Pneumatosis coli, graft versus host disease, acute aortic thrombus

Case contributed by Michael P Hartung


Abdominal pain. History of myelodysplastic syndrome and bone marrow tranplantation.

Patient Data

Age: 65 years
Gender: Male

Extensive pneumatosis of the ascending through mid transverse colon. Small amount of pneumoperitoneum, pneumoretroperitoneum, and pneumomediastinum. No colonic wall thickening or extraluminal collections. 

More diffuse small bowel thickening and enhancement from the proximal jejunum through terminal ileum. 

New large amount of soft plaque in the abdominal aorta. 

Small bowel inflammation involving the mid jejunum through distal ileum. Serosal and mucosal hyperenhancement with submucosal edema. Reactive inflammation in the mesentery. 

Note NO aortic thrombus. 

Case Discussion

Very complex case with several important complications of immunotherapy/chemotherapy and graft versus host disease (GVHD).  

Benign pneumatosis is favored over ischemia due to the extent and distribution, lack of wall thickening (typical of ischemic colitis), lack of stranding/fluid, and risk factors from chemo/immunotherapy and GVHD resulting in increased mucosal permeability2,4

Small bowel inflammation worsened since the baseline examination. Recent endoscopic biopsy confirmed GVHD. 

New soft plaque in the aorta is a very important finding that could be overlooked as simple atherosclerosis. However, it is NEW over just 2 months. Thrombus formation in the aorta has been described in the setting of chemotherapy/immunotherapy agents, particularly antiangiogenic agents1. Aortic thrombus could also be related to altered procoagulant/defective fibrinolytic systems (the same risk factors for developing venous thromboembolism) in the setting of GVHD resulting in inflammatory cytokines, hematological malignancy (myelodysplastic syndrome in this case), or infection3.

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