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Pneumatosis Intestinalis in the Adult: Benign to Life-Threatening Causes

Lisa M. Ho1, Erik K. Paulson and William M. Thompson

1 All authors: Department of Radiology, Duke University Medical Center, Box 3808 DUMC, Durham, NC 27710.


Figure 1
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  		Fig. 1A —Examples of linear and bubbly pneumatosis intestinalis (PI). Abdominal CT image in 54-year-old woman shows extraluminal gas tracking along small bowel mesentery (black arrowhead) and linear PI (arrows) in this case of PI associated with jejunostomy tube (white arrowhead).

 

Figure 2
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  		Fig. 1B —Examples of linear and bubbly pneumatosis intestinalis (PI). Abdominal CT image in 56-year-old man shows bubbly PI (arrows) and free air (arrowheads) in this case of PI in patient on chemotherapy for colon cancer.

 

Figure 3
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  		Fig. 2A —69-year-old woman with guaiac-positive stool—benign cause of pneumatosis intestinalis (PI). Scout radiograph from air-contrast barium enema shows cystic PI (arrow) consistent with pneumatosis cystoides intestinalis.

 

Figure 4
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  		Fig. 2B —69-year-old woman with guaiac-positive stool—benign cause of pneumatosis intestinalis (PI). Spot film images from air-contrast barium enema show polypoid filling defects (arrows) due to gas in bowel wall (arrowheads) from pneumatosis cystoides intestinalis.

 

Figure 5
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  		Fig. 3A —69-year-old man on chemotherapy for head–neck cancer with mild abdominal pain—benign cause of pneumatosis intestinalis (PI). Abdominal CT image using soft-tissue window setting shows PI of cecum and ascending colon (arrows).

 

Figure 6
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  		Fig. 3B —69-year-old man on chemotherapy for head–neck cancer with mild abdominal pain—benign cause of pneumatosis intestinalis (PI). Abdominal CT image shows PI of cecum and ascending colon (arrows) is much better seen using lung window setting. Patient improved without any special therapy.

 

Figure 7
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  		Fig. 4A —79-year-old woman after recent surgery for gastric cancer. Patient developed abdominal pain and blood pH, 7.24; lactic acid, 8.1 mmol/L; and plasma bicarbonate (HCO3), 18 mmol/L—life-threatening cause of pneumatosis intestinalis (PI). Supine digital abdominal radiograph shows free air (arrows), small-bowel distention, and small-bowel PI (arrowheads).

 

Figure 8
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  		Fig. 4B —79-year-old woman after recent surgery for gastric cancer. Patient developed abdominal pain and blood pH, 7.24; lactic acid, 8.1 mmol/L; and plasma bicarbonate (HCO3), 18 mmol/L—life-threatening cause of pneumatosis intestinalis (PI). Abdominal CT images show free air (long arrows) and small-bowel PI (short arrows, C) but also hepatic portal venous gas (arrowheads, B) not seen on radiograph. At surgery, diffuse ischemia of small bowel was found. Patient died 1 week later.

 

Figure 9
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  		Fig. 4C —79-year-old woman after recent surgery for gastric cancer. Patient developed abdominal pain and blood pH, 7.24; lactic acid, 8.1 mmol/L; and plasma bicarbonate (HCO3), 18 mmol/L—life-threatening cause of pneumatosis intestinalis (PI). Abdominal CT images show free air (long arrows) and small-bowel PI (short arrows, C) but also hepatic portal venous gas (arrowheads, B) not seen on radiograph. At surgery, diffuse ischemia of small bowel was found. Patient died 1 week later.

 

Figure 10
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  		Fig. 5A —Comparison of hepatic portal venous gas and biliary gas in two different patients. 23-year-old woman after heart transplant admitted for mild rejection but no abdominal symptoms and normal laboratory results. Abdominal CT image shows hepatic portal venous gas in periphery of liver (arrows).

 

Figure 11
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  		Fig. 5B —Comparison of hepatic portal venous gas and biliary gas in two different patients. 60-year-old man after Whipple procedure for pancreatic cancer. Abdominal CT image shows gas in bile ducts in central part of liver (arrowheads).

 

Figure 12
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  		Fig. 6A —51-year-old man after lung transplant for cystic fibrosis. Patient had free air on routine chest radiograph and no abdominal symptoms and normal laboratory results—benign cause of pneumatosis intestinalis (PI). Digital abdominal radiograph (A) and abdominal CT images (B and C) show free air (arrows, A and B) and diffuse linear PI of colon (arrowheads). Patient was observed and discharged.

 

Figure 13
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  		Fig. 6B —51-year-old man after lung transplant for cystic fibrosis. Patient had free air on routine chest radiograph and no abdominal symptoms and normal laboratory results—benign cause of pneumatosis intestinalis (PI). Digital abdominal radiograph (A) and abdominal CT images (B and C) show free air (arrows, A and B) and diffuse linear PI of colon (arrowheads). Patient was observed and discharged.

 

Figure 14
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  		Fig. 6C —51-year-old man after lung transplant for cystic fibrosis. Patient had free air on routine chest radiograph and no abdominal symptoms and normal laboratory results—benign cause of pneumatosis intestinalis (PI). Digital abdominal radiograph (A) and abdominal CT images (B and C) show free air (arrows, A and B) and diffuse linear PI of colon (arrowheads). Patient was observed and discharged.

 

Figure 15
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  		Fig. 7A —27-year-old woman with history of scleroderma who presented with abdominal distention. Physical examination and laboratory results were normal—benign cause of pneumatosis intestinalis (PI). Supine abdominal radiograph shows PI (arrows) of small bowel.

 

Figure 16
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  		Fig. 7B —27-year-old woman with history of scleroderma who presented with abdominal distention. Physical examination and laboratory results were normal—benign cause of pneumatosis intestinalis (PI). Upright abdominal radiograph shows pneumoperitoneum (arrows).

 

Figure 17
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  		Fig. 8A —Patients with sudden onset of abdominal pain—life-threatening cause of pneumatosis intestinalis (PI). Supine abdominal radiograph in 60-year-old man shows PI of small bowel (arrows).

 

Figure 18
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  		Fig. 8B —Patients with sudden onset of abdominal pain—life-threatening cause of pneumatosis intestinalis (PI). Superior mesenteric arteriogram of same patient as A shows acute thrombosis (arrows) resulting in small-bowel ischemia and infarction. Patient died.

 

Figure 19
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  		Fig. 8C —Patients with sudden onset of abdominal pain—life-threatening cause of pneumatosis intestinalis (PI). Abdominal CT in 65-year-old woman shows acute thrombus (arrows) in superior mesenteric artery.

 

Figure 20
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  		Fig. 9A —19-year-old man with toxic megacolon due to Crohn's disease—life-threatening cause of pneumatosis intestinalis (PI). Emergency colectomy was performed. Supine (A) and upright (B) abdominal radiographs show diffuse PI of colon (arrows).

 

Figure 21
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  		Fig. 9B —19-year-old man with toxic megacolon due to Crohn's disease—life-threatening cause of pneumatosis intestinalis (PI). Emergency colectomy was performed. Supine (A) and upright (B) abdominal radiographs show diffuse PI of colon (arrows).

 

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