Pneumatosis intestinalis and portal venous gas mimicking intestinal necrosis in organophosphate poisoning

INTRODUCTION: Organophosphate poisoning typically induces gastrointestinal hypermotility. Pneumatosis intestinalis and portal venous gas are rare, ominous signs often associated with intestinal necrosis. CASE SUMMARY: A 46-year-old woman ingested fenitrothion and malathion. Despite receiving a minimal cumulative dose of atropine (4.5 mg), she developed abdominal distension on day five. An emergency exploratory laparotomy revealed severe, diffuse intestinal edema without necrosis or perforation. The patient recovered with conservative decompression. IMAGES: Abdominal computed tomography performed on day five demonstrated severe small intestinal dilatation accompanied by pneumatosis intestinalis and gas within the portal vein branches. CONCLUSION: These radiological findings can result from direct chemical injury to the gut mucosa and dysbiosis, mimicking irreversible necrosis. In the absence of frank infarction, such cases may be successfully managed conservatively, independent of atropine toxicity.