Diffuse Pneumatosis Coli

Abstract

A 59-year-old woman with a history of a malignant neoplasm of the tongue and right hemi-colectomy 4 years previously due to cecal volvulus presented to our Emergency Department (ED) with several days of worsening left-sided abdominal and flank pain. Her tumor had been treated 2 years prior with composite resection and chemoradiation, and she was not currently receiving any chemotherapeutic or immunomodulatory agents. She was not vomiting and was passing flatus normally, thus, her symptoms were not thought to be suggestive of bowel obstruction. Physical examination revealed a visibly uncomfortable woman with a heart rate of 79 beats/min, blood pressure of 118/74 mm Hg, respiratory rate of 18 breaths/min, and temperature of 36.5°C. Her quick sepsis-related organ failure assessment score was 0. Her abdomen was diffusely tender to palpation in the left hemi-abdomen but without signs of peritonitis. Her laboratory studies were notable for a white blood cell count of 15.7 × 103/mm3, lactic acid of 3.1 mmol/L, and serum bicarbonate of 27 mmol/L. Abdomen and pelvis computed tomography (CT) revealed innumerable foci of intramural gas throughout the large intestine, as well as extraluminal air in the left upper quadrant concerning for diffuse pneumatosis with microperforation and pneumoperitoneum (Figure 1). The small bowel and mesentery were radiographically unremarkable. A supine abdominal x-ray study demonstrated distended loops of colon and subtle gas lucencies overlying the left colon, consistent with pneumatosis (Figure 2). Figure 2Coronal computed tomography scout (A) and supine abdominal x-ray study (B) demonstrating subtle gas lucencies consistent with pneumatosis (arrows). View Large Image Figure Viewer Download Hi-res image