Intramural bowel gas and portal venous gas

Case contributed by Dr Hidayatullah Hamidi


Late preterm (34-35 weeks), male neonate presented with fever, loose motion and poor sucking for last three days.

Patient Data

Age: 14 days
Gender: Male

Linear lucencies in the bowel walls (intramural gas), branching lucencies in the liver (portal venous gas).  

No abnormal bowel distension or evidence of free intraperitoneal gas.


Trans-abdominal ultrasound with high-frequency linear transducer revealed extensive small echogenic foci in the intestinal walls.

Branching echogenic foci also noted in the liver parenchyma extending to the liver edges.

Mild to moderate free fluid was detected in the peritoneal cavity. Mural thickening of the rectum. 

Case Discussion

Intramural gas in the bowel wall is an imaging sign, rather than a diagnosis. This entity can result from various pathologic processes in the neonatal period including prematurity, necrotizing enterocolitis, hypoplastic left or right heart syndrome, bowel obstruction, Hirschsprung disease and gastrointestinal Rotavirus.

Plain abdominal radiography and ultrasonography are the mainstays of imaging workup. A vertical beam and a horizontal beam radiography with the patient being in the supine position are necessary for diagnosis.

Portal venous gas appears as branching (lucencies on radiograph and echogenicity on ultrasonography) extending toward the periphery of the liver.  The advantage of ultrasound over radiograph is real time ability for depicting bowel mural thickness, echogenicity, peristalsis, mural gas, perfusion and intraperitoneal fluid.

With appropriate clinical history, the radiologist can play an important role in the detection of pneumatosis intestinalis, differentiation of its medical and surgical causes and finally suggesting appropriate treatment approach.

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Case information

rID: 51571
Published: 26th Feb 2017
Last edited: 14th Aug 2019
Inclusion in quiz mode: Included

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