netherlands journal of critical care

101neth j crit care • volume 11 • no 2 • april 2007

Air in the bowel wall

A 69-year-old man underwent a cystectomy for bladder carcinoma. He was admitted to the ICU with an ileus on the 12th postoperative day. Relaparotomy revealed an intact anastomosis. Again the post-operative period was characterized by persistent ileus for which the patient was successfully treated with erythromycin and neostigmin. Forty days after initial surgery, the patient was readmitted to the ICU with septic shock. Blood cultures were negative. A CT-scan (Figure 1) revealed bowel distension with pneumatosis intestinalis (PI). Bowel ischaemia was suspected and a second relaparotomy was per-formed, confirming PI of the small intestine with distention (Figure 2), although any obvious cause such as ischaemia or an obstruction could not be found. It was supposed that PI might have occurred as result of a prolonged pseudo-obstruction or ileus. The patient was treated with antibiotics and two weeks later he was discharged from the ICU. He made an uneventful recovery until discharge from hospital. PI is defined as the presence of multiple submucosal or subsero-sal gas cysts in the gastro-intestinal (GI) wall. The differential diag-nosis of PI includes traumatic, ischaemic, obstructive, infectious, inflammatory and pulmonary causes or may be cryptogenic [1, 2]. Possible pathophysiological mechanisms of PI are high intra-lumi-

nal pressure, mucosal injury, bacterial translocation / invasion with local gas production, or combinations of mechanisms[3]. PI may cause ‘benign’ free intra-peritoneal air by rupture of the gas cysts without true transmural perforation. Associated conditions may, however, also lead to perforation of the GI tract. This may cause the dilemma of whether or not to perform a laparotomy, in particular if bowel ischaemiais thought to be present. In conclusion, surgery should be performed if bowel obstruc-tion or necrosis are considered as a cause of PI, or if complications associated with PI (perforation or secondary peritonitis) develop [3, 4]. In other cases, non-operative treatment of PI and treatment of associated conditions should be the primary intention.

B. Lamme1, 2, E.J. Hesselink2, J.W. Gratama3, J.H. Rommes1, P.E. Spronk1,4

1Department of Intensive Care Medicine, Gelre Hospitals, location Lukas, Apeldoorn, the Netherlands2Department of Surgery, Gelre Hospitals, location Lukas, Apeldoorn, the Netherlands

3Department of Radiology, Gelre Hospitals, location Lukas, Apeldoorn, the Netherlands4HERMES critical care group, Amsterdam, the Netherlands

Correspondence:

P.E. Spronk, IntensivistE-mail: p.spronk@gelre.nl

References

1. Heng Y, Schuffler MD, Haggitt RC, Rohrmann CA. Pneumatosis intestinalis: a review. Am J Gastroenterol 1995;90:1747-58.

2. Pear BL. Pneumatosis intestinalis: a review. Radiology 1998;207:13-9.3 St Peter SD, Abbas MA, Kelly KA. The spectrum of pneumatosis intestinalis.

Arch Surg 2003;138:68-75.4. Knechtle SJ, Davidoff AM, Rice RP. Pneumatosis intestinalis. Surgical manage-

ment and clinical outcome. Ann Surg 1990;212:160-5.

Figure 1. Multiple locations of pneumatosis intestinalis, visible on CT-scan as indicated by white arrows

Figure 2. Subserosal pneumotosis intestinalis in ileal loops

Copyright ©2007, Nederlandse Vereniging voor Intensive Care. All Rights Reserved. Received February 2007; accepted in revised form March 2007

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