Transient pneumatosis intestinalis and leak from oesophagojejunal anastomosis after gastrectomy

Case contributed by Dr Vikas Shah

Presentation

Total gastrectomy and oesophagojejunal anastomosis. Feeding jejunostomy tube. Rising inflammatory markers on day 5 following surgery. CT to rule out anastomotic leak.

Patient Data

Age: 60 years
Gender: Male
CT

CT abdomen and pelvis on day 5 following surgery

CT with intravenous and oral contrast (200 ml of 5% Gastrografin given 5 minutes before image acquisition). The contrast fills the oesophagus and proximal small bowel with no leak from the oesophagojejunal anastomosis-jejunostomy. Air is present within the bowel wall of much of the small bowel. No filling defect in mesenteric vessels. No gas in the portal vein branches or its tributaries. No pneumoperitoneum. Oval shaped area of low attenuation at hilum of liver new compared to pre-operative imaging and inferred to be due to handling at surgery. Small left pleural effusion.

One explanation of the small bowel findings is ischaemia, possibly due to a period of hypoperfusion during surgery, or a new embolic event. Another explanation is benign pneumatosis intestinalis, a known complication of percutaneous jejunostomy placement. The patient wasn't "sick enough" to have ischaemic bowel and didn't undergo a laparotomy. The enteral feed was slowed and the patient monitored as it was increased again and there was no deterioration.

However, 10 days later, there is a clinical deterioration with rapidly rising inflammatory markers. Another CT with oral contrast is requested.

CT

CT abdomen and pelvis on day 15 following surgery

The same oral contrast protocol was used for this second CT. There is now leak of oral contrast from the oesophagojejunal anastomosis site into a gas and fluid containing left subphrenic abscess. The small bowel no longer contains gas in the wall. The liver haematoma has increased in size, as has the left pleural effusion which now appears loculated.

Case Discussion

This case illustrates two potential complications of upper GI surgery. Benign pneumatosis is a known complication of jejunostomy placement, attributed to the inadvertent introduction of gas into the submucosal space. There are myriad caused of benign pneumatosis intestinalis, but acute ischaemia should always be considered the most important cause of this radiologic finding. Whilst a leak from the anastomosis may have been inferred from the identification of a new subphrenic abscess, the oral contrast has helped to definitively confirm a leak.

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Case information

rID: 55559
Published: 18th Sep 2017
Last edited: 6th Oct 2017
Inclusion in quiz mode: Included

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