S3927 Return of the Gas Pockets: A Rare Case of Recurrent Colonic Pneumatosis

Introduction: Pneumatosis coli, gas accumulation within the colon wall, is frequently associated with IBD, infectious etiologies, ischemia, autoimmune disorders and immunodeficiency disorders. However, recurrent colonic pneumatosis is uncommon, especially when compared to the small bowel, and is actually protective against recurrence. We present a case of a 57-year-old woman with recurrent pneumatosis intestinalis with an unclear cause. Case Description/Methods: A 57-year-old woman with a history of multiple intra-abdominal presents with abdominal pain, non-bloody diarrhea and unintentional weight loss for 3 weeks. Her past surgical history was significant for 3 abdominal surgeries including lysis of adhesion, right hemicolectomy for diverticulitis, and hysterectomy, prior small bowel obstruction. Computed tomography of the abdomen and pelvis (CT A/P) with intravenous contrast 2 weeks prior revealed pneumatosis intestinalis, small pneumoperitoneum and a left perinephric abscess. Prior to arrival, she reported a recent colonoscopy which had revealed focally active colitis without chronicity. As she didn't show any signs of sepsis or intestinal ischemia, she was managed conservatively and received repeat CT A/P which revealed persistent pneumatosis coli, no anastomotic leak, and repeat colonoscopy was normal CT angiography (CTA) that didn’t show any sign of arterial occlusion or ischemia. Abdominal duplex ultrasound showed patent hepatic vasculature without any thrombus. Stool pathogen panel was negative. Her immunodeficiency workup revealed low levels of immunoglobulins IgG and IgM, possibly suggestive of an immunodeficiency such as CVID. HIV testing was also negative. Discussion: Recurrent colonic pneumatosis is rare, and when it does occur typically is in the context of chronic, non ischemic etiologies such as cystoides intestinalis. Pneumatosis is found secondary to mucosal disruption, however mucosal erosions that are from subclinical enteritis may allow for intraluminal gas in the bowel layers, especially in a patient with post surgical anatomy. Fulminant pneumatosis intestinalis is crucial to differentiate from transient pneumatosis, and should prompt investigation into the underlying etiology including CVID.