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Wong NLJ, Paredes SR, Seyfi D, Ng KS. Outcomes of patients with pneumatosis intestinalis and/or portal venous gas: a study of factors associated with survival and surgical intervention. ANZ J Surg 2024; 94:640-647. [PMID: 38263543 DOI: 10.1111/ans.18875] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 01/08/2024] [Accepted: 01/10/2024] [Indexed: 01/25/2024]
Abstract
BACKGROUNDS This study investigated the incidence of, and mortality and management outcomes following, pneumatosis intestinalis and/or portal venous gas on computed tomography. METHODS A retrospective study of patients identified with pneumatosis intestinalis and/or portal venous gas on computed tomography at a quaternary centre (2013-2021) was performed. Data relating to clinical presentation (including quick sequential organ failure assessment score), co-morbidities (Charlson Comorbidity Index), biochemical data (including peak lactate level), and radiological findings, were obtained. Factors associated with these were assessed by logistic regression. RESULTS From 16 428 scans, 107 (0.65%) demonstrated pneumatosis intestinalis and/or portal venous gas (mean 65.2 years [SD 15.2]; 60 [56%] male). Overall, 37 patients (35%) had both findings present. Thirty-three deaths (31%) were recorded. Fifty-four patients (51%) underwent surgery. Death was associated with quick sequential organ failure assessment score (score 1: OR 5.71, 95% CI 1.31-24.87; score 2: OR 10.00, 95% CI 1.94-51.54), Charlson Comorbidity Index ≥5 (OR 2.86, 95% CI 1.19-6.84), peak lactate ≥2.6 mmol/L (OR 14.53, 95% CI 4.39-48.14), and concomitant pneumatosis intestinalis and portal venous gas (OR 8.25, 95% CI 3.04-22.38). The presence of free peritoneal fluid (OR 3.23, 95% CI 1.44-7.28) or perforated viscus (OR 5.10, 95% CI 1.05-24.85) were the only predictors for surgery. CONCLUSION Pneumatosis intestinalis and portal venous gas are rare findings. Despite traditionally portending a poor prognosis, mortality occurred in only one-third of patients. There were clear indicators of mortality viz. sepsis severity, comorbidities, and concomitant pneumatosis intestinalis and portal venous gas. Factors predicting surgery warrant further investigation.
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Affiliation(s)
- Ngar Lok Joshua Wong
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Steven Ronald Paredes
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Doruk Seyfi
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
| | - Kheng-Seong Ng
- Department of Colorectal Surgery, Royal Prince Alfred Hospital, Camperdown, New South Wales, Australia
- Concord Institute of Academic Surgery, Concord Hospital, Concord, New South Wales, Australia
- Concord Clinical School, University of Sydney, Sydney, New South Wales, Australia
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2
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Rey Chaves CE, Fonseca JF, Ballen N, Bravo A, Becerra Sarmiento L, Parra Blanco FG, Peña Carvajalino LF, Azula Uribe MC. An unusual case of small bowel volvulus due to pneumatosis cystoides intestinalis: Case report and literature review. Int J Surg Case Rep 2024; 116:109328. [PMID: 38320416 PMCID: PMC10850951 DOI: 10.1016/j.ijscr.2024.109328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 01/27/2024] [Accepted: 01/29/2024] [Indexed: 02/08/2024] Open
Abstract
INTRODUCTION AND IMPORTANCE Pneumatosis cystoides intestinalis (PCI) is an uncommon condition characterized by intramural gas accumulation in the intestinal submucosa. Idiopathic or secondary is presented with non-specific clinical signs; in some cases, diagnosis is incidental. Its acute presentation is uncommon, and surgical management could be performed in selected cases. CASE PRESENTATION We present the case of an 85-year-old woman with 3 days of abdominal pain, 6 months of weight loss, and abdominal distension after meals. Abdominal computed tomography evidenced PCI at the small intestine with changes due to intestinal ischemia and internal mesenteric hernia. Intestinal resection and lateral-lateral mechanical anastomosis were performed with no complications after 90 days of follow-up. CLINICAL DISCUSSION PCI is an infrequent and benign condition; pathophysiology is, to date, poorly understood. Idiopathic or secondary to other gastrointestinal pathologies are described. The final diagnosis is performed with histopathological analysis. Nevertheless, in some cases, the benign nature could be presented as an acute abdomen, and surgical management should be in the physician's armamentarium. CONCLUSION PCI is an uncommon and benign entity. Nevertheless, in some cases, it could be presented as an acute abdomen. The surgical approach is appropriate, safe, and feasible.
