Benign Pneumatosis Intestinalis

Abstract

A 28-year-old healthy woman presented to the hospital with abdominal discomfort. She complained of colic type abdominal pain and bloat of 3 days' duration, associated with a 1-day history of nausea and nonbilious vomiting. There was no change in frequency of her bowel habits and she was able to pass flatus. On physical examination, all her vital signs were within normal limits. The abdominal examination was essentially normal except for generalized mild abdominal tenderness with no signs of peritonitis. Laboratory investigations were unremarkable. A plain radiograph (Figure A) and computerized tomography scan (Figures B and C) showed extensive pneumatosis coli throughout the nondilated colon, from the cecum to the splenic flexure, with scattered free intraperitoneal and retroperitoneal gas pockets. No intra-abdominal collection or portal venous gas was seen. The patient was treated conservatively with intravenous antibiotics and was discharged from the hospital after 2 days with oral antibiotics. She remained well on outpatient follow-up evaluation. Pneumatosis intestinalis (PI) is a radiologic finding, defined by the presence of gas in the bowel wall. Various hypotheses have been proposed regarding the pathophysiology of PI, although the exact mechanism remains unknown.1Ho L.M. Paulson E.K. Thompson W.M. Pneumatosis intestinalis in the adult: benign to life- threatening causes.AJR Am J Roentgenol. 2007; 188: 1604-1613Crossref PubMed Scopus (248) Google Scholar PI can occur as a primary idiopathic condition or secondary to an underlying condition. The latter may be subdivided into benign and life-threatening causes.1Ho L.M. Paulson E.K. Thompson W.M. Pneumatosis intestinalis in the adult: benign to life- threatening causes.AJR Am J Roentgenol. 2007; 188: 1604-1613Crossref PubMed Scopus (248) Google Scholar, 2Wu L.L. Yang Y.S. Dou Y. et al.A systemic analysis of pneumatosis cystoids intestinalis.World J Gastroenterol. 2013; 19: 4973-4978Crossref PubMed Scopus (106) Google Scholar Benign conditions include pulmonary diseases such as asthma and chronic obstructive pulmonary disease, systemic lupus erythematosus, and the use of medications such as corticosteroids or chemotherapeutic agents. Life-threatening conditions that may cause PI include intestinal obstruction and intestinal ischemia. Patients with primary idiopathic and secondary benign PI are usually asymptomatic and are diagnosed incidentally through radiologic imaging. Patients with secondary life-threatening causes of PI are usually symptomatic and require surgical intervention.1Ho L.M. Paulson E.K. Thompson W.M. Pneumatosis intestinalis in the adult: benign to life- threatening causes.AJR Am J Roentgenol. 2007; 188: 1604-1613Crossref PubMed Scopus (248) Google Scholar, 2Wu L.L. Yang Y.S. Dou Y. et al.A systemic analysis of pneumatosis cystoids intestinalis.World J Gastroenterol. 2013; 19: 4973-4978Crossref PubMed Scopus (106) Google Scholar A computerized tomography scan is the most sensitive imaging test for the identification of PI and is also useful to identify the underlying cause.1Ho L.M. Paulson E.K. Thompson W.M. Pneumatosis intestinalis in the adult: benign to life- threatening causes.AJR Am J Roentgenol. 2007; 188: 1604-1613Crossref PubMed Scopus (248) Google Scholar The main challenge in the management of PI hinges on the identification of patients who require surgical intervention.1Ho L.M. Paulson E.K. Thompson W.M. Pneumatosis intestinalis in the adult: benign to life- threatening causes.AJR Am J Roentgenol. 2007; 188: 1604-1613Crossref PubMed Scopus (248) Google Scholar, 2Wu L.L. Yang Y.S. Dou Y. et al.A systemic analysis of pneumatosis cystoids intestinalis.World J Gastroenterol. 2013; 19: 4973-4978Crossref PubMed Scopus (106) Google Scholar Patients who present with clinical and laboratory features of an acute abdomen should undergo an immediate exploratory laparotomy. Clinical features found to be predictive of the need for surgical intervention include the following: history and physical examination findings suggestive of an acute abdomen, metabolic acidosis, increased serum lactate level, increased serum amylase level, or the presence of portal venous gas.3Knechtle S.J. Davidoff A.M. Rice R.P. et al.Pneumatosis intestinalis. Surgical management and clinical outcome.Ann Surg. 1990; 212: 160Crossref PubMed Scopus (179) Google Scholar Most cases of PI can be managed conservatively with treatment targeted at the underlying cause, especially in cases secondary to benign conditions.2Wu L.L. Yang Y.S. Dou Y. et al.A systemic analysis of pneumatosis cystoids intestinalis.World J Gastroenterol. 2013; 19: 4973-4978Crossref PubMed Scopus (106) Google Scholar Conservative management may entail antibiotic therapy, elemental diet, supplemental/hyperbaric oxygen therapy, or endoscopic therapy of cysts to relieve obstruction.2Wu L.L. Yang Y.S. Dou Y. et al.A systemic analysis of pneumatosis cystoids intestinalis.World J Gastroenterol. 2013; 19: 4973-4978Crossref PubMed Scopus (106) Google Scholar However, because of the rarity of the condition, there remains little evidence to date supporting any of the treatment modalities.