Pneumatosis cystoides intestinalis in intestinal pseudoobstruction. Resolution after therapy with metronidazole

Understanding the Nuances of Hepatic Portal Venous Gas in Pneumatosis Intestinalis: An Indication of Bowel Ischemia?

Pneumatosis intestinalis (PI) is a relatively rare gastrointestinal finding that has a wide variety of causes - ranging from benign to life-threatening. It is described as the pathological presence of gas within the bowel wall with multiple hypotheses emerging as to the likely mechanism. An important indicator of a life-threatening source of PI is the presence of gas within the hepatic portal vein, referred to as hepatic portal venous gas (HPVG). While non-specific for isolated PI, HPVG has been reported in PI patients to be associated with bowel ischemia and is thereby considered an indication for emergent management. Herein we report a case involving an atypical presentation of altered mental status in which the patient was found to have PI with contemporaneous HPVG. These findings have been reported to have a high mortality rate. Our patient rapidly deteriorated during their hospital course, expiring shortly after being deemed a poor surgical candidate due to their severe co-morbidity burden. Through this case, we review evidence supporting the management of patients with PI and concurrent HPVG from an extensive review of available literature. While PI is a non-specific finding and commonly a source of diagnostic confusion, a better understanding of its natural course and potentially unorthodox sequela may afford more directed and crucial care for critically ill patients, in which time is often a precious commodity.

A rare case of benign pneumatosis intestinalis in Sjogren's syndrome

Pneumatosis intestinalis (PI)-the presence of intramural bowel gas-is an uncommon radiological finding, the severity of which depends on the underlying pathological process, ranging from benign disease to life-threatening ischaemia and intra-abdominal sepsis. PI has been described in systemic sclerosis and mixed connective tissue disease; however, few cases have been reported in Sjogren's syndrome (SjS). The exact pathogenesis of PI in systemic connective tissue disorders is not fully understood and likely multifactorial. We have described a unique case of PI without evidence of peritonitis in a stable patient with long-standing SjS managed non-operatively. An awareness of such benign PI, particularly amongst patients with systemic connective tissue disease, is crucial for diagnostic accuracy and safe patient care, particularly in preventing unnecessary surgical intervention.

Pneumatosis Intestinalis Induced by Anticancer Treatment: A Systematic Review

Simple Summary

Anticancer treatments commonly cause adverse events (AE). Among others, pneumatosis intestinalis (PI) is reported to be infrequent, though it can lead to severe consequences. The aim of our systematic review was to investigate the concurrency of PI and oncological therapy exposure; moreover, we defined the characteristics of patients and the primarily involved tumor types. We analyzed 88 different episodes of PI. The median time of onset was 6 weeks and oncological patients with respiratory system cancers and those treated with targeted therapies appeared be at higher risk. Symptoms were frequently mild to absent; nevertheless, life-threatening complications were reported. Therefore, this AE, although uncommon, should be considered in the case of specific symptoms. Potential pharmacological mechanisms of anticancer drugs in inducing PI are also discussed.

Abstract

Pneumatosis intestinalis (PI) is a rare condition due to the presence of gas within the bowel wall; it is mainly caused by endoscopic procedures, infections and other gastrointestinal diseases. Oncological therapies have been reported to be a cause of PI as well, but their role is not clearly defined. This systematic review investigates the concurrency of PI and antitumor therapy in cancer patients, considering both solid tumors and onco-hematological ones. We performed a literature review of PubMed, Embase and the Web of Science up to September 2021 according to the PRISMA guidelines. A total of 62 papers reporting 88 different episodes were included. PI was mainly reported with targeted therapies (sunitinib and bevacizumab above all) within the first 12 weeks of treatment. This adverse event mostly occurred in the metastatic setting, but in 10 cases, it also occurred also in the neoadjuvant and adjuvant setting. PI was mostly localized in the large intestine, being fatal in 11 cases, while in the remaining cases, symptoms were usually mild, or even absent. A significant risk of PI reoccurrence after drug reintroduction was also reported (6/18 patients), with no fatal outcomes. Potential pharmacological mechanisms underlying PI pathogenesis are also discussed. In conclusion, although uncommonly, PI can occur during oncological therapies and may lead to life-threatening complications; therefore, consideration of its occurrence among other adverse events is warranted in the presence of clinical suspicion.

Pneumatosis Intestinalis in a Patient With Asthma: A Case Report

Pneumatosis intestinalis (PI) is a rare condition marked by gas-filled cysts in the submucosa and subserosa of the intestine. It can be idiopathic or linked to several illnesses, including gastrointestinal, pulmonary, collagen vascular disease, organ transplantation, and immunodeficiency. Herein we present a relatively rare case of PI in a 74-year-old man with a childhood history of asthma, which was found during routine colonoscopy.

Clostridium difficile Infection Leading to Intestinal Pneumatosis in a Patient with a Recent Diagnosis of Pancreatic Cancer Local Recurrence: A Case Report and Literature Review

Clostridium difficile infection (CDI) causing pneumatosis intestinalis (PI) is a rare event, described mostly in immunocompromised patients. We present the case of a 65-year-old female diagnosed with adenocarcinoma of the pancreas who underwent a duodenopancreatectomy with lymphadenectomy and adjuvant gemcitabine and capecitabine. Four months after the end of chemotherapy, she experienced abdominal pain and intermittent diarrhea which became aggravated within 6 months. CT scans revealed diffuse intestinal pneumatosis and recurrence of ductal adenocarcinoma. We hypothesize that local pancreatic cancer recurrence may lead to gastrointestinal dysmotility with consequent increased risk for CDI. The patient had almost complete resolution of PI during the CDI treatment, thus we believe that the CDI was directly responsible for PI in this case.