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Affiliation(s)
- Carlos Eduardo Rey Chaves
- Estudiante de posgrado Cirugía General, Pontificia Universidad Javeriana, Facultad de Medicina. Bogotá, Colombia.
| | - Juan Fernando Fonseca
- Estudiante de posgrado Cirugía General, Pontificia Universidad Javeriana, Facultad de Medicina. Bogotá, Colombia
| | - Natalia Ballen
- Estudiante de posgrado Cirugía General, Pontificia Universidad Javeriana, Facultad de Medicina. Bogotá, Colombia
| | - Andrés Bravo
- Estudiante de posgrado Cirugía General, Pontificia Universidad Javeriana, Facultad de Medicina. Bogotá, Colombia
| | | | | | - Laura Felisa Peña Carvajalino
- Patologa, Pontificia Universidad Javeriana, Facultad de Medicina, Hospital Universitario San Ignacio, Bogotá, Colombia
| | - Maria Camila Azula Uribe
- Cirugía General, Pontificia Universidad Javeriana, Facultad de Medicina, Hospital Universitario San Ignacio, Bogotá, Colombia
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3
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Erdem S, Patel SV, Patel D, Patel S, Patel S, Chaudhary AJ. Understanding the Nuances of Hepatic Portal Venous Gas in Pneumatosis Intestinalis: An Indication of Bowel Ischemia? Cureus 2023; 15:e45330. [PMID: 37849594 PMCID: PMC10577153 DOI: 10.7759/cureus.45330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/15/2023] [Indexed: 10/19/2023] Open
Abstract
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.
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Affiliation(s)
- Saliha Erdem
- Internal Medicine, Wayne State University School of Medicine, Detroit, USA
| | - Suraj V Patel
- Internal Medicine, Ross University School of Medicine, Miramar, USA
| | - Dhruvil Patel
- Internal Medicine, Wayne State University School of Medicine, Detroit, USA
| | - Shivam Patel
- Biomedical Sciences, University of South Florida, Tampa, USA
| | - Shlok Patel
- Pharmaceutical Science, University of Michigan, Ann Arbor, USA
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4
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Teh R, Lee D, Tee YC, Menon T. Bowel Ischemia Secondary to Campylobacter Enterocolitis: A Case Series and Review of the Literature. Cureus 2023; 15:e39183. [PMID: 37332410 PMCID: PMC10276580 DOI: 10.7759/cureus.39183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/10/2023] [Indexed: 06/20/2023] Open
Abstract
Campylobacter is the most common cause of diarrheal illness worldwide and is generally self-limiting. We present two cases of Campylobacter enterocolitis complicated by bowel ischemia in a 79-year-old male and a 53-year-old male, both presenting with abdominal pain and diarrhea and elevated lactate and C-reactive protein (CRP) levels. CT demonstrated common findings of pneumatosis intestinalis (PI) and portal venous gas. Exploratory laparotomy performed on the former demonstrated extensive small bowel infarction that was noncompatible with life and he was palliated postoperatively. The latter improved clinically after resection of the ischemic section of the small bowel with primary stapled anastomosis and closure. Clinicians need to be aware of the potentially fatal complications of Campylobacter-associated enterocolitis and should maintain a high clinical index of suspicion so that early surgical intervention can be considered in this patient population.
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Affiliation(s)
- Ryan Teh
- General Surgery, Fiona Stanley Hospital, Perth, AUS
| | - Daniel Lee
- General Surgery, Fiona Stanley Hospital, Perth, AUS
| | | | - Tulsi Menon
- General Surgery, Fiona Stanley Hospital, Perth, AUS
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5
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Peixoto A, Pereira R, Leitão J. Idiopathic pneumatosis cystoides coli: An uncommon cause of pneumoperitoneum. Radiol Case Rep 2022; 17:4408-4412. [PMID: 36188071 PMCID: PMC9520510 DOI: 10.1016/j.radcr.2022.08.067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 08/18/2022] [Indexed: 02/07/2023] Open
Abstract
Pneumatosis cystoides intestinalis (PCI) is a rare entity characterized by the presence of gaseous cystic within the intestinal wall. The primary or idiopathic type represents 15% of cases and is a self-limited or chronic benign entity. The secondary type represents 85% of cases and is associated with various factors, such as surgery, pharmacotherapy, chemotherapy, autoimmune diseases, inflammatory diseases, and pulmonary illness. Pneumatosis cystoides intestinalis affects the colon (pneumatosis cystoides coli) in about half of the cases. The differential diagnosis of PCI includes potentially life-threatening diseases that cause pneumatosis intestinalis. The misdiagnosis of PCI is common and can lead to unnecessary treatments and surgical procedures. We describe an asymptomatic pneumoperitoneum incidentally seen on chest radiograph. The cause was pneumatosis cystoides coli, which did not require treatment.
