Pediatric Pneumatosis Intestinalis

  • Etiology:
    — Neonate: Necrotizing enterocolitis
    — Older child: High-dose steroid therapy in the setting of bone marrow transplant (benign pneumatosis intestinalis), bowel ischemia
  • Imaging: Pneumatosis intestinalis is a finding and not a diagnosis so once you see it you need to determine the cause
  • Imaging Radiograph:
    — Bubbly pneumatosis intestinalis = submucosal gas
    — Curvilinear pneumatosis intestinalis = subserosal gas
    — Usually in the colon
  • Imaging US: Sensitive for diagnosis of pneumatosis intestinalis but need systematic evaluation of bowel
  • DDX: Air mixed with formed stool – note that newborns do not yet have formed stool
  • Complications: Can cause intraperitoneal free air without bowel perforation like popped bubble wrap with outer wall of bubble rupturing but not inner wall
  • Treatment:
  • Clinical: Not all etiologies cause bowel ischemia

Radiology Cases of Pneumatosis Intestinalis

Radiology Cases of Pneumatosis Intestinalis in Necrotizing Enterocolitis

AXR of necrotizing enterocolitis
Supine AXR shows linear pneumatosis intestinalis involving several loops of bowel in the left lower quadrant of the abdomen.

Radiology Cases of Pneumatosis Intestinalis in Graft Versus Host Disease

AXR of pneumatosis intestinalis in graft versus host disease
AXR AP shows diffuse pneumatosis intestinalis of the colon from the cecum to the rectum.

Radiology Cases of Pneumatosis Intestinalis in Meckel Diverticulum Resulting in a Closed Loop Obstruction and Small Bowel Ischemia

CT of Meckel diverticulum causing distal small obstruction due to small bowel volvulus around the Meckel diverticulum resulting in a closed loop obstruction and small bowel ischemia of the ileum and pneumatosis intestinalis from necrosis in the ileum
AXR AP (above left) shows multiple dilated loops of small bowel and a decomopressed colon. Coronal CT with contrast of the abdomen (above right) shows normal caliber and normal enhancement of the proximal jejunum loops in the left upper quadrant. The distal ileum loops in the right lower quadrant are dilated and do not enhance. There is pneumatosis intestinalis in the walls of the most lateral loop of ileum. Axial CT (below) again shows the pneumatosis in the walls of the most lateral loop of ileum on the right and again shows the difference in bowel wall enhancement between the normal jejunum on the left and the abnormal ileum on the right.