Pneumatosis cystoides intestinalis, a rare case in a pediatric patient following allogeneic hematopoietic stem cell transplantation: CT findings and literature review

Pneumatosis cystoides intestinalis (PCI) is a rare condition characterized by the presence of gas-filled cysts in the subserosa or submucosa of the bowel wall. It is associated with various disorders including chronic obstructive pulmonary diseases, autoimmune disorders, and organ transplantation. PCI has also been observed following Hematopoietic Stem Cell Transplantation (HSCT), associated with chemotherapy, acute Graft versus Host Disease (GvHD), immunosuppression, and infections. Computed tomography (CT) provides an easy diagnosis because it highlights the presence of air bubbles in the intestinal wall and possible pneumoperitoneum. We report the case of a patient with severe acquired medullary aplasia undergoing allogeneic HSCT with subsequent development of cutaneous GvHD and an incidental finding of PCI during a CT scan of the chest in absence of gastrointestinal symptoms. Our work aims at clarifying a possible complication in pediatric patients undergoing HSCT to guide young or non-pediatric radiologists in the identification of this rare condition, helping the clinician in the correct conservative management of these patients and reserving the surgical treatment only to specific complications.

Pneumatosis cystoides intestinalis accompanied by intestinal spirochetosis

Pneumatosis cystoides intestinalis (PCI) is a rare but well-recognized entity characterized by multiple gas-filled cysts in the intestinal wall. Although the pathogenesis of PCI remains unclear, several theories, including a bacterial theory, have been postulated. Intestinal spirochetosis (IS) is an uncommon condition defined by the presence of spirochetes attached to the surface of the colonic epithelium. The nature of IS as a commensal or pathogenic process remains debatable. However, recent evidence supports the idea that IS can be invasive and highly pathogenic in both immunocompromised and immunocompetent individuals. We present the case of a 35-year-old asymptomatic and immunocompetent man who underwent colonoscopy because of a positive fecal blood test. Multiple submucosal cystic lesions were detected accompanied by erythematous areas along the ascending colon. Computed tomography-colonography and biopsy specimens from the erythematous areas confirmed coexisting PCI and IS. Both PCI and IS recovered completely 3 months after administration of metronidazole. To the best of our knowledge, this case represents only the second report of the extremely rare concurrence of PCI with IS. Taking into account the published literature, we also discuss the possibility that the development of PCI may be related to IS.

Idiopathic Pneumatosis of Small Bowel and Bladder

An 81-year-old woman presented with multiple episodes of loose bowel movements. CT scan of the abdomen and pelvis revealed pneumatosis cystoides intestinalis and asymptomatic emphysematous cystitis. The patient had an extensive workup with no obvious identified pathology to explain diffuse pneumatosis of the small bowel and bladder. Her symptoms improved with symptomatic management, empirical antibiotics, and no surgical intervention.

Pneumatosis cystoides intestinalis: case report and review of literature

Pneumatosis intestinalis is the presence of gas in the bowel wall and is divided into two categories: life-threatening pneumatosis intestinalis and benign pneumatosis intestinalis. Pneumatosis cystoides intestinalis is a rare condition characterized by gas-filled cysts in submucosa and subserosa. The pathogenesis is unclear, although some causes have been theorized. The presenting clinical findings may be very heterogeneous. Intestinal pneumatosis may lead to various complications. Distinguishing between pneumatosis cystoides intestinalis and life-threatening pneumatosis intestinalis may be challenging, although computed tomography scan allows the detection of additional findings that may suggest an underlying, potentially worrisome cause of pneumatosis intestinalis. To correctly manage the patients affected with this disease is important to differentiate the two types of pneumatosis. The patients with pneumatosis cystoides intestinalis are usually treated conservatively; the surgical treatment is reserved for complications. We described a case of a patient with pneumatosis cystoides intestinalis and gastric perforation. The medical history of the patient revealed a breast cancer treated with mastectomy and chemotherapy; the patient did not report a history of gastrointestinal disease. The abdomen CT showed abscess formation at the level of the antro-pylorus, linear pneumatosis in the gastric wall, and free abdominal air. Multiple small air bubbles was observed in intestinal wall. The intestinal wall was not thickened with normal contrast mucosal enhancement. CT examination showed neither mesenteric stranding nor portal venous gas embolism. The findings of the surgery were gastric perforated peptic ulcer and benign pneumatosis intestinalis.

Pneumatosis Cystoides Intestinalis - A Review

Pneumatosis cystoides intestinalis is a rare disease characterized by presence of multilocular cysts in the gastrointestinal wall. Idiopatic and secondary forms of the disease can be distinguished. There are presented several theories explaining pneumatogenesis in this article. The specific and non-specific symptoms are described. Attention is drawn to the pneumoperitoneum without signs of peritoneal irritation, what is a typical complication of this disease. The suspition of pneumatosis cystoides intestinalis may be based on plain abdominal X-ray, and is usually confirmed by computer tomography or magnetic resonance imaging. The therapy can be conservative or surgical. In conclusion, although pneumatosis cystoides intestinalis is a rare disease, it may represent a problem in differential diagnosis of abdominal pain.

