Secondary Logo

Journal Logo

Image of the Month

Pnematosis Intestinalis and Portal Venous Gas in Pediatric Liver Transplant Recipient

Varma, Sharat*; Dumitriu, Dana; Stephenne, Xavier*; Smets, Françoise*; Clapuyt, Philippe; Sokal, Etienne*

Author Information
Journal of Pediatric Gastroenterology and Nutrition: February 2016 - Volume 62 - Issue 2 - p e14
doi: 10.1097/MPG.0000000000000388
  • Free

A 6-year-old girl received a liver transplant from a living donor for cirrhosis attributable to biliary atresia. The initial posttransplant course was uneventful. As per protocol, Doppler ultrasound of the liver was done each day for the first week posttransplant. On day 6 the ultrasound image showed evidence of massive portal venous gas and pneumatosis intestinalis, although the child was asymptomatic (Fig. 1A and B).

Abdominal ultrasound, transverse scan of the epigastric region displaying the transplanted liver. A, Air bubbles are present in the portal vein (arrow), its branches, and diffusely throughout the liver parenchyma. B, Pulsed Doppler waveform of the portal flow demonstrates multiple typical superimposed spikes (arrowheads) caused by the air bubbles.

Consequently, oral feeding was stopped; parenteral nutrition and intravenous antibiotics were started. The patient continued to remain asymptomatic, and the biochemical parameters remained on similar pattern as before. The Doppler ultrasound performed 24 hours later showed complete resolution of these findings (Fig. 2).

Abdominal ultrasound, transverse scan of the left flank: pneumatosis intestinalis in the wall of the left colon (arrows); (*= air in the bowel lumen).

Enteral nutrition was restarted after 5 days, and the course was uneventful. Control ultrasounds done later were normal, and the biochemical patterns continued to show an improving trend.

Post–liver transplant pneumatosis intestinalis in the pediatric population is rare, associated with severe symptoms, and directly attributable to steroids in the immune suppression regime or underlying Epstein–Barr virus infection (1–3). Our patient remained asymptomatic, was on steroid-free immune suppression, with no rejection, and had a benign course, thereby having a unique presentation and progress.


1. Koep LJ, Peters TG, Starzl TE. Major colonic complications of hepatic transplantation. Dis Colon Rectum 1979; 22:218–220.
2. King S, Shuckett B. Sonographic diagnosis of portal venous gas in two pediatric liver transplant patients with benign pneumatosis intestinalis. Pediatr Radiol 1992; 22:577–578.
3. Wallot MA, Klepper J, Clapuyt P, et al. Repeated detection of gas in the portal vein after liver transplantation: a sign of EBV-associated post-transplant lymphoproliferation? Pediatr Transplant 2002; 6:332–336.
© 2016 by European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and North American Society for Pediatric Gastroenterology,