A 73-year-old man with a history of appendectomy 50 years earlier visited our hospital complaining of abdominal pain and vomiting. The patient had been hospitalized twice in the past 2 months because of bowel obstruction. Abdominal X-ray showed dilated small-bowel loops with air-fluid levels. Computed tomography (CT) scans revealed dilation of the upper small bowel and the presence of intramural gas in a part of the dilated bowel segments. No causative lesion was identified (Fig. 1). We diagnosed small-bowel obstruction associated with intestinal pneumatosis secondary to increased intraluminal pressure. Surgery was indicated because the patient’s condition was serious enough to have warranted hospitalization three times in a period of only 2 months.
Laparotomy revealed that an approximately 160-cm loop of the proximal small bowel was dilated from the Treitz ligament. No significant stenosis was found. The dilated bowel had multiple small palpable nodules in the wall with areas of focal emphysema. Because confirmative diagnosis could not be made intraoperatively, we decided to partially resect the dilated small bowel, excising approximately 65 cm of the jejunum where the nodules were mainly distributed (Fig. 2).
Histopathological examination of the excised bowel revealed that the nodules were composed of multiple, gas-filled intramural cysts. Inflammatory cell infiltrates were noted in the stroma, although no specific finding was found in the cell population (Fig. 3).
High output discharge from a nasogastric tube (NGT), ranging from 0.9 to 2.7 L/day, was observed after the operation. The patient was diagnosed with postoperative ileus with underlying PCI and managed conservatively. The amount of drainage, however, did not decrease despite long-tube decompression and oxygen insufflation (Fig. 4). The patient was transferred to a university hospital for hyperbaric oxygen therapy (HBOT). However, CT enterography at the university hospital suggested anastomotic stenosis because the balloon of the long tube was retained there, although water-soluble contrast medium could pass (Fig. 5). Reoperation was recommended and the patient underwent laparotomy 35 days after the first operation.
On laparotomy, the proximal small bowel was noted to be markedly dilated although the jejunoileal anastomosis was not stenotic (Fig. 6). We divided the jejunum 15 cm distal from the Treitz ligament and excised the atonic, dilated jejunum, 36 cm in length. The proximal end of the ileum was anastomosed to the duodenal second portion in a double tract fashion, which bypassed the dilated third portion of the duodenum and the jejunal cuff. Histopathological examination revealed that the excised jejunum also had small gas-filled cysts, while the myenteric nerve plexuses were normally distributed.
The patient had prolonged ileus even after the second operation. Prostaglandin F2 alpha and long-acting octreotide were somewhat effective, but the effects were temporary. Endoscopic examination revealed that the passage created by duodenoileostomy was widely open and the fiberscope easily entered the ileal limb. The patient underwent HBOT for 9 days. Thereafter, the incidence of vomiting, which repeatedly occurred, gradually decreased. The patient resumed oral intake and was discharged 53 days after the second operation. Although a cyst-like dilatation of the third portion of the duodenum was seen on a follow-up CT scan conducted 15 months later, the patient’s quality of life is presently good, and he is able to tolerate a normal daily diet.