Pneumatosis cystoides intestinalis: case report and review of literature

Pneumatosis intestinalis is the presence of gas in the bowel wall and is divided into two categories: life-threatening pneumatosis intestinalis and benign pneumatosis intestinalis. Pneumatosis cystoides intestinalis is a rare condition characterized by gas-filled cysts in submucosa and subserosa. The pathogenesis is unclear, although some causes have been theorized. The presenting clinical findings may be very heterogeneous. Intestinal pneumatosis may lead to various complications. Distinguishing between pneumatosis cystoides intestinalis and life-threatening pneumatosis intestinalis may be challenging, although computed tomography scan allows the detection of additional findings that may suggest an underlying, potentially worrisome cause of pneumatosis intestinalis. To correctly manage the patients affected with this disease is important to differentiate the two types of pneumatosis. The patients with pneumatosis cystoides intestinalis are usually treated conservatively; the surgical treatment is reserved for complications. We described a case of a patient with pneumatosis cystoides intestinalis and gastric perforation. The medical history of the patient revealed a breast cancer treated with mastectomy and chemotherapy; the patient did not report a history of gastrointestinal disease. The abdomen CT showed abscess formation at the level of the antro-pylorus, linear pneumatosis in the gastric wall, and free abdominal air. Multiple small air bubbles was observed in intestinal wall. The intestinal wall was not thickened with normal contrast mucosal enhancement. CT examination showed neither mesenteric stranding nor portal venous gas embolism. The findings of the surgery were gastric perforated peptic ulcer and benign pneumatosis intestinalis.

Pneumatosis intestinalis a trap for the unwary: Case series and literature review

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Pneumatosis Intestinalis is a rare condition that may manifest with a wide range of symptoms from mild abdominal pain to acute peritonitis.

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In general, surgery is only indicated in symptomatic patients where medical therapy has failed and in patients presenting acutely unwell with a surgical abdomen.

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Treatment is generally medical and even with radiological evidence of perforation laparotomy may not be indicated if the patient is clinically well.

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Treatment with oxygen or hyperbaric oxygen has been shown to be effective.

Introduction

Pneumatosis Intestinalis (PI) can present with a broad range of presentations from chronic and non-specific to acute and life threatening. It is paradoxically one of the few conditions where a pneumoperitoneum found in the diagnostic workup is not necessarily an indication for laparotomy.

Presentation of cases

The first case is of a 75 year old gentlemen who attended the emergency department after several weeks of worsening abdominal pain and weight loss. At laparotomy, two segments of nodular, abnormal-looking small bowel were identified with bubbles of air seen in the small bowel mesentery.

The second case is of an 86 year old man with of a 5-month history of abdominal pain, weight loss, nausea and diarrhoea. A subsequent endoscopy revealed diffuse gastritis with a small antral gastric ulcer with a small amount of blood. The CT scan demonstrated free air within the bowel wall, with a follow up scan performed 3 weeks later revealing an increase in the amount of free air.

Discussion

PI is a rare condition characterised by the presence of subserosal and submucosal gas filled cysts occurring anywhere in the gastrointestinal tract from the oesophagus to the anus.

Numerous conditions have been associated with PI including bowel obstruction, infections, ischemia and there have been reported cases suggesting as association with Crohn’s disease.

Conclusion

PI is a condition that may manifest with a wide range of symptoms from mild abdominal pain to acute peritonitis. Its treatment is generally medical and even with radiological evidence of perforation laparotomy may not be indicated if the patient is clinically well.

Combination therapy for systemic sclerosis-associated pneumatosis intestinalis

We present a case of a patient with pneumatosis intestinalis and pneumoperitoneum secondary to gastrointestinal systemic sclerosis, who presented following recurrent accident and emergency attendances with abdominal pain. Pneumatosis intestinalis is a rare complication of systemic sclerosis; management approaches focus largely on exclusion of life-threatening surgical pathologies and subsequent symptom control. To date, there are still no established gold-standard treatment strategy and no large-scale trial data to support a specific management strategy. We describe a case of successful medical management with a combination of antimicrobial, elemental diet and high-flow inhalation oxygen therapy, with supporting evidence of CT image confirming resolution. This case therefore contributes to the literature, being the first to report both symptomatic and radiological improvement following combination therapy without the need for surgical intervention.

Combination therapy for systemic sclerosis-associated pneumatosis intestinalis

We present a case of a patient with pneumatosis intestinalis and pneumoperitoneum secondary to gastrointestinal systemic sclerosis, who presented following recurrent accident and emergency attendances with abdominal pain. Pneumatosis intestinalis is a rare complication of systemic sclerosis; management approaches focus largely on exclusion of life-threatening surgical pathologies and subsequent symptom control. To date, there are still no established gold-standard treatment strategy and no large-scale trial data to support a specific management strategy. We describe a case of successful medical management with a combination of antimicrobial, elemental diet and high-flow inhalation oxygen therapy, with supporting evidence of CT image confirming resolution. This case therefore contributes to the literature, being the first to report both symptomatic and radiological improvement following combination therapy without the need for surgical intervention.

Management of pneumatosis intestinalis in children over the age of 6 months: a conservative approach

BACKGROUND

Pneumatosis intestinalis (PI) is an uncommon and poorly understood condition. Although it can be an incidental finding in asymptomatic individuals, it can also be secondary to life-threatening bowel ischaemia and sepsis. In premature infants, it is a pathognomonic sign of necrotising enterocolitis. There is no consensus regarding management and long-term outcome of children with PI.

