Presentation
Acute onset of abdominal pain and distension. History of previous surgery for pancreatic neoplasia.
Patient Data
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There is extensive small bowel dilatation with loops showing absent mural enhancement and mural gas (particularly in the jejunum).
The ascending colon appears thick-walled, up to the proximal transverse colon.
Gas is also seen in the branches of the superior mesenteric vein, and peripherally in the liver.
Cavernous transformation of the portal vein.
A small amount of free peritoneal fluid is present.
There is evidence of prior pancreatic surgery with a mass seen in the surgical bed, encasing and occluding the superior mesenteric artery.
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Extensive small bowel dilatation, absent mural enhancement with prominent mural gas seen best in the jejunum ( * ).
The ascending colon appears thick-walled (yellow arrows), up to the proximal transverse colon.
Gas is also seen in the branches of the superior mesenteric vein, and peripherally in the liver (green arrows).
There is evidence of prior pancreatic surgery with a mass seen in the surgical bed (red), encasing and occluding the superior mesenteric artery (SMA) and celiac trunk (CT)
Cavernous transformation of the portal vein (orange).
Case Discussion
Intramural gas (also known as pneumatosis intestinalis) refers to gas within the wall of the bowel and can be associated with ischemia and infarction, and usually carries a dismal prognosis. Even if this patient were to survive the acute illness, she would require most of the small bowel resected which leads to enormous morbidity (e.g. short bowel syndrome, requiring total parenteral nutrition etc...).
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