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6
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Sinz S, Schneider MA, Graber S, Alkadhi H, Rickenbacher A, Turina M. Prognostic factors in patients with acute mesenteric ischemia-novel tools for determining patient outcomes. Surg Endosc 2022; 36:8607-8618. [PMID: 36217056 PMCID: PMC9613727 DOI: 10.1007/s00464-022-09673-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Accepted: 09/24/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND Acute mesenteric ischemia (AMI) is a devastating disease with poor prognosis. Due to the multitude of underlying factors, prediction of outcomes remains poor. We aimed to identify factors governing diagnosis and survival in AMI and develop novel prognostic tools. METHODS This monocentric retrospective study analyzed patients with suspected AMI undergoing imaging between January 2014 and December 2019. Subgroup analyses were performed for patients with confirmed AMI undergoing surgery. Nomograms were calculated based on multivariable logistic regression models. RESULTS Five hundred and thirty-nine patients underwent imaging for clinically suspected AMI, with 216 examinations showing radiological indication of AMI. Intestinal necrosis (IN) was confirmed in 125 undergoing surgery, 58 of which survived and 67 died (median 9 days after diagnosis, IQR 22). Increasing age, ASA score, pneumatosis intestinalis, and dilated bowel loops were significantly associated with presence of IN upon radiological suspicion. In contrast, decreased pH, elevated creatinine, radiological atherosclerosis, vascular occlusion (versus non-occlusive AMI), and colonic affection (compared to small bowel ischemia only) were associated with impaired survival in patients undergoing surgery. Based on the identified factors, we developed two nomograms to aid in prediction of IN upon radiological suspicion (C-Index = 0.726) and survival in patients undergoing surgery for IN (C-Index = 0.791). CONCLUSION As AMI remains a condition with high mortality, we identified factors predicting occurrence of IN with suspected AMI and survival when undergoing surgery for IN. We provide two new tools, which combine these parameters and might prove helpful in treatment of patients with AMI.
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Affiliation(s)
- Stefanie Sinz
- Department of Surgery, University Hospital Zurich, Raemistrasse 100, CH-8091, Zurich, Switzerland
| | - Marcel A Schneider
- Department of Surgery, University Hospital Zurich, Raemistrasse 100, CH-8091, Zurich, Switzerland
| | - Simon Graber
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Raemistrasse 100, CH-8091, Zurich, Switzerland
| | - Hatem Alkadhi
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, Raemistrasse 100, CH-8091, Zurich, Switzerland
| | - Andreas Rickenbacher
- Department of Surgery, University Hospital Zurich, Raemistrasse 100, CH-8091, Zurich, Switzerland
| | - Matthias Turina
- Department of Surgery, University Hospital Zurich, Raemistrasse 100, CH-8091, Zurich, Switzerland.
- Section of Colorectal Surgery, Department of Surgery, University Hospital of Zurich, Raemistrasse 100, CH-8091, Zurich, Switzerland.
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7
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Pswarayi R, Sanders CJ. Pneumatosis cystoides intestinalis: A complicated case presentation. Ann Med Surg (Lond) 2022; 82:104514. [PMID: 36268340 PMCID: PMC9577395 DOI: 10.1016/j.amsu.2022.104514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 08/21/2022] [Accepted: 08/21/2022] [Indexed: 10/27/2022] Open
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8
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Gibson D, Watters A, Pieracci F, Reiss R, Mehler PS. Pneumatosis Intestinalis and Anorexia Nervosa. Surg Infect (Larchmt) 2022; 23:661-666. [PMID: 35969259 DOI: 10.1089/sur.2022.127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: Pneumatosis intestinalis (PI), the presence of gas within the intestinal wall, is a condition historically associated with many diagnoses and can be life-threatening. The purpose of this article is to understand PI better in the setting of malnutrition secondary to anorexia nervosa (AN), a condition not historically affiliated with PI. Patients and Methods: In this retrospective study, the clinical findings of seven patients with AN are reported. Results: The patients were all found to have PI involving the right colon, with only a single patient also found to have PI involving additional colonic areas. No patients had small intestine involvement, and most of the patients were also diagnosed with the binge-purge subtype of AN, were receiving tube feeds, and had tenderness on abdominal examination. All seven patients were managed non-operatively. Conclusions: The authors propose that there may be an association between AN and PI. Given the surgical risks associated with malnutrition, the decision to pursue surgery, in the absence of the discussed pathologic risk factors, should be made in a very thoughtful manner. Future studies are warranted to better understand this potential association between PI and AN.