AIM

Review of our experience of PI in children beyond the early infantile period.

METHODS

Retrospective review of patient's records and radiological images from 2013 to 2015.

RESULTS

Eighteen patients (three girls) had radiologically confirmed PI. The median age was 4.5 years (range 8 months-13 years). Background medical conditions (number): short bowel syndrome (one), congenital heart disease (two), sickle cell disease (one), epilepsy (three), cerebral palsy (six), myotonic dystrophy (four) and peroxisomal biogenesis defect (one).Six children (33%) presented with abdominal distension, four (22%) with abdominal pain, three (17%) with bilious vomiting, two (11%) with diarrhoea and one (6%) with rectal bleeding. Two (11%) were asymptomatic. One had air in portal vein and two had pneumoperitoneum.All patients with symptomatic PI were treated conservatively with successful outcome and complete resolution of PI. None required surgical intervention.

CONCLUSION

PI in children who are not on chemotherapy or immunosuppressant appears to follow a benign course and is responsive to conservative management. In contrast to adults, portal venous gas and pneumoperitoneum do not predict the need for surgical intervention.

Successful treatment of pneumatosis intestinalis with associated pneumoperitoneum and ileus with hyperbaric oxygen therapy

Pneumatosis intestinalis (PI), or the presence of air in the bowel wall, is a rare disorder that is associated with a variety of underlying diseases, including connective tissue disorders. PI presents on a spectrum from asymptomatic to bowel obstruction and acute abdomen. In general, treatment of PI consists of treating the underlying disease. Both normobaric and hyperbaric oxygen have been used to treat PI directly. Here we report a symptomatic scleroderma-related case of PI that responded clinically to hyperbaric oxygen therapy. This report adds to a growing body of literature supporting a role for hyperbaric oxygen therapy in symptomatic PI.

Pneumatosis intestinalis an increasingly common radiological finding, benign or life-threatening? A case series

This case series reviews two cases where elderly patients were found to have pneumatosis intestinalis on imaging. The two clinical presentations differed from one another, however, both were managed conservatively to good effect. In case one the patient presented with abdominal pain, a change in bowel habit and weight loss. In case two the patient presented with problematic diarrhoea, reduced oral intake, lethargy and weight loss. Both patients were haemodynamically stable and neither had an abnormal abdominal examination. Case 2 was started on oral metronidazole and by day 11 of treatment there was resolution of the pneumatosis on her abdominal X-ray and her diarrhoea had settled. These two cases illustrate the benefit of conservative management and avoidance of unnecessary surgical intervention in primary pneumatosis intestinalis. However, it is important to distinguish between these benign causes of pneumatosis intestinalis and those which are life-threatening in which surgery may be necessary.

[Intestinal cystic pneumatosis secondary to a peptic ulcer: report of three cases]

La pneumatose kystique intestinale (PNK) est une pathologie rare qui se caractérise par la présence de kystes gazeux dans la paroi intestinale. Elle est asymptomatique ou pauci symptomatique, et le plus souvent découverte lors d'un examen d'imagerie ou d'endoscopie. Nous rapportons une série de trois cas de pneumatose kystique secondaire à un ulcère peptique. A travers ce travail nous essayons de mettre la lumière sur les différents aspects cliniques, radiologiques et thérapeutiques de cette pathologie.

An approach to pneumatosis intestinalis: Factors affecting your management

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Surgical intervention is necessary in patients that are unstable or in the presence of probable bowel wall compromise.

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Medical management of PI includes antibiotics, elemental diet and oxygen therapy.

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We propose a management algorithm for the treatment of PI based on clinical, laboratory and radiological findings.

Pneumatosis Intestinalis (PI) is defined as the presence of extra-luminal gas confined to the bowel wall. PI is an ominous condition often requiring emergent surgery. The management can be challenging in some circumstances, as the choice of surgery versus medical treatment can be difficult.

In this study, we first report the case of a seventy-seven year old woman presenting to the emergency department with the presence of PI on computed tomography of the abdomen. Secondly, we review the existing literature regarding the management of PI and we suggest a treatment algorithm based on clinical, laboratory and radiological findings.

Pneumatosis cystoides intestinalis associated with toxic epidermal necrolysis: A case report

Toxic epidermal necrolysis (TEN) is a severe adverse drug reaction, which is characterized by erythema, blisters, and/or erosions of the mucous membranes and skin, but intestinal involvement is rare. In contrast, pneumatosis cystoides intestinalis (PCI) is a rare condition associated with a wide variety of underlying diseases, but to date no patient has presented with PCI associated with TEN. A 55-year-old man was admitted to intensive care unit for treatment of TEN caused by phenobarbital. On day 8 after admission, he presented with progressive abdominal distention and hypotension. Computed tomography (CT) showed gas in the superior mesenteric vein and air filled cysts in the walls of the small intestine. He was suspected of having septic shock due to PCI. As there were no indications of bowel ischemia or necrosis, the patient was managed conservatively with antibiotics and oxygen therapy. On day 10 after admission, he was weaned off catecholamines, with CT on day 11 showing complete resolution of gas in the superior mesenteric vein and air filled cysts. To our knowledge, this article describes the first patient presenting with PCI associated with TEN.

Diagnostic laparoscopy for pneumatosis intestinalis: to do or not to do?

