The Chemotherapy Trap: Catastrophic Imaging and Benign Reality of Pneumatosis Intestinalis Following Neoadjuvant Treatment

A 69-year-old female with adenocarcinoma underwent a Whipple procedure following neoadjuvant FOLFIRINOX chemotherapy. Five days post-operatively, she presented with mild abdominal pain and elevated inflammatory markers. A contrast-enhanced computed tomography (CT) scan revealed pneumatosis intestinalis (PI) of the ileum with associated gas in the superior mesenteric vein (SMV).

Given the early post-operative setting, the primary imaging differential diagnosis included acute bowel ischemia. These catastrophic imaging findings prompted an emergent exploratory laparotomy. However, surgery revealed an entirely viable, non-ischemic bowel with no perforation.

While the exact etiology remains uncertain, we hypothesize this benign presentation may be secondary to anti-cancerous treatment. Cytotoxic regimens can cause mucosal barrier injury, potentially allowing intraluminal gas to dissect into the mesenteric venous system.

Teaching points: PI and SMV gas are not uniformly ischemic. A systematic review of anticancer treatment-induced PI analyzed 88 cases, finding that while 11 were fatal, symptoms were usually mild or even absent in the remaining cases. Although a single case cannot establish a general rule, this highlights the radiologist`s critical role in correlating alarming imaging features with medication history to broaden the differential and potentially avoid unnecessary laparotomies.