M.B., B.Chir POSTGRAD. MED. J. (I96I), 37, 554 Postgrad Med J: first published as 10.1136/pgmj.37.431.554 on 1 September 1961. Downloaded from A CASE OF PNEUMATOSIS CYSTOIDES INTESTINALIS ASSOCIATED WITH PEPTIC ULCER KAMAL MANSOUR, M.B., B.CHIR. (CAIRO) Baptist Hospital, Gaza, via Egypt Pneumatosis (or gas cysts) of the intestines is a In I949, Gazin, Brooke, Lerner and Price rare disease that was first described in man by reported the first pre-operative radiological diag- Bang in I876. It has been identified more nosis and more recently cases involving the frequently in animals, particularly swine fed on sigmoid colon have been reported by Matthews dairy refuse. It is characterized by the presence (I954), McGee, Penny and Williamson (1956), of cysts in the submucosal or subserosal layers, and Griffiths (I955). Two further cases of usually of the lower ileum, rarely of the duo- intestinal pneumatosis both involving the sigmoid denum, rectum or appendix. These cysts are colon were described by Shoesmith and Crone tiny collections of gas enclosed within a wall of (1I959)- connective tissue supporting an inner layer of The etiology is puzzling; several ingeniousProtected by copyright. endothelium. The gas contained within the theories have been advanced. It has been sug- cysts is odourless, non-inflanunable and is com- gested that the gas is a product of aerogenic posed principally of nitrogen (up to go%), with organisms, but this is not supported by bacterio- smaller proportions of oxygen and carbon dioxide; logical evidence. Many authors have suggested on occasions other gases such as hydrogen and that the origin of the cysts is mechanical, and thit methane have been found. gas of intestinal origin is forced through minute Males are three times more commonly affected fissures in the mucous membrane as a 'result of than females and the condition is commonest in the vomiting, or irregular peristaltic action, but fourth and fifth decades-the decades of peptic against this view is the-absence of intestinal flora ulcer. MacKenzie (195I) reported I2 cases in within the cysts. Nevertheless the commonly infants, as well as finding over 30 cases in the accepted theory is that of Masson (1925), wh6 literature occurring in childhood. studied the condition in swine. He believed that It is difficult to attribute a definite clinical the cysts were due to dilatation of lymphatic ok picture to the presence of multiple gas cysts in the chyliferous channels, and that the gas is derived walls of the intestines; usually symptoms occur from chyle by chemical interaction with acidhttp://pmj.bmj.com/ because of some associated gastro-intestinal products of intestinal fermentation. disease, the most common reported one being a stenosing ulcer of the pylorus and also intestinal Case History tuberculous ulceration and gastric carcinoma. G.A., male, aged 50, admitted to Southern Baptist Symptoms may also occur from complications of Hospital, Ajloun, Jordan, on October i6, I959, com- the disease. Intestinal obstruction- plaining of intermittent abdominal pain as well as following chronic constipation for the past two to three years. blockage of the lumen by a mass of cysts, volvulus Used to taking purgatives every two weeks. Took on September 26, 2021 by guest. and intussusception has been recorded. Radio- purgative on day before admission which was followed logically, gas may be seen under the diaphragm by poor result and accompanied by distension and to spontaneous of a Pneuma- colicky pain. On day of admission he had repeated owing rupture cyst. colics and the passage of only few cc.s of faeces. tosis cystoides intestinalis is the only known On Examination. Abdomen: markedly distended, condition which can explain a 'prolonged' or tympanitic note with few high-pitched bowel sounds. 'recurrent' pneumoperitoneum. Mild tenderness all over, but no rigidity. Rectal: Hahn (I899) first reported the condition in a negative. Lungs: normal. Heart: regular, pulse living subject and since then despite its early 8p/min. Temp.: 36.9gC. (98.40F.). Invsptigation. Hb. II.5 gm-./fpo ml. Total white count: recognition, Schorr, Ullmnann and Laufer (1951) 9,400.; Differential csunt: non-segmented neuti., and Koss (1952) have extensively reviewed the 69%.;, segmented neutr., I5%; lymphocytes,. i6%. literature and have only found about 250 cases. ESR: I/33 mm., Westergren. Urine analysis, negatipe; September I96 1 MANSOUR: A Case of Pneumatosis Cystoides Intestinalis Associated with Peptic Uker .S55 Postgrad Med J: first published as 10.1136/pgmj.37.431.554 on 1 September 1961. Downloaded from .49 -/ I KW': Protected by copyright. stools for occult blood, positive. Straight X-Ray of the bowel on both sides was resected with end-to-end abdomen showed multiple fluid levels. anastomosis. Four mattress sutures of catgut 00 A tentative diagnosis of intestinal obstruction was chromic over an omental patch were applied to cover made. To elicit a diagnosis a laparotomy under ether the perforation in the pylorus. Penicillin +- strepto- an2sthesia was performed. mycin solution was put in the peritoneum. Abdomen Operation. Right paramedian incision; free fluid was closed without drainage. was found in the peritoneal cavity, straw-.coloured and Convalescenrce was uneventful and the patient was not offensive. A sealed-off perforation in the pyloric discharged 12 days later, free from symptoms with region of the stomach was found with adhesions to.the nornal bowel actions. transverse colon and the gallbladder. Adhesions freed. Histology. Sections revealed large cyst-like structures The whole ileum was found to be studded with vesicles lined by flattened cells with a chronic inflammatory full of air with a big mass of the same invading and process around, which is composed of lipid-laden infiltrating a loop of small intestine about 3 in. from the macrophages, lymphocytes and a few giant cels, ileo-c;cal junction. Some gangrenous areas were together with proliferating blood iessels lined by some in noticed this mass. The whole mass with healthy endothelial cells in the neighbourhood. http://pmj.bmj.com/ REFERENCES BANG, B. L. F. (1876): Luftholdige Kyster i vAggen af ileum og i nydannet bindev&;u pi sammes serosa, Nord. me'd. Ark., 8,- I.I GAzIN, A. I., BROOKE, W. S., LERNER, H. H., and PRICE, P. B. (I949): Pneumatosis Intestinalis; Roentgen Diagnosis and Surgical Management, Amer. J. Surg., 77,r563. GRIFFITHS, G. J. (1955): Pneumatosis Cystoides Intestinalis, Lancet, ii, 905.. HAHN, E. (I899): tOber Pneumatosis cystoides intestinorum hominis und einen duech Laparotomie behandelten Fall, on September 26, 2021 by guest. Dtsch. med. Wschr., 25, 657. Koss, L. G. (1952): Abdominal Gas Cysts (Pneurnatosis Cystoides Intestinorum Hominis); Analysis with Rep6rt of Case and Critical Review of Literature, Arch. Path. Lab. Med., 53, 523. McGKE, A. R., PENNY, S. F., and WILLIAMSON, N. L. (1956): Pneumatosis Cystoides Intestinalis, with Case Report, Radiology, 66, 88. MACKENZIE, E. P. (195I): Pneumatosis Intestinalis; 1eview of 1iterature with Report of I3 Cases, Pediatrits? 7, 537. MASSON, P. (I925): Ann. Anat. path. med. chir., 2,, 541. MATrHEWS, F.J. C. (1954): Enteric Pneumatosis, Brit. med. J., i, 85I. SCHORR, S., ULLMANN, T. D., and LAUFE, S. (I9I):.Pneumatosis Cystoides Intestinalis, A.M.A. Arch. intern. Med. 889,362. SIIOiEMITH, J. H., and CRONE, W.. P. (I 59): Pneum'atosis Cystoides Intestinalis, Brit. J. Surg., 46, 6oI..
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