Radiology Cases in Pediatric Emergency Medicine
Volume 7, Case 14
Loren G. Yamamoto, MD, MPH

This is a 5-month old male who presented to an emergency department with emesis. He was assessed as having gastroenteritis with some mild dehydration. He was given IV fluids and discharged from the ED on oral hydration after he was noted to improve clinically. Two days later, he developed diarrhea which persisted for the next two days and today he was noted to have some bloody streaks in the diarrhea. This prompted his parents to take him to an acute care clinic. He was noted to be moderately dehydrated and lethargic, but he did not appear to have an acute abdomen. Some laboratory studies were drawn, IV fluids were started and an abdominal series was ordered.

Transfer to a children's hospital was arranged and he was noted to improve clinically just before he was transferred. Upon arrival at the children's hospital, the following examination is noted.

T37.3 (rectal), P122, R26, BP 100/63, oxygen saturation 100% in room air. He is alert and active in no acute distress. He is not toxic and not irritable. His anterior fontanelle is soft and flat and his neck is supple. His eyes are not sunken and his oral mucosa is moist. Neck supple. Heart regular without murmurs. Lungs clear. Abdomen soft, flat, non-tender with active bowel sounds. No organomegaly or masses are noted. There are no hernias and his genitalia are normal. His skin turgor, color and perfusion are good. He moves his extremities well. His strength and tone are good. His facial function is good.

Laboratory studies from the acute care clinic are available for review. CBC WBC 7,200 35% segs, 51% lymphs, 9% monos, 5% eos, Hgb 14, Hct 41, platelet count 473,000. Na 141, K 3.9, Cl 109, Bicarb 13, BUN 10, Cr 0.4, glucose 80. Liver function studies are normal.

After reviewing the set of abdominal radiographs from the acute care clinic, another abdominal series is ordered.

These radiographs show marked pneumatosis intestinalis. There is air dissecting through the wall of the rectum, sigmoid and distal colon. No free air is noted. An abdominal ultrasound is performed which shows the presence of microbubbles in the hepatic portal venous circulation and increased echogenicity of the liver secondary to trapped microbubbles throughout the liver. These findings are indicative of bowel pneumatosis with air entering the mesenteric veins draining into the portal venous system. He is evaluated by a pediatric surgeon who feels that he has necrotizing enterocolitis despite his benign abdominal examination. He is admitted to the pediatric intensive care unit for observation because of the risk of bowel perforation and the development of shock. Antibiotics are started.

Later in the evening, his abdominal series is repeated and the degree of pneumatosis is noticeably decreased. No free air is noted.

His clinical course is benign and he recovers nicely. Cultures of his blood, urine and stool are all negative. So signs of hemolytic uremic syndrome or intussusception are present. He is later restarted on feedings and does well. A follow-up barium enema is negative for any bowel strictures.

Pneumatosis intestinalis is most notably associated with necrotizing enterocolitis (NEC) in neonates, a serious condition often associated with very ill premature neonates. NEC frequently results in sepsis, bowel perforation, bowel gangrene, and bowel strictures.

Pneumatosis intestinalis in older infants and children is uncommon. It is associated with a variety of conditions such as short gut syndrome, pyloric stenosis, bowel ischemia, congenital heart disease, bronchopulmonary dysplasia, corticosteroid therapy, chemotherapy and immunosuppression. In many instances, no etiology other than gastroenteritis can be determined. Pneumatosis intestinalis in older infants and children does not carry as high a morbidity as it does in premature neonates, but this finding is often associated with a surgical abdominal emergency.

Adults with obstructive pulmonary disease will sometimes manifest pneumatosis intestinalis and these cases are usually benign.

Loren Yamamoto, MD, MPH, Professor of Pediatrics, University of Hawaii John A. Burns School of Medicine.Loreny@hawaii.edu