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Affiliation(s)
- Dennis Gibson
- ACUTE Center for Eating Disorders at Denver Health, Denver, Colorado, USA.,Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Ashlie Watters
- ACUTE Center for Eating Disorders at Denver Health, Denver, Colorado, USA.,Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Fredric Pieracci
- Department of Surgery, Denver Health Hospital Authority, Denver, Colorado, USA.,Department of Surgery, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Rebecca Reiss
- Department of Pharmacy, Denver Health Hospital Authority, Denver, Colorado, USA
| | - Philip S Mehler
- ACUTE Center for Eating Disorders at Denver Health, Denver, Colorado, USA.,Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA.,Eating Recovery Center, Denver, Colorado, USA
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9
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Bailey KA, Kodikara H, Mauguen A, Price A, LaQuaglia M, Boulad F. Pneumatosis intestinalis in the pediatric oncology population: An 11-year retrospective review at Memorial Sloan Kettering Cancer Center. Pediatr Blood Cancer 2022; 69:e29539. [PMID: 34962703 PMCID: PMC10499335 DOI: 10.1002/pbc.29539] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 11/12/2021] [Accepted: 12/03/2021] [Indexed: 11/08/2022]
Abstract
BACKGROUND Pneumatosis intestinalis (PI) is characterized by the presence of intramural gas in the gastrointestinal (GI) tract. The overall aim of this study was to review risk factors and outcome of pediatric oncology patients at our institution who developed PI. PROCEDURE Patients diagnosed with PI between 2007 and 2018 were identified from ICD-10 coding of radiology reports at Memorial Sloan Kettering Kids, a tertiary pediatric oncology center. Outcomes of interest were (a) resolution and time to resolution of PI, (b) surgical intervention within 2 weeks of diagnosis of PI, or (c) death secondary to PI. To capture the resolution of PI, we defined the "time to recovery (TTR)" as the time elapsed between date of PI diagnosis and the date of recovery. RESULTS Forty-two patients were identified. Within 30 days of diagnosis of PI, three patients had surgical intervention for PI (7%) and two patients died (5%) due to non-PI causes. Median TTR of PI was 4.5 days (95% CI: 3-7 days). In univariable and multivariable analyses, only steroid use in the prior 30 days was significantly associated with a faster TTR of PI (HR = 2.27 [95% CI: 1.17-4.41], p = .02). CONCLUSIONS This is the largest case series of patients with PI in the pediatric oncology population, which reveals significantly lower surgical and mortality rates than other published PI series. For the majority of patients, conservative medical management is indicated. A prospective study is warranted to define diagnosis and management guidelines for PI in the pediatric oncology population in a cooperative group setting.
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Affiliation(s)
- Kayleen A. Bailey
- Division of Pediatric Hematology-Oncology, Mount Sinai Kravis Children’s Hospital, New York, NY
| | - Hemal Kodikara
- Department of Pediatric Surgery, Memorial Sloan Kettering Kids, New York, NY
| | - Audrey Mauguen
- Department of Epidemiology and Biostatistics, Memorial Sloan KetteringCancer Center, New York, NY
| | - Anita Price
- Department of Pediatric Radiology, Memorial Sloan Kettering Kids, New York, NY
| | - Michael LaQuaglia
- Department of Pediatric Surgery, Memorial Sloan Kettering Kids, New York, NY
| | - Farid Boulad
- Department of Pediatrics, Memorial Sloan Kettering Kids, New York, NY
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10
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Wei S, Huang L, Huang T. Chronic bronchiectasis complicated with benign jejuno‐ileal pneumatosis intestinalis. Respirol Case Rep 2022; 10:e0985. [PMID: 35685847 PMCID: PMC9171679 DOI: 10.1002/rcr2.985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 05/23/2022] [Indexed: 11/26/2022] Open
Abstract
Patients with chronic bronchiectasis are susceptible to various respiratory complications. In this report, however, we describe a 53‐year‐old male with chronic bronchiectasis who developed extensive but asymptomatic jejuno‐ileal pneumatosis intestinalis. The patient did not have preceding pneumothorax or pneumomediastinum, and he did not receive cytotoxic or immunosuppressive therapy. Nor did he exhibit any clinical or radiographic evidence of intestinal ischaemia, obstruction or infection. Mucosal defects, due to his severe diarrhoea relating to the prolonged anti‐pseudomonal antibiotic treatment for his lungs, and the intestinal luminal pressure fluctuation, resulting from his exacerbated cough and from his frequent abdominal straining during defecation, were considered to have precipitated the condition. Following conservative treatment, the patient recovered well. In addition to adverse respiratory events, clinicians managing patients with bronchiectasis should also be alert to such an unusual extrapulmonary complication, because either neglecting the condition or unnecessary exploratory surgery may lead to hazardous outcomes.
