Case of the Week: June 14-June 21, 2012

3 year old with recurrent neuroblastoma.Asymptomatic on chemotherapy. Findings and possible etiology?

Etiology- Iatrogenic

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Case Details

CT demonstrates an absent left kidney, absent adrenal gland, pneumatosis of the bowel and free intraperitoneal air.


Diagnosis: Pnematosis and free air secondary to Avastin

Pneumatosis occurs in primary and secondary form.

      Primary form occurs in 15% of patients and has no known cause or treatment, so is a diagnosis of exclusion.

Secondary pneumatosis occurs in children due to multiple causes including:   

Necrotizing Enterocolitis

Caustic ingestion

Mesenteric ischemia   

Obstruction of the GI tract: pyloric stenosis, Hirshsprung’s disease, neoplasia.    

Pulmonary emphysema: emphysema dissects into the retroperitoneum and into the serosa and subserosa.

     Immunosuppression: leukemia, AIDS, Transplants.     Drug effects: multiple drugs can cause this including steroids and chemotherapy such as 5FU, etoposide, cefotaximab and bevacizumab (Avastin) as in this case. 

    Differential includes stool on plain radiograph.

Stool, though is dependent, whereas, pneumatosis will persist within the wall regardless of position.

CT is beneficial primarily for evaluation of secondary findings to help in diagnosis such as vascular compromise, bowel thickening, ascites, portomesenteric gas.

     Treatment is of the primary cause and possible repair of intestine if perforation.

Pathological Classification of Pneumatosis intestinalis

Bowel Necrosis

Mucosal Disruption

Increased Mucosal Permeability

Pulmonary Disease


Pyloric obstruction


§  Graft versus host disease

§  Organ transplantation

§  Bone marrow transplantation


Ischemia and infarction

Bowel obstruction

AIDS enterocolitides

Chronic pulmonary disease 

Neutropenic colitis

Blunt abdominal trauma

Steroid therapy

Cystic fibrosis


Trauma of child abuse


Chest trauma

Emphysematous gastritis

Hirschsprung disease

Collagen vascular disease

Caustic ingestion

Crohn’s disease

Ulcerative colitis

Correct answers by users

VCU Resident
Radiology Pediatrics
  • Susan Back
  • Joseph Eason
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  • Bradford Moore
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  • Aaron NordgrenUnited States of America
    VCU Department of Pediatric Radiology Virginia Commonwealth University VCU Medical Center