The subsequent CT examination confirms the linear diffuse presence of air throughout the colonic wall with extensive air now tracking into the mesenteric venous system and the mesentery. These appearances are highly suggestive of mesenteric ischaemia with colonic infarction. Other significant considerations for such diffuse linear pneumatosis include neutropenic colitis, sepsis and if the anatomic configuration is appropriate, volvulus.
Although this appearance is clearly a sign of significant concern, this sign is frequently incorrectly stated to have a universally fatal outcome predictor. This is incorrect. Several cases have been described in which transient severe pneumatosis intestinalis and even portal venous gas can recover spontaneously.
In this instance no mesenteric arterial or venous occlusion could be identified at CT. The patient was to unwell/old for surgery and was conservatively managed. A follow-up radiograph demonstrates that the colonic luminal air has completely resolved and the patient recovered from this acute episode. The precise aetiology was therefore never determined, and the case considered to reflect transient pneumatosis intestinalis.
Transient pneumatosis intestinalis, often linear as in this case, is considered to occur due to focal mucosal integrity loss with increased intraluminal gaseous distension pressure. This may occur in patients with COPD, asthma or cystic fibrosis, often after episodes of prolonged coughing, vomiting or retching. However, this entity is also recognised inpatients who are immunocompromised by use of steroids, chemotherapy, radiation therapy, organ transplantation or HIV. In these patients transient linear pneumatosis may result from intraluminal bacterial gas entering the bowel wall due to increased mucosal permeability caused by a defect in the bowel wall lymphoid tissue. Clinically the precise cause of these reversible cases is frequently not determined, however, clinical prudence requires exclusion of pathological pneumatosis related to infarction or infection which is a far more frequent occurrence. The entity of transient pneumatosis should be considered when there is a discrepancy of clinical symptomatology and imaging.