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Affiliation(s)
- Sheng‐Huan Wei
- Division of Chest Medicine, Department of Internal Medicine National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University Tainan Taiwan
| | - Li‐Ting Huang
- Department of Diagnostic Radiology National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University Tainan Taiwan
| | - Tang‐Hsiu Huang
- Division of Chest Medicine, Department of Internal Medicine National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University Tainan Taiwan
- Institute of Clinical Medicine College of Medicine, National Cheng Kung University Tainan Taiwan
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11
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Graber SD, Sinz S, Turina M, Alkadhi H. Pneumatosis intestinalis in abdominal CT: predictors of short-term mortality in patients with clinical suspicion of mesenteric ischemia. Abdom Radiol (NY) 2022; 47:1625-1635. [PMID: 35050403 PMCID: PMC9038897 DOI: 10.1007/s00261-022-03410-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 01/03/2022] [Accepted: 01/05/2022] [Indexed: 11/26/2022]
Abstract
Purpose Pneumatosis intestinalis (PI) in the bowel wall demonstrated in computed tomography (CT) of the abdomen is unspecific and its prognostic relevance remains poorly understood. The purpose of this study was to identify predictors of short-term mortality in patients with suspected mesenteric ischemia who were referred to abdominal CT and showed PI. Methods In this retrospective, IRB-approved, single-centre study, CT scans and electronic medical records of 540 patients who were referred to abdominal CT with clinical suspicion of mesenteric ischemia were analysed. 109/540 (20%) patients (median age 66 years, 39 females) showed PI. CT findings were correlated with surgical and pathology reports (if available), with clinical and laboratory findings, and with patient history. Short-term outcome was defined as survival within 30 days after CT. Results PI was found in the stomach (n = 6), small bowel (n = 65), and colon (n = 85). Further gas was found in mesenteric (n = 54), portal (n = 19) and intrahepatic veins (n = 36). Multivariate analysis revealed that PI in the colon [odds ratio (OR) 2.86], elevated blood AST levels (OR 3.00), and presence of perfusion inhomogeneities in other abdominal organs (OR 3.38) were independent predictors of short-term mortality. Surgery had a positive effect on mortality (88% lower likelihood of mortality), similar to the presence of abdominal pain (65% lower likelihood). Conclusions Our study suggests that in patients referred for abdominal CT with clinical suspicion of mesenteric ischemia, location of PI in the colon, elevation of blood AST, and presence of perfusion inhomogeneities in parenchymatous organs are predictors of short-term mortality. Graphical abstract ![]()
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Affiliation(s)
- Simon D Graber
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Raemistr. 100, 8091, Zürich, Switzerland
| | - Stefanie Sinz
- Department of Visceral Surgery, University Hospital Zurich, University of Zurich, Zürich, Switzerland
| | - Matthias Turina
- Department of Visceral Surgery, University Hospital Zurich, University of Zurich, Zürich, Switzerland
| | - Hatem Alkadhi
- Institute of Diagnostic and Interventional Radiology, University Hospital Zurich, University of Zurich, Raemistr. 100, 8091, Zürich, Switzerland.
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12
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Lassandro G, Picchi SG, Romano F, Sica G, Lieto R, Bocchini G, Guarino S, Lassandro F. Intestinal pneumatosis: differential diagnosis. Abdom Radiol (NY) 2022; 47:1529-1540. [PMID: 32737548 DOI: 10.1007/s00261-020-02639-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 06/21/2020] [Accepted: 07/04/2020] [Indexed: 01/04/2023]
Abstract
Intestinal pneumatosis (IP) is an infrequent radiological sign defined as pathological gas infiltration into the bowel wall. It may be associated to different underlying clinical conditions-inflammatory bowel diseases, malignancies, chemotherapy, infections, immune deficiency status, trauma, intestinal ischemia, and necrosis-that are often related to emergency state and require a prompt diagnosis. All the imaging techniques, especially abdominal radiography and Computed Tomography, could detect the presence of IP and discern the forms related to emergency conditions. The differential diagnosis is essential to start an immediate clinical or surgical management and treatment. The aim of this article is to review the radiological features of IP in different illnesses, with particular attention to differential diagnosis.