Pneumatosis intestinalis (PI) is a rare clinical condition, which is commonly associated with mesenteric vascular ischemia, bowel obstruction, and chemotherapy. Although the pathophysiology of PI remains unclear, 2 theories, one mechanical and the other bacterial, have been proposed. Nonoperative medical treatment and observation should be considered in mild cases, but occasionally, the situation requires emergency surgical intervention. In cases of suspectful complicated PI, the clinician should not avoid performing diagnostic laparoscopy to rule out bowel ischemia and perforation.

A simple score for predicting mortality in patients with pneumatosis intestinalis

BACKGROUND AND AIM

This study was conducted to identify simple computerized tomography (CT) and clinical predictors of mortality in patients with pneumatosis intestinalis (PI). Thus, the clinical characteristics and outcomes of PI were assessed and the predictors of mortality were identified.

METHODS

The medical records of 123 patients with PI were reviewed retrospectively. Multivariate logistic regression models were constructed to determine independent predictors of mortality. These data were used to develop a simple score that would predict mortality on the first and seventh day after diagnosis.

RESULTS

The median age at diagnosis was 62 (range, 20-91) years. The most common cause of PI was mesenteric vascular ischemia (n=43, 35.0%). Twenty-nine (23.6%) disease-related deaths occurred during the index admission. Both signs of peritoneal irritation on physical examination and decreased or absent enhancement of the bowel wall were associated with increased mortality. If both factors were absent, the in-hospital mortalities on both the first and seventh days after the diagnosis of PI were less than 5%. However, if both factors were present, the in-hospital mortality was 57% on the first day and 59% on the seventh day.

CONCLUSIONS

A simple and novel risk score that predicts mortality in patients with PI was proposed. Patients with both peritoneal irritation and decreased or absent enhancement of bowel wall on CT should be observed vigilantly and early intervention should be instituted.

Incidental finding of esophageal pneumatosis

Pneumatosis of the gastrointestinal tract is a rare condition characterized by the presence of air filled cavities in the gastrointestinal tract wall. Its occurrence has been described throughout the gastrointestinal tract from the esophagus to the rectum, however it is most commonly reported in the small intestine. Despite multiple case reports in literature, its pathogenesis still remains unclear. Pneumatosis may be idiopathic or associated with a variety of disorders namely peptic ulcer disease, jejunoileal bypass, intestinal obstruction and non-gastrointestinal disorders like asthma, chronic obstructive pulmonary disease, systemic lupus erythematosus, infectious enteritis, etc. We here present a rare case of pneumatosis of the esophagus diagnosed incidentally at an esophagogastroduodenoscopy (EGD). A 78-year-old asymptomatic woman underwent EGD and colonoscopy at our hospital for evaluation of anemia. Few months prior to EGD, she had undergone excision of laryngocele at our hospital. EGD revealed extensive submucosal blebs distributed throughout the esophagus, otherwise unremarkable stomach and duodenum. Colonoscopy showed a tubular adenomatous polyp. Since our patient was asymptomatic she did not require any surgical intervention. Management of pneumatosis depends on the underlying cause.

Pneumatosis intestinalis in a patient with recurrent Clostridium difficile infection

A 65-year-old man with long-standing diarrhoea, recurrent Clostridium difficile infection (CDI) in the previous 5 months presented to the gastroenterology clinic with recurrent diarrhoea and abdominal cramping. Physical examination was negative for signs of acute abdomen. Stool C difficile PCR was positive. Abdominal imaging demonstrated an extensive pneumatosis intestinalis involving the small bowel and a dilated small bowel loop. He was treated conservatively with oral vancomycin for recurrent CDI with resolution of diarrhoea and abdominal cramping on 1-month follow-up visit.

Pneumatosis cystoides intestinalis

Pneumatosis cystoides intestinalis (PCI) is a rare condition that may be associated with a variety of diseases. The presenting clinical picture may be very heterogeneous and represent a challenge for the clinician. In the present paper we describe both a common and an uncommon clinical presentation of PCI and review the pertaining literature. Our cases confirm that, apart from asymptomatic cases, the clinical presentation of PCI may be widely different and suggest that a new onset of stipsis might be the presenting symptom. Diagnosis might be suggested by a simple X-ray of the digestive tract showing a change in the characteristics of the intestinal wall in two-thirds of these patients. However, one third of the patients do not have a suggestive X-ray and require a computed tomography (CT) scan/nuclear magnetic resonance that may reveal a thickened bowel wall containing gas to confirm the diagnosis and distinguish PCI from intraluminal air or submucosal fat. CT also allows the detection of additional findings that may suggest an underlying, potentially worrisome cause of PCI such as bowel wall thickening, altered contrast mucosal enhancement, dilated bowel, soft tissue stranding, ascites and the presence of portal air. Our results also point out that clinicians and endoscopists should be aware of the possible presentations of PCI in order to correctly manage the patients affected with this disease and avoid unnecessary surgeries. The increasing number of colonoscopies performed for colon cancer screening makes PCI more frequently casually encountered and/or provoked, therefore the possible endoscopic appearances of this disease should be well known by endoscopists.

Computed tomography colonography imaging of pneumatosis intestinalis after hyperbaric oxygen therapy: a case report

Introduction

Pneumatosis intestinalis is a condition characterized by the presence of submucosal or subserosal gas cysts in the wall of digestive tract. Pneumatosis intestinalis often remains asymptomatic in most cases but may clinically present in a benign form or less frequently in fulminant forms. Treatment for such conditions includes antibiotic therapy, diet therapy, oxygen therapy and surgery.

