INTRODUCTION:Pneumatosis intestinalis (PI) is the presence of gas within the wall of the small or large intestine. While the pathogenesis is poorly understood, the etiology is often secondary to ischemia, obstruction, or on occasion, an endoscopic procedure.CASE PRESENTATION: 50-year-old male with past medical history of chronic kidney disease stage 4 and uncontrolled insulindependent type 2 diabetes presented with decreased urine output, shortness of breath and abdominal distention of 3 days. On initial exam, the abdomen was firm as well as diffusely tender to palpation. He was alert and oriented with no focal deficits noted. Initial CT abdomen revealed a considerable volume of stool within the colon. Hepatic and abdominal vasculature were unremarkable. One lactulose enema was given without initial complication at 1155 AM. At 1345 the patient was documented to be slightly lethargic and weak by physical therapy. At 1435 the patient was found to be unresponsive to verbal or tactile stimuli and developed emesis. Physical exam revealed tachypnea, sluggish pupillary response bilaterally, and rigid abdomen. Stat CT head revealed gas within multiple left cerebral veins. Repeat CT abdomen showed interval colonic pneumatosis intestinalis and intrahepatic portal venous gas suspected by radiology to be related to recent enema. Emergent intubation was performed for stabilization. Transfer to a center capable of providing hyperbaric oxygen therapy to a ventilated patient was initiated. Unfortunately, due to lack of resources and considerable distance to a capable facility, ground transport was not an option. To further complicate the picture, air transport was delayed by several hours due to severe weather. Following the patient's arrival at the outside facility, the family elected for comfort measures and the patient subsequently expired shortly thereafter.DISCUSSION: One proposed mechanism of PI is termed the mechanical theory. Gas dissects into the wall of the intestines at a point of disrupted mucosal integrity. This has been reproduced by insufflating an excised colonic segment in one study [1]. Enema has been shown to cause massive portal venous gas [2] while retrograde venous air embolism has been demonstrated [3], most often following central line removal. In this case, air emboli traveled through portal venous circulation, then retrograde after the level of the heart to the cerebral vessels. To our knowledge this is the only documented case in which enema has resulted in stroke.CONCLUSIONS: Pneumatosis intestinalis is an exceedingly rare complication of enema. Being aware of this possibility can provide early recognition and intervention, leading to better outcomes for future patients.