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Affiliation(s)
- Giulia Lassandro
- Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy
| | | | | | - Giacomo Sica
- Department of Radiology, Monaldi Hospital, Naples, Italy
| | - Roberta Lieto
- Department of Radiology, Monaldi Hospital, Naples, Italy
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13
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Sun S, Zheng X, Zhang H, Han C, Zhao G. Hepatic portal venous gas associated with rapid infusion of postoperative early enteral nutrition after radical total gastrectomy. Nutrition 2022; 101:111685. [DOI: 10.1016/j.nut.2022.111685] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 04/01/2022] [Accepted: 04/03/2022] [Indexed: 11/25/2022]
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14
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Yang L, Zhong X, Yang H, Wu Q, Gong Y, Wang B. Pneumatosis cystoides intestinalis associated with etoposide in hematological malignancies: a case report and a literature review. BMC Gastroenterol 2022; 22:150. [PMID: 35346061 PMCID: PMC8959780 DOI: 10.1186/s12876-022-02219-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 03/16/2022] [Indexed: 12/17/2022] Open
Abstract
Pneumatosis cystoides intestinalis (PCI) is a rare condition characterized by the presence of air collection within the subserosa and/or submucosa of the gastrointestinal wall. Due to the lack of specific symptoms, PCI is likely to be misdiagnosed or missed without the use of imaging techniques or gastrointestinal endoscopy. Here, we report a patient who complained of abdominal distention and constipation after chemotherapy for hematological malignancies, and was diagnosed with secondary PCI via computed tomography (CT) and exploratory laparotomy. Pneumoperitoneum was no longer observed after two weeks of conservative treatments. Notably, the possibility of intra-abdominal pressure (IAP) as a predictor for surgical intervention was proposed. Furthermore, we conducted a literature review on PCI after chemotherapy in hematological malignancies to raise awareness of etoposide-related PCI, while whether PCI could be identified as an adverse event of etoposide requires more evidence.
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Pneumatosis Intestinalis Induced by Anticancer Treatment: A Systematic Review. Cancers (Basel) 2022; 14:cancers14071666. [PMID: 35406436 PMCID: PMC8996919 DOI: 10.3390/cancers14071666] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 03/16/2022] [Accepted: 03/22/2022] [Indexed: 02/06/2023] Open
Abstract
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.
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Abramov A, Luks VL, De Bie F, Hwang R, Allukian M, Nace GW. Pneumatosis intestinalis in children beyond the neonatal period: is it always benign? Pediatr Surg Int 2022; 38:399-407. [PMID: 34837497 DOI: 10.1007/s00383-021-05048-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/20/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE The significance and management of pediatric pneumatosis intestinalis (PI) remains poorly defined. We sought to add clarity in children beyond the neonatal period. METHODS Pediatric patients 3 months-18 years admitted to a quaternary children's hospital with a diagnosis of PI were included in this retrospective study. Pathologic PI was defined as irreversible, transmural intestinal ischemia. RESULTS 167 children were identified with PI. Of these children, 155 (92.8%) had benign PI and 12 (7.2%) developed pathologic PI. The most common underlying diagnosis for pathologic PI was global developmental delay (75%), although we identified a spectrum of underlying diagnoses at risk for PI. Physical exam notable for abdominal distension (p = 0.023) or guarding (p = 0.028), and imaging with portal venous gas (p < 0.001) or bowel distension (p = 0.001) were significantly associated with pathologic PI. Only 6.6% of all children underwent an operation. For those undergoing non-surgical management of benign PI, 75% of children received antibiotics and average duration of bowel rest was 6.8 days. CONCLUSIONS PI in children is primarily a benign phenomenon and often does not warrant surgical intervention. Bowel rest and antibiotics are therapeutic strategies frequently used in the treatment of this finding.
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Affiliation(s)
- Alexey Abramov
- Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Valerie L Luks
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Felix De Bie
- Division of Pediatric General, Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Rosa Hwang
- Division of Pediatric General, Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Myron Allukian
- Division of Pediatric General, Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Gary W Nace
- Division of Pediatric General, Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA.
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Tasha T, Dutta P, Atiquzzaman B. Pneumatosis Intestinalis in a Patient With Asthma: A Case Report. Cureus 2022; 14:e22116. [PMID: 35308724 PMCID: PMC8918300 DOI: 10.7759/cureus.22116] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/10/2022] [Indexed: 12/03/2022] Open
Abstract
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.
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18
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Thompson JS, Mannon P. Celiac disease and the surgeon. Am J Surg 2022; 224:332-338. [PMID: 35221098 DOI: 10.1016/j.amjsurg.2022.02.048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 02/14/2022] [Accepted: 02/16/2022] [Indexed: 11/16/2022]
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19
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Law JH, Soon GST, Tan KK. Bubbles in the colon. Frontline Gastroenterol 2022; 14:87. [PMID: 36561779 PMCID: PMC9763646 DOI: 10.1136/flgastro-2022-102086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Affiliation(s)
- Jia Hao Law
- Division of Colorectal Surgery, Department of Surgery, National University Hospital, Singapore
| | | | - Ker-Kan Tan
- Division of Colorectal Surgery, Department of Surgery, National University Hospital, Singapore
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20
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Castater C, Gliga LA, Meyer C, Hazen B, Greene W, Fiza B. Successful Non-Operative Management of Extensive Pneumatosis Cystoides Intestinalis Due to Graft Versus Host Disease. Am Surg 2022; 88:1000-1002. [DOI: 10.1177/00031348211060454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Graft versus host disease is a serious complication of allogenic stem cell transplants and can manifest with gastrointestinal complications including pneumatosis cystoides intestinali (PCI). A 43-year-old male with a history of acute myeloid leukemia presented to the hospital with abdominal pain and sepsis. The patient was intubated and admitted to the ICU. His CT scan demonstrated extensive colonic pneumatosis. He was high risk for laparotomy so was treated non-operatively. He improved and his abdominal exam remained benign. With aggressive resuscitation, close monitoring, and antibiotics, the patient was able to avoid major abdominal surgery. pneumatosis cystoides intestinali is a concerning finding that often leads to surgical interventions. Concurrent sepsis, gut ischemia, and frank perforation often lead to surgical intervention. In patients with high surgical risk and lack of critical bowel findings, non-operative management can be successful.
