A 34-year-old male patient with confirmed botulism (serotype B, detection in stool sample), on mechanical ventilation for 7 days suffered from severe paralytic ileus despite early treatment with trivalent antitoxin. Under pro-kinetic therapy, acute abdominal guarding developed. Computed tomography (CT) scan showed dilated intestinal loops and a widespread pneumatosis intestinalis with intramural gas in multiple small bowel loops as well as extensive portal gas, especially in the left lobe of the liver (Fig. 1). Explorative laparotomy ruled out intestinal perforation or ischemia. After 7 days of conservative treatment with abdomen apertum, a CT scan confirmed full recovery and surgical closure of the abdomen could be performed. Pathogenesis of pneumatosis intestinalis remains unclear. As previously described for Clostridium perfringens, bacterial invasion of the intestinal wall may have been followed by intramural gas production. An alternative pathogenetic theory postulates intraluminal gas production and subsequent pressure increase as a cause of gas penetration into the intestinal wall. Both pathogenetic mechanisms may be facilitated by locally disturbed integrity of the gut wall on a microscopic level.

Fig. 1
figure 1

Abdominal CT scan showing intramural gas in the small intestine and portal gas

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While 70% of botulism patients suffer from constipation due to disturbed postganglionic transmission, this case highlights the importance of the often underrated gastrointestinal complications of the disease.