Shahroud University of Medical siences Shahroud Journal of Medical Sciences 2423-6594 12 4 2026 08 09 Diagnostic Challenges: Pneumatosis Cystoid Intestinalis Presenting as Pneumoperitoneum Leading to Wrong Management - A Case Report 20 24 eng Abolfazl Hekmatshoar Medical school, Sabzevar University of Medical Sciences, Sabzevar, Iran.. A.Hekmat.sh@gmail.com Ali Khatib Department of Nursing, Faculty of Nursing and Midwifery, Neyshabur University of Medical Sciences, Neyshabur, Iran.. khatib.nurse@gmail.com Yasaman Mohebbifar Student Research Committee, Sabzevar University of Medical Sciences, Sabzevar, Iran.. yasamanmohebbifar@gmail.com Shamim Shahrestani Student Research Committee, Sabzevar University of Medical Sciences, Sabzevar, Iran.. sh.shahrestani82@gmail.com 2025 05 30 2026 01 27 Pneumatosis cystoid intestinalis (PCI) is a rare disorder characterized by the presence of gas-filled cysts within the wall of the small or large intestine. Its radiologic appearance may closely mimic pneumoperitoneum, creating significant diagnostic challenges and increasing the risk of unnecessary surgical intervention. We report the case of a 37-year-old man who was misdiagnosed with bowel perforation and underwent laparotomy, which revealed PCI without evidence of perforation. As benign forms of PCI respond well to conservative management, clinicians should consider this entity when evaluating suspected pneumoperitoneum.