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Special Feature
Mar 2012

Image of the Month—Diagnosis

Arch Surg. 2012;147(3):292. doi:10.1001/archsurg.147.3.292

Pneumatosis intestinalis is the presence of gas in the intestinal wall and may be associated with gas in the portal vein.1 Two nonexclusive theories to explain the source of the gas have been proposed: (1) the gas may enter the circulation because of increased pressure in the bowel lumen associated with damaged mucosa or increased pressure inside an abscess; or (2) gas-forming bacteria may be present in the portal venous system.2 While clostridial organisms are widely recognized for their gas-forming potential, other gram-negative pathogens (eg, Escherichia coli) may produce a similar clinical picture.3

In our patient, coronal computed tomography (Figure 1) showed diffuse pneumatosis intestinalis (small- and large-bowel wall), intrahepatic and extrahepatic portal vein gas (including superior mesenteric and splenic veins), intestinal edema, and ascites. He also had a reducible inguinal hernia. Because there was suspicion of acute mesenteric ischemia due to a high lactate level, the patient underwent urgent laparotomy and resection of ascending colon and distal ileum (Figure 2A). He died of multiorgan failure associated with sepsis (E coli) on postoperative day 2. The resected colon specimen showed signs of ischemic damage of the mucosa without intramural necrosis, edema, and hemorrhage (Figure 2B). At autopsy there was no evidence of mesenteric artery stenosis or thromboembolism. No diverticulum was found. Perforation of the duodenum in the setting of recent endoscopic retrograde cholangiopancreatography was also ruled out. The liver showed evidence of cholangitis (cholestasis and marked neutrophilic infiltrates with evidence of bacteria) and no evidence of rejection. There were also scattered areas with empty spaces, which most likely corresponded to the parenchymal gas observed in the computed tomographic scans. Splanchnic hypoperfusion associated with cholangitis or sepsis was the most likely mechanism to explain the ischemic colitis (watershed zones of the colon) and pneumatosis intestinalis.