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.
AXR of pneumatosis intestinalis in necrotizing enterocolitis
AXR AP shows curvilinear appearing air in the wall of the descending colon.
AXR of necrotizing entercolitis
AXR AP (above) shows an extremely dilated bowel gas pattern with cuvilinear air in the wall of the entire colon. There is increased lucency in the center of the image just beneath the diaphragm. AXR left lateral decubitus (below) shows a small amount of air between the abdominal wall and the liver. There is also an extensive amount of branching air seen within the liver.
Radiograph of pneumatosis intestinalis in necrotizing enterocolitis
The diagnosis was pneumatosis intestinalis of the ascending colon and proximal transverse colon in a patient with necrotizing enterocolitis.
AXR of pneumatosis intestinalis of whole colon in necrotizing enterocolitis
AXR AP shows bubbly appearing air in the wall of the entire colon from the cecum to the sigmoid colon.

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 Hyper IgM Syndrome

AXR of pneumatosis intestinalis
AXR AP shows marked curvilinear air throughout the bowel wall of the transverse, descending and sigmoid colon and rectum.

Radiology Cases of Pneumatosis Intestinalis in Hemophagocytic Lymphohistiocytosis

AXR of pneumatosis intestinalis of the colon
AXR AP shows serpiginous lucencies in the abdomen representing a marked amount of curvilinear appearing air in the wall of the ascending and transverse colon.

Radiology Cases of Pneumatosis Intestinalis in Cystic Fibrosis

Radiograph of pneumatosis intestinalis
AXR AP (above) shows bubbly appearing air in the walls of the ascending colon, transverse colon, descending colon and sigmoid colon. There is also linear appearing air in the walls of the descending colon and sigmoid colon. Left lateral decubitus radiograph of the abdomen (below) shows no evidence of free air.

Radiology Cases of Pneumatosis Intestinalis of Unknown Etiology

AXR of pneumatosis intestinalis of the colon
AXR AP (above) shows curvilinear air throughout the wall of the colon from the cecum to the rectosigmoid colon which is also appreciated on the AXR left lateral decubitus (below). There was no free air or portal venous gas.
AXR of CT of pneumatosis intestinalis of the colon
AXR AP (above left) shows extensive curvilinear air throughout the wall of the colon from the cecum to the rectum. There is contrast in the bladder from the contemporaneously performed CT. Axial (above right) and coronal (below) CT with contrast of the abdomen show a large amount of air in the wall of the colon throughout the entire colon.
Radiograph of pneumatosis intestinalis of the colon
Initial AXR (left) shows linear appearing air throughout the wall of the ascending colon. AXR obtained 4 hours later shows cystic as well as linear appearing air throughout the wall of the ascending colon. AXR obtained 12 hours later (right) again shows cystic as well as linear appearing air throughout the wall of the ascending colon.

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.