Case presentation

The present report describes the case of a 56-year-old Swiss-born man with symptomatic pneumatosis intestinalis resistant to all treatment except hyperbaric oxygen therapy, as showed by computed tomography colonography images performed before, during and after treatment.

Conclusions

The current case describes the response to hyperbaric oxygen therapy using virtual colonoscopy technique one month and three months after treatment. Moreover, after six months of follow-up, there has been no recurrence of digestive symptoms.

[Marked efficacy of metronidazole for the intestinal pseudoobstruction associated with systemic sclerosis]

In May 2009, a 57-year-old woman who had rheumatoid arthritis since 9 years was admitted to our hospital for dyspnea due to interstitial pneumonia (IP). On admission, she exhibited proximal scleroderma, finger edema, Raynaud's phenomenon, digital pitting scars, ankyloglossia, and esophageal dysmotility. The patient was diagnosed as having systemic sclerosis (SSc), according to the American College of Rheumatology criteria. After initiation of high-dose corticosteroid therapy, gradual amelioration of IP was observed. However, the patient complained of abdominal fullness. Computed tomography and intestine series findings revealed significant dilatation of the small intestine due to intra-abdominal free air and pneumatosis cystoides intestinalis but no mechanical obstruction, leading to a diagnosis of SSc with pseudo-obstruction. The patient underwent decompression with a long intestinal tube, which led to improvement in her symptoms. Although erythromycin (EM) and some prokinetic agents were administered, abdominal involvement recurred several days after resumption of oral ingestion. Therefore, we changed the antibiotic from EM to metronidazole (750 mg/day). Her manifestations were promptly ameliorated by metronidazole therapy in 4 days and did not recur. Metronidazole is an antibiotic used to treat intra-abdominal anaerobic bacterial infections and is also commonly used in preoperative treatment for colorectal surgery. In conclusion, we report a case where SSc-associated pseudo-obstruction was successfully managed by metronidazole therapy.

Pneumatosis intestinalis with complete remission: a case report

Introduction

Pneumatosis cystoides intestinalis is a rare disease characterized by presence of multilocular cysts in the gastrointestinal wall. Rarely, patients may experience symptoms secondary to the cysts. The pathogenesis of pneumatosis cystoides intestinalis is still unclear and many theories have been advocated to explain the exact origin. Complications occur in about 3% of cases and include obstruction, intussusception, volvulus, haemorrhage and intestinal perforation.

Case presentation

The author reported a male patient aged 56 years presented to the emergency department with acute upper abdominal pain. Widespread variable sized serosal intestinal air cysts were seen at the first look involving long segment of jejunum and ileum. Perforated duodenal ulcer, as the cause of generalized peritonitis, was repaired with direct closure and omental patch. A second laparotomy, was done and exploration was systematically performed and denoted hugely distended stomach with cicatrisation at the site of previous closure of perforated duodenal ulcer and the whole length of small gut was completely free from the already described pneumatosis cystoides intestinalis.

Conclusion

The pneumatosis cystoides intestinalis is a rare disease and suspicion of this disease process should be based on imaging and clinical finding. The therapy can be conservative or surgical in restricted situations.

Pneumatosis Intestinalis: Can We Avoid Surgical Intervention in Nonsurgical Patients?

Pneumatosis intestinalis (PI) is the presence of gas within the wall of the gastrointestinal tract and represents a tremendous spectrum of conditions and outcomes, ranging from benign diseases to abdominal sepsis and death. It is seen with increased frequency in patients who are immunocompromised because of steroids, chemotherapy, radiation therapy, or AIDS. PI may result from intraluminal bacterial gas entering the bowel wall due to increased mucosal permeability caused by defects in bowel wall lymphoid tissue. We present a case of PI who was treated conservatively and in whom PI resolved completely and we present a literature review of conservative management. It is not difficult to make a precise diagnosis of PI and to prevent unnecessary surgical intervention, especially when PI presents without clinical evidence of peritonitis. Conservative treatment is possible and safe for selected patients. Awareness of these rare causes of PI and close observation of selected patients without peritonitis may prevent unnecessary invasive surgical explorations.

Pneumatosis intestinalis with complete remission: a case report

INTRODUCTION

Pneumatosis cystoides intestinalis is a rare disease characterized by presence of multilocular cysts in the gastrointestinal wall. Rarely, patients may experience symptoms secondary to the cysts. The pathogenesis of pneumatosis cystoides intestinalis is still unclear and many theories have been advocated to explain the exact origin. Complications occur in about 3% of cases and include obstruction, intussusception, volvulus, haemorrhage and intestinal perforation.

CASE PRESENTATION

The author reported a male patient aged 56 years presented to the emergency department with acute upper abdominal pain. Widespread variable sized serosal intestinal air cysts were seen at the first look involving long segment of jejunum and ileum. Perforated duodenal ulcer, as the cause of generalized peritonitis, was repaired with direct closure and omental patch. A second laparotomy, was done and exploration was systematically performed and denoted hugely distended stomach with cicatrisation at the site of previous closure of perforated duodenal ulcer and the whole length of small gut was completely free from the already described pneumatosis cystoides intestinalis.

CONCLUSION

The pneumatosis cystoides intestinalis is a rare disease and suspicion of this disease process should be based on imaging and clinical finding. The therapy can be conservative or surgical in restricted situations.

