A case of pneumoperitoneum and retropneumoperitoneum without bowel perforation due to extensive intestinal necrosis as a complication to chemotherapy: CT evaluation

Abstract

Acute intestinal ischemia continues to be a challenging diagnostic problem with high mortality. We describe a rare case of acute intestinal necrosis, due to vasculitis, related with chemotherapy. A patient was examined in our emergency department, presenting with abdominal pain. Three months before he had undergone an operation for lung carcinoma (lobectomy) and received chemotherapy. CT of the abdomen demonstrated free air in 10 different locations: hepatic part of the portal vein, branches of mesenteric veins, femoral and iliac veins, the bowel wall, peritoneal cavity and retroperitoneal space, abdominal muscles, inguinal canals, meso-sigmoid space, and in the para-rectal space. Moreover, pathological findings revealed that the free air in the peritoneum and retropneumoperitoneum occurred without intestinal perforation, but with transudation through the necrotic bowel wall. This is a rare complication of chemotherapy. This case refers to the unusual CT findings which appeared in this patient. The key to a better outcome is early diagnosis of this condition and the CT examination of the abdomen plays an important role.

Keywords: CT; Pneumoperitoneum; chemotherapy; intestinal; ischemia; necrosis.

Fig. 1.

Abdominal CT scan shows portal venous air in the left hepatic lobe, pleural effusion and atelectasis in both lower lobes.

Fig. 2.

Abdominal CT scan depicts retropneumoperitoneum – mainly in the right space – in the lateral border of the psoas muscle and in the right preperitoneal compartment.

Fig. 3.

Abdominal CT scan demonstrates: (i) pneumatosis intestinalis in rectum and free air in the pararectal space; (ii) pneumatosis intestinalis in sigmoid colon; and (iii) free air in lower pelvis in contact with the right inguinal canal.

Fig. 4.

Abdominal CT scan demonstrates intravascular air in both femoral veins and air in both inguinal canals.