Pneumotosis Intestinalis with Pneumoperitoneum in Acute Inpatient Rehabilitation: A Case Report

Case Diagnosis: A 61-year-old female admitted to an inpatient rehabilitation facility (IRF) for debility and severe dysphagia as late effects of cancer treatment developed diffuse intra-abdominal free air without abdominal symptoms.

Case Description or Program Description: During the patient’s acute hospitalization, a percutaneous gastrostomy tube was placed for nutritional support given severe dysphagia and recurrent aspiration resulting in hypersensitivity pneumonitis. Therefore, she was strictly nil per os (NPO) and treated with a prolonged course of high-dose steroids. One week into her rehabilitation stay she developed new onset midsternal chest pressure, and workup revealed free air beneath the right hemidiaphragm. Subsequent computed tomography (CT) scan demonstrated extensive pneumatosis as well as retroperitoneal free air.

Setting: Inpatient Rehabilitation Facility

Assessment/Results: The concerning findings on CT scan necessitated surgical consultation. Given that the patient was in a freestanding rehabilitation center, this required transfer to an acute care hospital. Her benign presentation without abdominal pain or rigidity allowed for conservative management with 14 days of intravenous Zosyn, proton pump inhibitor, and ongoing NPO orders. The presumed cause of intra-abdominal free air was favored to be most likely secondary to high-dose steroid use, a known but uncommon side effect of steroid treatment. Despite the interruption in her rehabilitation stay, the patient was ultimately able to return to the IRF and complete a therapy course with documented improvement in function and Quality Indicator Scores.

Discussion (relevance): Intra-abdominal free air is an uncommon radiographic finding in the IRF setting and can represent a range of pathophysiologic mechanisms from incidental finding in asymptomatic patients to surgical emergency in patients with an acute abdomen. While not typically a diagnostic challenge, the decision to manage cases conservatively versus surgically can significantly impact both short- and long-term patient functional outcomes. This management decision also directly impacts the length of interruption in IRF stay as well as potential financial burden to the patient.

Conclusions: The rare finding of intra-abdominal free air in IRF settings requires urgent surgical consultation, and the management decision can impact length of patient stay and functional recovery. Physiatrists should be aware of chest pain as a possible symptom of intra-abdominal free air especially in patients on high-dose steroid treatments.