Images in Clinical Medicine

Pneumatosis Intestinalis and Portal Venous Gas

Craig See, M.D., and David Elliott, M.D.

N Engl J Med 2004; 350:e3January 22, 2004

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A 53-year-old woman who had recently been treated for ulcerative colitis with high-dose prednisone and mercaptopurine was admitted with severe abdominal pain and signs of peritoneal irritation. Colonoscopy, radiography of the small intestine with contrast medium, and surgical exploration of the abdomen revealed fulminant colitis, primarily involving the left colon, but no apparent small-bowel disease. Total colectomy and an ileostomy were performed. On the fifth postoperative day, the patient's clinical condition deteriorated rapidly, with respiratory failure, anuric renal failure, and profound metabolic acidosis. Computed tomography (CT) of the abdomen showed slight dilatation, mesenteric edema, diffuse pneumatosis intestinalis throughout the small intestine, and gas in the bowel wall (arrow, Panel A). CT imaging also revealed gas throughout the portal venous system, including the hepatic venous radicals, and portal venous air–fluid levels (arrow, Panel B). The patient had an unrelenting, downhill course and died shortly thereafter. At autopsy there was no clear explanation for the deteriorating clinical course, aside from the findings of diffuse inflammatory and ischemic changes of the small bowel.

Radiographic findings of diffuse pneumatosis intestinalis and portal venous gas, such as those seen in this patient, are characteristic of necrotizing enterocolitis. Although it is typically found in premature neonates, necrotizing enterocolitis has also been described in adults, particularly those with cirrhosis and immunocompromise.

Craig See, M.D.
David Elliott, M.D.
Madigan Army Medical Center, Tacoma, WA 98431-1100

Citing Articles (4)

Citing Articles

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   J. Cyrany, M. Kopacova, S. Rejchrt, A. Ryska, P. Dvorak, J. Brozik, J. Bures. (2011) Pneumatosis cystoides intestinalis. Acta Endoscopica 41:5, 243-252
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   Young Min Choi, Jun Won Seo, Woo Jin Lee, Hyeong Jin Park, Ji Hye Shin, Seung Bum Kang, Jun Lee, Jin Hwa Kim, Sang Yong Kim, Hak Yeon Bae. (2011) Diabetic Ketoacidosis Associated with Emphysematous Gastritis: A Case Report. Endocrinology and Metabolism 26:4, 355
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   G. Clemente, C. Chiarla, I. Giovannini, A.M. De Rose, A. Astone, C. Barone, G. Nuzzo. (2010) Gas in portal circulation and pneumatosis cystoides intestinalis during chemotherapy for advanced rectal cancer. Current Medical Research and Opinion 26:3, 707-711
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   Ana María García-Cabrera, Francisco García-Padial, José Antonio Jiménez-Ríos, Pablo Vázquez-Barros, Francisco Herrera-Fernández, José María Iza-Goñola, Carlos del Olmo, Manuel Martín-Díaz, José Carlos Hermoso-Torres, Benjamina Espadas-Padial. (2005) Neumatosis intestinal y gas portal secundarios a obstrucción de origen adherencial. Cirugía Española 78:6, 394
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