Gastric pneumatosis intestinalis associated with malignancy: An unusual case report

Pneumatosis intestinalis (PI) is an uncommon disease defined as gas-filled cysts that are found in the wall of the gastrointestinal (GI) tract. The exact causes of PI are still unclear, but it may associated with coexisting diseases, such as some GI disorders, connective tissue disease, some medication and drugs, and rarely malignancy. The most common localization is the small intestine. Gastric PI secondary to malignancy has been rarely documented. We report on a 94-year-old man with gastric PI associated with inoperable adenocarcinoma localized in the duodenum. Following the gastrojejunostomy and choledochojejunostomy bypass, his general condition improved and PI disappeared, but he died due to poor performance status and malignancy 6 mo later. We suggest that in patients presenting with PI, malignancy should be considered in the differential diagnosis.

Pneumatosis intestinalis in a patient with chronic bronchiectasis

Pneumatosis intestinalis has been described in association with many gastrointestinal tract disorders including infection, ischemia and obstruction. It has also been described in patients with chronic obstructive pulmonary disease, connective tissue disorders, organ transplantation, leukemia and various states of immunodeficiency. In the present paper, the case of a 66-year-old woman with chronic bronchiectasis who subsequently developed pneumatosis intestinalis is described.

Pneumatosis coli in a dog

A 17-year-old, castrated male Maltese was presented with chronic polyphagia and a 2-week history of tenesmus, diarrhea, hematochezia, weight loss, and ribbon-like feces. Pneumatosis coli was diagnosed by abdominal radiography. Concurrent hyperadrenocorticism was suspected. The clinical signs of colorectal disease resolved within 2 days of initiating a lowresidue diet and oral metronidazole. Pneumatosis coli should be considered as a differential diagnosis for colorectal disease in dogs.

Pneumatosis Cystoides Intestinalis with Systemic Sclerosis, Limited Type Resulting in a Poor Prognosis

Pneumatosis cystoides intestinalis (PCI) is a rare disease characterized by the presence of multilocular intramural clusters of gas in the alimentary tract and has been considered to have a favorable response to conservative treatment. We describe the first case of limited type of systemic sclerosis (SSc) with PCI. A 74-year-old Japanese woman presented with a 4-month history of an unhealed cutaneous ulcer on the right third finger, along with sclerodactyly of bilateral hands. Proximal skin sclerosis was absent. The patient reported acute abdominal pain, and a diagnosis of PCI was established on plain radiography. The patient died of multiple organ failure 5 months after the development of PCI. PCI is rarely complicated with SSc, and all cases previously reported were associated with diffuse SSc. Because PCI is one of the poor prognostic factors of SSc, we should recognize the presence of this condition even in patients with limited cutaneous involvement.

Pneumatosis Intestinalis in a Burn Patient: Case Report and Literature Review

Pneumatosis Intestinalis (PI) is a rare condition characterized by gas in the intestinal wall. PI is not a disease in itself but a sign of an underlying problem. It is associated with a wide variety of underlying disorders, ranging from benign to life-threatening. When found, it should prompt a search for the underlying cause. Diagnostic efforts should be aimed at ruling out catastrophic problems such as intestinal ischemia and necrosis. The presence of peritonitis, rectal bleeding, portomesenteric venous gas, and lactic acidosis are important factors to determine the best course of action. Burn patients have multiple risk factors for developing this condition. Despite this, PI is not well-described in the burn literature. We present here a case report, a brief review of the literature, and clinical considerations.

Colonic pseudolipomatosis, microscopically classified into two groups

BACKGROUND

Colonic pseudolipomatosis is rare and the pathogenesis is controversial. The purpose of the present paper was to clarify endoscopic and histological characteristics of colonic pseudolipomatosis and to discuss the etiology.

METHODS

A total of 15 lesions from 14 patients was reviewed. They were able to be histologically classified into two groups on the basis of variety in size of the vacuoles: Group A, the ratio of largest vacuole to smallest vacuole in size is less than three, Group B, the ratio is more than four.

RESULTS

Four of 15 lesions were group A, and were endoscopically polypoid or flat lesions covered with normal-looking mucosa. They were microscopically characterized by (i) predominant location in the upper portion of the lamina propria; (ii) no submucosal involvement; (iii) less variation in vacuolar size; and (iv) no association with lymph follicles. The vacuoles of group A contained proteinaceous materials in two of four lesions. Group B (11 lesions) had small elevated mucosa with normal-looking surface or non-elevated reddish mucosa. Microscopically, the lesions were mainly located in the lower portion of the lamina propria, occasionally also in the submucosa, had variable-sized vacuoles, and were related to lymph follicles.

CONCLUSION

It is suggested that the vacuoles in group A contain fluid, and may indicate an abnormal stagnation of interstitial fluid. Microscopic appearance of group B is essentially similar to that of pneumatosis coli. It is thought that group B probably results from penetration of gas from the crypts into the mucosa during colonoscopy. It is unclear why group B had a preference for ileocecal valve and an association with lymph follicles.

[A pneumatosis cystoides coli revealed by a pseudo-obstruction]

Pneumatosis Intestinalis is a rare benign and often asymptomatic disease; we report the case of a 74 year-old woman with a pneumatosis coli revealed by a pseudo-obstruction; the diagnosis was suspected at radiology. The course under medical treatment was uneventfull.

