Pneumatosis intestinalis after adult living donor liver transplantation: report of three cases and collective literature review

Abstract

Backgrounds/aims: Pneumatosis intestinalis (PI) is a condition in which multiple gas-filled mural cysts develop in the gastrointestinal tract. Although its exact etiology remains obscure, PI is rarely observed in liver transplant (LT) recipients.

Methods: In 317 cases of adult living donor LT (LDLT) performed during 2011, PI developed in three patients during the 3 year follow-up.

Results: Of these three patients, the two who demonstrated PI at 6 weeks and 2 months after LT, respectively, were asymptomatic and showed no signs of secondary complications. Diagnosis was made incidentally using abdominal radiographs and computed tomography (CT) scans. PI was identified in the right ascending colon with concomitant pneumoperitoneum. These two patients received supportive care and maintained a regular diet. Follow-up CT scans demonstrated spontaneous resolution of PI with no complications. The third patient was admitted to the emergency room 30 months after LDLT. His symptoms included poor oral intake and intermittent abdominal pain with no passage of gas. Abdominal radiography and CT scans demonstrated PI in the entire small bowel, with small bowel dilatation, pneumoperitoneum, and pneumoretroperitoneum, but no peritonitis. Physical examination revealed abdominal distension but no tenderness or rebound tenderness. After 1 week of conservative treatment, including bowel rest and antibiotics therapy, PI and pneumoperitoneum resolved spontaneously without complications.

Conclusions: We suggest that adult LDLT recipients who develop asymptomatic or symptomatic PI with no signs of secondary complications can be successfully managed with conservative treatment.

Keywords: Living donor liver transplantation; Pneumatosis intestinalis; Pneumoperitoneum.

Fig. 1. Imaging of the case 1 and 2: Computed tomography (CT) scans of case 1 patient revealed pneumatosis intestinalis (PI) (white arrows) involving the right ascending colon on an axial image (A) and a coronal image (B). CT scans of case 2 patient revealed PI (white arrows) involving the right ascending colon (C), which was spontaneously resolved after 3 weeks (D).

Fig. 2. Imaging of the case 3: Computed tomography (CT) scan demonstrated pneumatosis intestinalis (white arrows) involving the entire bowel with pneumoperitoneum (white arrowheads) and pneumoretroperitoneum (white arrowheads) (A-C). After 1 week of treatment, gas was almost completely resolved (D).