A case of small bowel mesenteric pneumatosis: A multidisciplinary approach to clinical interpretation and intervention

INTRODUCTION: Pneumatosis of the small bowel mesentery is rare and the preserve of case reports. This case report describes the importance of a multi-disciplinary team (MDT) approach to rare pathologies. CASE REPORT: A 78-year-old man presented to our unit with a two-day history of upper abdominal pain associated with nausea and intermittent vomiting. An urgent computed tomography (CT) scan was organised. The scan was grossly abnormal and difficult to interpret; it was reported as widespread intra-mural gas within the small bowel wall most likely secondary to extensive small bowel ischaemia. Although surgical intervention was very high risk (predicted P-possum mortality of over 60%) and there was a strong possibility that the patient would not recover from surgery, the disparity between clinical and radiological findings meant that a diagnostic laparoscopy was indicated. A diagnostic laparoscopy showed that the small bowel itself was normal but there was extensive gas within the mesentery, caused by a band adhesion which had eroded into the peritoneal layer of the small bowel mesentery. DISCUSSION: Pneumatosis of the small bowel mesentery is a pathological sign rather than a diagnosis and is characterised by gas within the mesenteric sleeves. It is likely associated with significant morbidity and therefore rarely observed as the majority with this sign would not be deemed suitable for surgical intervention. CONCLUSION: The case highlights an unusual pathology, rare imaging findings, the importance of a multi-disciplinary approach and the value of clear communication and informed consent when considering major intervention or surgery.