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Conservative management of pneumatosis intestinalis after allogeneic hematopoietic SCT

Bone Marrow Transplantation volume 49, pages 1436–1438 (2014)Cite this article

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Pneumatosis intestinalis (PI) is characterized by the accumulation of gas in the intestinal wall. It is not considered to be a disease itself, but rather a pathologic and radiographic finding. PI is associated with various disorders including chronic obstructive pulmonary disease, autoimmune disorders and solid organ transplantation.1,2 The radiographic imaging is diagnostic, showing air-filled bullae along the intestinal border and occasionally a pneumoperitoneum.3 PI has been observed and reported after allogeneic hematopoietic SCT (alloHSCT).3, 4, 5, 6, 7 The occurrence of PI in this setting is thought to be associated with chemotherapy, acute GVHD (aGVHD), immunosuppression and infections. As symptoms of PI may mimic gastrointestinal aGVHD (GI-aGVHD), PI is frequently diagnosed incidentally during imaging performed to evaluate GI-aGVHD. We describe a series of 16 patients presenting with PI after alloHSCT. The majority of our patients had GI-aGVHD treated with prednisone and non-absorbable oral steroids beclomethasone dipropionate (BDP) and budesonide (BUD). We discuss the possible role of systemic steroids, as well as BUD, in the development of PI.

We retrospectively searched our radiology database for the images obtained by performing computerized tomography (CT) on patients who underwent alloHSCT from January 2005 to September 2013. Search terms included ‘pneumatosis’, ‘pneumatosis intestinalis’ and ‘pneumatosis cystoides intestinalis’. An extensive chart review was performed on identified cases for the information on age, gender, diagnosis, conditioning chemotherapy, type of transplant, stem cell source, aGVHD, immunosuppression, CMV status and Clostridium difficile infection. In addition, the onset, management and outcome of PI were recorded. Approval for the study was obtained from our Institutional Review Board. During that time period, 1288 patients underwent alloHSCT at our institution. Sixteen patients were diagnosed with PI at a median of 108 days after alloHSCT (range, 25–578). Three cases of PI were identified between 2005 and 2010 (for 900 alloHSCT performed) and 13 cases between 2010 and 2013 (for 388 alloHSCT performed). This represents a statistically significant increase in the incidence of PI using Fisher’s exact test (P<0.0001). All patients had aGVHD at the time of PI diagnosis: 15 patients had GI +/− skin aGVHD and 1 patient had liver-only aGVHD. Two of the patients who developed PI late after alloHSCT have received donor lymphocyte infusion 2 months prior to PI development and two additional patients had a biopsy-proven GI-aGVHD. Fifteen patients were receiving systemic steroids at the time of PI diagnosis and 11 were also on BUD +/− BDP. Nobody had active C. difficile or CMV colitis. Twelve patients had evidence of intraperitoneal or extraluminal free air, however, without clinically evident peritonitis. All patients were managed conservatively with bowel rest, total parenteral nutrition, antibiotics, temporary discontinuation of BUD/BDP and the reduction of prednisone dose. On repeated imaging, 11 patients had resolution of PI, 2 had significant improvement and 3 had no repeated imaging. Ten patients have died at the median of 72 days (range, 7–798) after PI diagnosis: six had documented resolution of PI, two had documented improvement and two had no repeated imaging prior to death. Patients and transplant characteristics are shown in Tables 1 and 2.

Table 1 Patient and transplant characteristics
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Table 2 PI onset and outcome
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Authors and Affiliations

  1. Division of Hospital Medicine, Department of Internal Medicine, Washington University School of Medicine, St Louis, MO, USA

    P K Bhamidipati

  2. Division of Oncology, Department of Internal Medicine, Washington University School of Medicine, St Louis, MO, USA

    A Ghobadi, S Bauer, J F DiPersio & I Pusic

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  1. P K Bhamidipati
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Bhamidipati, P., Ghobadi, A., Bauer, S. et al. Conservative management of pneumatosis intestinalis after allogeneic hematopoietic SCT. Bone Marrow Transplant 49, 1436–1438 (2014). https://doi.org/10.1038/bmt.2014.148

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