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Affiliation(s)
- Christine Castater
- Emory University School of Medicine, Grady Memorial Hospital, Atlanta, GA, USA
| | - Louise A. Gliga
- Emory University School of Medicine, Grady Memorial Hospital, Atlanta, GA, USA
| | - Courtney Meyer
- Emory University School of Medicine, Grady Memorial Hospital, Atlanta, GA, USA
| | - Ben Hazen
- Emory University School of Medicine, Grady Memorial Hospital, Atlanta, GA, USA
| | - Wendy Greene
- Emory University School of Medicine, Grady Memorial Hospital, Atlanta, GA, USA
| | - Babar Fiza
- Emory University School of Medicine, Grady Memorial Hospital, Atlanta, GA, USA
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Toda S, Iwasaki H, Murayama D, Isoda M, Nakayama H, Suganuma N, Masudo K. Pneumatosis intestinalis associated with lenvatinib during thyroid cancer treatment: a case report. J Med Case Rep 2021; 15:556. [PMID: 34763724 PMCID: PMC8588671 DOI: 10.1186/s13256-021-03158-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 10/19/2021] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Pneumatosis intestinalis is a rare disease characterized by gas-filled cysts within the submucosa or serosa of the intestinal tract. In recent years, pneumatosis intestinalis was reported in patients undergoing cancer treatment, and some case reports exist that report that pneumatosis intestinalis occurs during administration of vascular endothelial growth factor inhibitors, such as bevacizumab and sunitinib. Here, we report the first case of pneumatosis intestinalis during lenvatinib treatment. CASE PRESENTATION A 77-year-old Japanese man presented to our hospital with a chief complaint of numbness in the right leg and weakness of the lower limbs 9 years after right thyroid lobectomy. Computed tomography showed a tumor 90 mm in size from the lumbar spine to the sacrum, causing spinal cord compression. Blood tests showed that the patient's thyroglobulin level was increased to 11,600 ng/ml. We diagnosed him with thyroid cancer with bone metastases. External beam radiotherapy (39 Gy/13 Fr) was performed on the bone metastases, followed by total thyroidectomy and radioactive iodine therapy. Four months after radioactive iodine therapy, lenvatinib was introduced because the symptoms of numbness and weakness recurred. Lenvatinib was introduced at dose of 24 mg, and then it was reduced to 14 mg owing to Common Terminology Criteria for Adverse Event grade 3 paronychia of the right foot. Although no further significant adverse events occurred, a scheduled computed tomography image showed pneumatosis intestinalis of the ascending colon 14 weeks after the introduction of lenvatinib. No abdominal or digestive symptoms were observed; therefore, we selected conservative treatment. We discontinued lenvatinib for a week, but we were required to restart lenvatinib as the numbness in the right leg worsened after withdrawal. Since the introduction of lenvatinib, 3 years and 5 months passed; we continued lenvatinib treatment, and the therapeutic effect remains partial response. There has been no recurrence of pneumatosis intestinalis. CONCLUSIONS Although rare, it is important to recognize that pneumatosis intestinalis can occur in association with lenvatinib and should be differentiated from intestinal perforation. Pneumatosis intestinalis association with lenvatinib can be improved by withdrawal.
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Affiliation(s)
- Soji Toda
- Department of Breast and Endocrine Surgery, Kanagawa Cancer Center, 2-3-2 Nakao, Asahi-ku, Yokohama, 241-8515, Japan.
