Clinical significance of pneumatosis intestinalis - correlation of MDCT-findings with treatment and outcome

Abstract

Objectives: To evaluate the clinical significance of pneumatosis intestinalis (PI) including the influence on treatment and outcome.

Method and materials: Two radiologists jointly reviewed MDCT-examinations of 149 consecutive emergency patients (53 women, mean age 64, range 21-95) with PI of the stomach (n = 4), small (n = 68) and/or large bowel (n = 96). PI extension, distribution and possibly associated porto-mesenteric venous gas (PMVG) were correlated with other MDCT-findings, risk factors, clinical management, laboratory, histopathology, final diagnosis and outcome.

Results: The most frequent cause of PI was intestinal ischemia (n = 80,53.7 %), followed by infection (n = 18,12.1 %), obstructive (n = 12,8.1 %) and non-obstructive (n = 10,6.7 %) bowel dilatation, unknown aetiologies (n = 8,5.4 %), drugs (n = 8,5.4 %), inflammation (n = 7,4.7 %), and others (n = 6,4 %). Neither PI distribution nor extension significantly correlated with underlying ischemia. Overall mortality was 41.6 % (n = 62), mostly related to intestinal ischemia (p = 0.003). Associated PMVG significantly correlated with underlying ischemia (p = 0.009), as did the anatomical distribution of PMVG (p = 0.015). Decreased mural contrast-enhancement was the only other MDCT-feature significantly associated with ischemia (p p < 0.001). Elevated white blood count significantly correlated with ischemia (p = 0.03).

Conclusion: In emergency patients, ischemia remains the most common aetiology of PI, showing the highest mortality. PI with associated PMVG is an alerting sign. PI together with decreased mural contrast-enhancement indicates underlying ischemia.

Key points: • In emergency patients, PI may be caused by various disorders. • Intestinal ischemia remains the most common cause of PI in acute situations. • PI associated with decreased mural contrast-enhancement indicates acute intestinal ischemia. • PI associated with PMVG should alert the radiologist to possible underlying ischemia.

Keywords: Intestinal ischemia; Intestines; Multidetector computed-tomography; Pneumatosis intestinalis; Portomesenteric venous gas.

Fig. 1

Overview of the different aetiologies (in percentages) of pneumatosis intestinalis presented by our study population

Fig. 2

A 19-year-old patient known for ulcerative colitis developed septic shock 3 days after confection of a J-Pouch. Axial (a, b) and coronal (c) MDCT images reveal PI (a, black arrows) of a jejunal loop associated with absent mural contrast enhancement (b–c, white arrows), thus clearly indicating acute ischemia

Fig. 3

A 63-year-old woman presented in emergency with acute abdominal pain and elevated serum lactate (3.1 mmol/l). Axial (a, b) and coronal (c) MDCT images reveal a recto-sigmoid cancer (a, white arrow) causing mechanical obstruction with proximal luminal dilatation, fecal stasis (b–c) and PI (b, black arrows). Total colectomy was immediately performed, resecting both the tumour and the whole proximal colon because of ischemic necrosis of the latter

Fig. 4

a–b A 51-year-old man known for multimetastatic ileal neuroendocrine tumour, and previously treated with surgery, hepatic radioembolisation, and systemic radiotherapy (Dotatoc®), presented with severe abdominal pain and peritonism. Lab tests, including lactate, were normal. Coronal (a) and axial (b) non-enhanced MDCT-images reveal extensive colonic PI (black arrows), confirmed by immediate laparotomy, but the colon was viable. The aetiology of PI remained unknown

Fig. 5

Flow chart giving an overview of the chosen treatment in patients with ischemic PI