Intra-operatively patient was found to have pneumatosis
of the small intestine and the mesentery extending from the mid jejunum to the mid ileum with one short segment of normal bowel.
Axial CT images, in soft tissue window, show a large dilated loop of bowel in the left upper quadrant (Figure 3) as well as pneumatosis
in the colonic wall (Figures 3).
An approach to pneumatosis
intestinalis: Factors affecting your management.
A request for autopsy was declined by the patient's family, but a postmortem CT scan one hour after death revealed extensive pneumatosis
intestinalis of the entire small bowel, right colon and sigmoid, gas in the portal system, and blood vessels, with free air and unclear fluid in the peritoneal cavity (Figures 1 and 2).
CT scan of the abdomen and pelvis showed pericecal inflammatory stranding without pneumatosis
concerning cecal typhlitis as well as an "apple-core mass" of the ascending colon near the hepatic flexure concerning colon cancer (Figure 1).
The CT also showed extensive pneumomediastinum, the presence of pneumopericardium, large epidural pneumatosis
, retropharyngeal-prevertebral pneumatosis
, and air in paraesophageal spaces without pneumothorax (Figure 4).
Workup revealed a normal echocardiogram with no concern for transplant rejection as well as a normal abdominal ultrasound, but abdominal X-ray (KUB) was concerning for diffuse pneumatosis
intestinalis due to linear lucencies adjacent to the cecal wall and significantly dilated and edematous bowel (Figure 1).
A small amount of mesenteric fluid is seen, without significant ascites, small bowel wall thickening, differential mucosal enhancement, or pneumatosis
to indicate bowel compromise.
Images of the month: gastric pneumatosis
due to sevelamer-mediated necrosis.
Conclusion: Cerebral venous air embolism may occur after pneumatosis
intestinalis by a retrograde flow of air from the mesenteric veins and portal vein.
Purulent peritonitis manifests as thickened parietal peritoneum, seroperitoneum, pneumatosis
, thickening and edema of omentum majus and mesentery of small intestine, etc.
Description of CT features in stercoral colitis CT findings Description Fecal impaction Colon lumen filled with hard stool material Colon dilatation Colon segment with increased cross-sectional diameter (>6 cm) secondary to stool impaction Colon wall thickening Wall thickness >3 mm at the impacted site Mucosal discontinuity Lack of mucosal enhancement due to pressure Pericolonic fat stranding Increased density and streaks of fat caused by the inflammation Extraluminal free air Air migrating from colon lumen into (pneumatosis
coli) or beyond (pneumoperitoneum or air in veins) the wall of the colon Table 2.