An unusual triad of pneumatosis intestinalis, portal venous gas and pneumoperitoneum in an asymptomatic patient

Pneumatosis intestinalis (PI) is defined as the presence of gas within the serosal or mucosal layer bowel wall. This sign is usually found upon radiographic imaging and is most commonly secondary to acute gastro-intestinal ischaemia. Fifteen per cent of cases can present with a primary condition called pneumatosis cystoides intestinalis (PCI). PCI is usually a benign condition and patients are usually asymptomatic. Portal venous gas (PVG) or the presence/accumulation of free gas within the hepatic portal vein. It is most commonly associated with acute bowel ischaemia, and when seen in the presence of ischaemia the mortality rate is between 75 and 90%. Other associations include mechanical causes (e.g. obstruction), chemotherapy, liver transplant and diverticulitis. Benign PI has previously been described with PVG, but usually in the presence of other associated conditions such as AIDS, malignancy or chemotherapy. Some examples have been described without these associations, but not with free intra-peritoneal air. We describe a case of PCI and PVG with pneumoperitoneum, investigations and ongoing management.