The significance of pneumatosis intestinalis or bowel perforation in patients with gynecologic malignancies

OBJECTIVES

The objectives of this study were to evaluate the clinical significance and outcome of pneumatosis intestinalis or bowel perforation in patients with gynecologic malignancies.

METHODS

A retrospective review of all gynecologic oncology patients at our institution from 1996 to the present was performed to identify computed tomography examinations showing pneumatosis, free air, or the presence of portal venous gas. Admission symptoms, laboratory testing, radiographic and operative findings, and overall survival were evaluated. At the discretion of the attending gynecologic oncologist, patients were managed either surgically or conservatively. Statistical analysis was performed with Fisher's exact test.

RESULTS

Twenty-eight patients met study criteria. Thirteen patients were excluded as a result of radiographic free air immediately following surgery, thus leaving 15 patients for analysis. Sixty percent (n = 9) of patients were managed surgically while 40% (n = 6) were managed conservatively. Pain and tenderness at presentation prompted surgical intervention in a statistically significant number of patients (P = 0.04). No other sign or symptom was significant. Of the 6 patients managed conservatively, 3 (50%) died within 1 week of diagnosis. Survival for the others was 2, 4, and 6 months. Of the 9 patients managed surgically 6 (67%) patients died, 4 within 2 weeks of surgery and the remainder at 2 and 12 months postoperatively. The 3 patients who survived all had surgical intervention and none had radiographic or pathologic evidence of cancer at the time of presentation (P = 0.01). Overall mortality at 6 months was 73% (11/15). Surgical management was associated with prolonged ICU care, mechanical ventilation, and sepsis.

CONCLUSIONS

Pneumatosis intestinalis and bowel perforation carry a grave prognosis for patients with gynecologic malignancies. These data suggest that patients explored for radiographic evidence of pneumatosis or perforation with preoperative evidence of active malignancy do not survive the immediate postoperative period. The balance between quality and quantity of life must be considered when weighing the options for the management of this condition.

[Pneumatosis cystoides intestinalis, treated with laparoscopic colectomy]

The authors report a case of pneumatosis cystoides intestinalis which, after failure of medical treatment, was treated by laparoscopic partial colectomy. Surgical treatment is a last resort and the laparoscopically-assisted approach seems to be a good indication in colectomy for pneumatosis cystoides intestinalis.

Pneumoperitoneum: a review of nonsurgical causes

OBJECTIVE

To review causes of nonsurgical pneumoperitoneum (NSP), identify nonsurgical etiologies, and guide conservative management where appropriate.

DATA SOURCE

We conducted a computerized MEDLINE database search from 1970 to 1999 by using key words pneumoperitoneum and benign, nonsurgical, spontaneous, iatrogenic, barotrauma, pneumatosis, diaphragmatic defects, free air, mechanical ventilation, gynecologic, and pelvic. We identified 482 articles by using these keywords and reviewed all articles. Additional articles were identified and selectively reviewed by using key words laparotomy, laparoscopy, and complications.

STUDY SELECTION

We reviewed all case reports and reviews of NSP, defined as pneumoperitoneum that was successfully managed by observation and supportive care alone or that required a nondiagnostic laparotomy.

DATA SYNTHESIS

Each unique cause of nonsurgical pneumoperitoneum was recorded. When available, data on nondiagnostic exploratory laparotomies were noted. Case reports were organized by route of introduction of air into the abdominal cavity: abdominal, thoracic, gynecologic, and idiopathic.

CONCLUSIONS

Most cases of NSP occurred as a procedural complication or as a complication of medical intervention. The most common abdominal etiology of NSP was retained postoperative air (prevalence 25% to 60%). NSP occurred frequently after peritoneal dialysis catheter placement (prevalence 10% to 34%) and after gastrointestinal endoscopic procedures (prevalence 0.3% to 25%, varying by procedure). The most common thoracic causes included mechanical ventilation, cardiopulmonary resuscitation, and pneumothorax. One hundred ninety-six case reports of NSP were recorded, of which 45 involved surgical exploration without evidence of perforated viscus. The clinician should maintain a high index of suspicion for nonsurgical causes of pneumoperitoneum and should recognize that conservative management may be indicated in many cases.

Chronic Intestinal Pseudo-obstruction

For many patients, nutritional support and relief of symptoms remain the primary management goal of pseudo-obstruction. Specific pharmacological agents for this disorder are, in general, lacking. Given that the efficacy of many of the individual available agents is far from excellent, several centers have turned to combination therapy. Though there is at present no evidence from controlled studies to support this strategy, it is, at the very least, theoretically attractive as these agents act through a number of separate mechanisms. The combination of a prokinetic and an emetic may prove especially useful. As the pseudo-obstruction syndromes are, individually, rare, and experience with any given prokinetic agent in these disorders limited, it is difficult to develop strict guidelines for their use in this context. It stands to reason that a response to a prokinetic agent would seem unlikely in a patient with an advanced myopathic process; anecdotal evidence suggests, however, that some patients with severe scleroderma may derive some symptomatic improvement. Where oral therapy is tolerated, cisapride would appear the best choice among available agents. When this fails, subcutaneous octreotide may be added or substituted. In the acute situation, intravenous erythromycin may alleviate gastroparesis, but probably exerts little beneficial effect beyond the pylorus; parenteral metoclopramide may be tried, but, here again, convincing evidence of efficacy is lacking. The roles of endoscopy and surgery are largely confined to facilitating nutrition and providing decompression.