Elderly Woman With Abdominal Pain

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An 87-year-old woman presented with acute onset of diffuse abdominal pain, chills, and fever up to 38.5°C (101.3 °F), with 2-day history of vomiting and diarrhea without blood. She had lost 5 kg during the last 3 months. C-reactive protein level was 327 mg/L.

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Diagnosis 

Secondary pneumatosis intestinalis. Abdominal radiograph showed dilated loops of small and large bowel, and multislice computed tomography (CT) delineated an infiltrative and partially obstructive process of hepatic flexure of the colon with gas in the bowel wall, suggesting bowel ischemia (Figure 1). CT also showed intrahepatic portal venous gas, suggesting advanced mesenteric ischemia. Exploration confirmed preoperative findings of intestinal pneumatosis (Figure 2) and infiltrative process of the colon with peritoneal carcinomatosis. Loop ileostomy was made but intestinal ischemia progressed, with evident stomal necrosis. The patient died after 3 days.

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• Figure 1. 

  Multislice CT: gas in the bowel wall of small and large intestine.

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• Figure 2. 

  Intraoperative photograph: gas at the junction of mesentery and small bowel wall. Used with permission of Goran Augustin, MD, MSc, University Hospital Center Zagreb, Department of Surgery, Division of Gastrointestinal Surgery, Zagreb, Croatia.