Pneumoperitoneum caused by pneumatosis cystoides coli

Pneumatosis cystoides intestinalis (PCI) is a rare disease with the incidence of 0.03% in the general population, and the symptoms are diverse, ranging from asymptomatic to life-threatening scenario. Herein, we present a case of pneumatosis cystoides coli with pneumoperitoneum and an unknown origin of septic shock undergoing exploratory laparotomy. A 70-year-old woman with a history of Bechet disease was admitted to the internal medicine department because of Bechet disease with acute exacerbation, and she received high-dose steroid therapy. Emergency computed tomography of the abdomen disclosed diffuse pneumatosis coli with pneumoperitoneum and mild ascites. Ischemic bowel disease was highly suspected. Exploratory laparotomy was done with intraoperative findings of an intact gastrointestinal tract without ischemic change and gas within the wall of the colon. Pneumoperitoneum could be a life-threatening condition and also be a nonsurgical scenario. Arterial gas examination could be a considerable clue to distinguish pneumatosis cystoides coli-related pneumoperitoneum from surgical pneumoperitoneum. Close and serial observation of clinical presentation, laboratory examination, and image study would be helpful to identify the possible etiologies of pneumoperitoneum. Laparoscopic exploration may also be a safe and feasible option to examine the integrity of the gastrointestinal tract.