IMAGE OF THE MONTH Benign Pneumatosis Intestinalis Cheryl X. Q. Lim,*,‡ Winson J. H. Tan,* and Brian K. P. Goh*,§ *Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital, Singapore; ‡ Yong Loo Lin School of Medicine, National University of Singapore, Singapore; §Duke-NUS Graduate Medical School, Singapore

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.1 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.1,2 Benign conditions include pulmonary diseases such as

A

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 lifethreatening causes of PI are usually symptomatic and require surgical intervention.1,2 A computerized tomography scan is the most sensitive imaging test for the identification of PI and is also useful to identify the underlying cause.1 The main challenge in the management of PI hinges on the identification of patients who require surgical intervention.1,2 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.3 Most cases of PI can be managed conservatively with treatment targeted at the underlying cause, especially in cases secondary to benign conditions.2 Conservative management may entail antibiotic therapy, elemental diet, supplemental/hyperbaric oxygen therapy, or endoscopic therapy Clinical Gastroenterology and Hepatology 2014;12:xxv–xxvi

IMAGE OF THE MONTH, continued of cysts to relieve obstruction.2 However, because of the rarity of the condition, there remains little evidence to date supporting any of the treatment modalities.

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Knechtle SJ, Davidoff AM, Rice RP, et al. Pneumatosis intestinalis. Surgical management and clinical outcome. Ann Surg 1990;212:160.

References 1.

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Ho LM, Paulson EK, Thompson WM. Pneumatosis intestinalis in the adult: benign to life- threatening causes. AJR Am J Roentgenol 2007;188:1604–1613. Wu LL, Yang YS, Dou Y, et al. A systemic analysis of pneumatosis cystoids intestinalis. World J Gastroenterol 2013;19: 4973–4978.

Conflicts of interest The authors disclose no conflicts. © 2014 by the AGA Institute 1542-3565/$36.00 http://dx.doi.org/10.1016/j.cgh.2013.12.031

Benign pneumatosis intestinalis.

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