ONLINE CASE REPORT

Ann R Coll Surg Engl 2020; 102: e145–e147

doi 10.1308/rcsann.2020.0145

Extensive pneumatosis intestinalis and portal

venous gas mimicking mesenteric ischaemia
in a patient with SARS-CoV-2
J Kielty1, WP Duggan2, M O’Dwyer1

1
Department of Anaesthesiology and Critical Care, St Vincent’s University Hospital, Dublin, Ireland
2
Department of Surgery, St Vincent’s University Hospital, Dublin, Ireland
ABSTRACT
We present the case of a critically ill 47-year-old man diagnosed with SARS-CoV-2 (COVID-19) who developed extensive
pneumatosis intestinalis and portal venous gas in conjunction with an acute abdomen during the recovery phase of his acute
lung injury. A non-surgical conservative approach was taken as the definitive surgical procedure; a complete small-bowel
resection was deemed to be associated with an unacceptably high long-term morbidity. However, repeat computed tomography
four days later showed complete resolution of the original computed tomography findings. Pneumatosis intestinalis from
non-ischaemic origins has been described in association with norovirus and cytomegalovirus. To our knowledge, this is the
first time that this has been described in COVID-19.

KEYWORDS
COVID-19 – SARS-CoV-2 – Mesenteric ischaemia – Pneumatosis intestinalis
Accepted 2 June 2020
CORRESPONDENCE TO
Jennifer Kielty, E: jenkielty1@gmail.com

Background To facilitate ventilation over the initial 48 hours, paralysis

This case highlights an unusual association between active
SARS-CoV-2 infection and a computed tomography (CT)
appearance that mimics extensive mesenteric ischaemia.
Case history
A 47-year-old man presented to the emergency department
with a one-week history of fever, dry cough and vomiting.
His past medical history was unremarkable except for
anxiety, treated with fluoxetine, and obstructive sleep
apnoea for which he was on nocturnal continuous positive
airway pressure (CPAP). His body mass index (BMI) was
slightly elevated at 31.
At presentation, he was hypoxic with an arterial oxygen
tension (PaO2) of 75mmHg on 40% oxygen via a face mask.
Chest x-ray showed bilateral patchy opacities (Fig 1). The
patient received augmentin and clarithromycin as treatment
for a community-acquired pneumonia and was placed in
isolation on the ward. Subsequently, a nasopharyngeal swab
for SARS-CoV-2 returned positive. The patient deteriorated
on day two of his hospital admission with increasing
inspired oxygen requirements and required admission to
intensive care for mechanical ventilation.
was induced with an atracurium infusion and nebulised
prostacyclin was used to minimise hypoxic pulmonary
vasoconstriction. A modest negative fluid balance was
achieved with the aid of frusemide and acetazolamide.
There was no haemodynamic compromise and no vasopressor
requirement throughout the intensive care stay. Enteral
feeding was established on day 2 of this period and his
bowel motions were normal. His respiratory function
improved gradually and by day 8 he had largely weaned
from the ventilator and required 30% oxygen to maintain
saturations above 92%.
However, on day 8 of intensive care, a distended yet soft
abdomen was noted with associated diarrhoea. His lactate
remained below 2mmol/l and he did not require vasopressor
support, although he did develop a sinus tachycardia. He
became intolerant of his enteral feed and feculent-like
material was aspirated from the nasogastric tube. A
contrast-enhanced CT of the abdomen revealed diffuse
small-bowel distension with widespread pneumatosis,
circumferential mural thickening, free fluid, mesenteric free
air and portal venous gas (Fig 2). There was pneumatosis
affecting the jejunum, proximal ileum and caecum with
skipped normal segments of distal small bowel. Normal
blood flow was visualised through the origin of the

Ann R Coll Surg Engl 2020; 102: e145–e147 e145

KIELTY DUGGAN O’DWYER EXTENSIVE PNEUMATOSIS INTESTINALIS AND PORTAL VENOUS
GAS MIMICKING MESENTERIC ISCHAEMIA IN A PATIENT WITH
SARS-COV-2

superior mesenteric artery. CT of the thorax showed

bilateral ground glass changes in keeping with his
diagnosis of SARS-CoV-2 (Fig 3).
A surgical opinion was sought. The initial opinion was
that the CT was highly suspicious of extensive mesenteric
ischaemia. A decision was made not to proceed to
laparotomy because the definitive surgical procedure, if the
CT appearance was truly indicative of extensive mesenteric
ischaemia, would be a complete small bowel resection,
which would be associated with a very poor outcome.

