BACKGROUND: Pnuematosis intestinalis (PI), characterized by gas in the bowel wall, is a rare pathologic finding in pediatric liver transplantation (PLT) recipients. PI has been shown to be associated with steroid and immunosuppressive medication and can range from clinically benign to acute and life threatening. Taking into consideration the clinical signs and symptoms of PI, along with radiographic workup and laboratory findings, we present the results of conservative management of PI in a sample of PLT patients.

METHODS: Retrospective medical chart review was conducted on PLT recipients between November 1995 and May 2016. Imaging findings for patients with PI were reviewed by a pediatric radiologist and classified into one of five categories based on the location of pneumatosis and the presence of free air or portal venous gas. Other parameters evaluated at the time of diagnosis included: presenting symptoms, laboratory findings, and transplant-related factors (immunosuppressants, steroids).

RESULTS: PI developed in 10 of 130 PLT patients (7.7%) between 8 days and 7 years (median: 113 days) post-transplant. Five were male, and the median age was 2 years (range, 1-17). PI was located in 1-2 abdominal quadrants in the majority of patients (n=6), and 2 patients had portal venous gas. At the time of diagnosis, all patients were on steroids and immunosuppressant medication (tacrolimus, 9; mycophenolate mofetil, 8; sirolimus, 1). Laboratory findings were unremarkable. Symptoms were present in 7 patients, and included diarrhea (n=6), emesis (n=2), fever (n=2), abdominal pain (n=1), and blood in stool (n=1). Nine patients were managed conservatively with bowel rest (median: 6 days; range, 2-25), total parenteral nutrition (median: 8 days; range, 5-22), and broad-spectrum antibiotics (median: 14 days; range, 3-19), and one patient was monitored clinically after a bowel clean out for severe constipation. All patients had resolution of PI at a median of 7 days (range, 2-14).

CONCLUSION: PI can occur at any time after PLT and appears to be associated with steroid use. Accurate interpretation of radiographic imaging and initiation of a standard management algorithm may help treat PLT with PI conservatively, thus avoiding a surgical intervention.

CITATION INFORMATION: Hendrickson R, Ryan J, Dandridge L, Andrews W, Daniel J, Fischer R, Rivard D. Conservative Management of Pneumatosis Intestinalis After Pediatric Liver Transplantation. Am J Transplant. 2017;17 (suppl 3).

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