Figure 1 Chest x-ray showing bilateral pulmonary infiltrates

Figure 3 Computed tomography of the thorax showing bilateral

ground glass changes

Figure 2 Coronal computed tomography image showing Figure 4 Coronal computed tomography of the abdomen
extensive pneumatosis intestinalis, bowel wall thickening, showing complete resolution of the pneumatosis intestinalis
mesenteric free air and portal venous gas and the portal venous gas

e146 Ann R Coll Surg Engl 2020; 102: e145–e147

KIELTY DUGGAN O’DWYER
The patient was commenced on an infusion of
unfractionated heparin with a targeted activated partial
thromboplastin time ratio of 2.0–2.5 and crystalloid fluid
boluses were administered. A dobutamine infusion was
commenced at 5μg/kg/minute for 12 hours and nasogastric
feeding was stopped.
The patient remained haemodynamically stable. His lactate
levels never increased above 2mmol/l and vasopressor
support was never required. His abdomen remained soft
but distended. A repeat CT was performed 4 days later, on
day 12 of his intensive care stay. This showed complete
interval resolution of pneumatosis intestinalis (Fig 4). Enteral
feeding recommenced uneventfully. He was successfully
extubated the following day and was discharged to the
ward 48 hours later, and subsequently to home.
Discussion
SARS-CoV-2 is known to be present within the bowel and
gastrointestinal upset is a common presenting feature in
these patients.1 Direct mucosal damage as opposed to
mesenteric ischaemia is likely to have led to the CT
findings we describe here. This is supported by the normal
levels of lactate, haemodynamic stability and presence of
normal blood flow through the superior mesenteric artery.
Furthermore, the original SARS virus was described as
causing degenerative changes in the lymphoid component
EXTENSIVE PNEUMATOSIS INTESTINALIS AND PORTAL VENOUS
GAS MIMICKING MESENTERIC ISCHAEMIA IN A PATIENT WITH
SARS-COV-2
of the intestine, and lymphoid follicles showed a marked
decrease in lymphocytes. In severe cases only the depleted
stromal framework structure remained.2 Pneumatosis
intestinalis has also been described in association with
other viruses, including norovirus and cytomegalovirus,3,4
and the mechanism is purported to be mucosal disruption.
We propose that atrophy of the lymphoid follicles,
caused by SARS-CoV-2, resulted in increased mucosal
permeability permitting dissection of the gas into the bowel
wall.5 To our knowledge, this is the first time that this
condition has been described in COVID-19. We suggest
that a conservative approach can be considered when
these findings occur in the absence of signs of systemic
deterioration and that a good outcome is possible.
References
1. Xiao F, Tang M, Zheng X et al. Evidence for gastrointestinal infection of
SARS-CoV-2. Gastroenterology 2020 Mar 3. [Epub ahead of print.]
2. Gu J, Gong E, Zhang B et al. Multiple organ infection and the pathogenesis of
SARS. J Exp Med 2005; 202: 415–424.
3. Kim MJ, Kim YJ, Lee JH et al. Norovirus: a possible cause of pneumatosis
intestinalis. J Pediatr Gastroenterol Nutr 2011; 52: 314–318.
4. Balasuriya HD, Abeysinghe J, Cocco N. Portal venous gas and pneumatosis coli
in severe cytomegalovirus colitis. A N Z J Surg 2018; 88: 113–114.
5. Devgun P, Hassan H. Pneumatosis cystoides intestinalis: a rare benign cause
of pneumoperitoneum. Case Rep Radiol 2013; 2013: 353245.
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