| | - Hiroyuki Iwasaki
- Department of Breast and Endocrine Surgery, Kanagawa Cancer Center, 2-3-2 Nakao, Asahi-ku, Yokohama, 241-8515, Japan
| | - Daisuke Murayama
- Department of Breast and Endocrine Surgery, Kanagawa Cancer Center, 2-3-2 Nakao, Asahi-ku, Yokohama, 241-8515, Japan
| | - Maya Isoda
- Department of Breast and Thyroid Surgery, Yokohama City University Medical Center, Yokohama, Japan
| | | | - Nobuyasu Suganuma
- Department of Breast and Endocrine Surgery, Kanagawa Cancer Center, 2-3-2 Nakao, Asahi-ku, Yokohama, 241-8515, Japan.,Department of Surgery, Yokohama City University School of Medicine, Yokohama, Japan
| | - Katsuhiko Masudo
- Department of Breast and Thyroid Surgery, Yokohama City University Medical Center, Yokohama, Japan
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22
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Arman Bilir Ö, Demir AM, Akçabelen YM, Ok Bozkaya İ, Gürlek Gökçebay D, Güneş A, Özbek NY, Yaralı N. Pneumatosis cystoides intestinalis: A rare complication after hematopoietic stem cell transplantation. Pediatr Transplant 2021; 25:e14136. [PMID: 34505744 DOI: 10.1111/petr.14136] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 06/03/2021] [Accepted: 08/25/2021] [Indexed: 01/02/2023]
Abstract
BACKGROUND Pneumatosis cystoides intestinalis (PCI) is a disorder in which widespread air sacs are present in mucosa, submucosa, subserosa, and intraabdominal area of the intestinal wall. It has a heterogeneous clinical presentation as a rare complication of intestinal graft-versus-host disease (GVHD). Computed tomography is the preferred imaging method for the diagnosis. Since the air sacs could be ruptured spontaneously, the presence of free air in the peritoneal cavity does not confirm intestinal perforation. The conservative treatment approach is sufficient in cases that do not require urgent surgical intervention, such as perforation or obstruction. CASE Here, we present a 2.5-year-old patient diagnosed with primary hemophagocytic lymphohistiocytosis (pHLH), who underwent allogeneic hematopoietic stem cell transplantation from a matched unrelated donor (MUD) and developed PCI secondary to intestinal GVHD 14th months after HSCT. CONCLUSIONS Pneumatosis cystoides intestinalis, which is a rare complication, should be kept in mind, especially in patients with intestinal GVHD and receiving intensive immunosuppressive, octreotide, and steroid treatment after HSCT.
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Affiliation(s)
- Özlem Arman Bilir
- Department of Pediatric Hematology and Oncology, Ministry of Health Ankara City Hospital, Ankara, Turkey
| | - Arzu Meltem Demir
- Department of Pediatric Gastroenterology, Ministry of Health Ankara City Hospital, Ankara, Turkey
| | - Yunus Murat Akçabelen
- Department of Pediatric Hematology and Oncology, Ministry of Health Ankara City Hospital, Ankara, Turkey
| | - İkbal Ok Bozkaya
- Department of Pediatric Hematology and Oncology, Ministry of Health Ankara City Hospital, Ankara, Turkey
| | - Dilek Gürlek Gökçebay
- Department of Pediatric Hematology and Oncology, Ministry of Health Ankara City Hospital, Ankara, Turkey
| | - Altan Güneş
- Department of Pediatric Radiology, Ministry of Health Ankara City Hospital, Ankara, Turkey
| | - Namık Yaşar Özbek
- Department of Pediatric Hematology and Oncology, Ministry of Health Ankara City Hospital, Ankara, Turkey
| | - Neşe Yaralı
- Department of Pediatric Hematology and Oncology, Ministry of Health Ankara City Hospital, Ankara, Turkey
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Lebert P, Ernst O, Zins M, Lanchou M, Nzamushe JR, Vermersch M. Pneumatosis intestinalis and portal venous gas in mechanical small bowel obstruction: Is it worrisome? Diagn Interv Imaging 2021; 102:545-551. [PMID: 34030989 DOI: 10.1016/j.diii.2021.05.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 05/04/2021] [Accepted: 05/05/2021] [Indexed: 12/12/2022]
Abstract
PURPOSE The purpose of this study was to evaluate the clinical significance of pneumatosis intestinalis (PI) and portal venous gas (PVG) in patients with mechanical small bowel obstruction (SBO), using surgical findings or clinical follow-up as standard of reference. MATERIALS AND METHODS Fourteen patients with mechanical SBO associated with PI and PVG were retrospectively included. There were 7 men and 7 women with a mean age of 59±19 (SD) (range: 25-93 years). CT examinations were reviewed by two radiologists to confirm the diagnosis of mechanical SBO and make a description of PI. Interobserver agreement was calculated. The reference standard was intraoperative appearance of the bowel wall (10/14; 71%) or the recovery of a normal bowel function in patients who were managed conservatively (4/14; 29%). RESULTS Among the 10 patients who underwent surgery, a normal appearance of the bowel in association with PI on CT was found intraoperatively in 8/10 (80%) patients and a reversible ischemia in the remaining 2/10 (20%) patients. The four patients who were managed conservatively recovered normal bowel function. Two patients died within two weeks following SBO. CONCLUSION PI and PVG are not specific signs of bowel necrosis in mechanical SBO.
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Affiliation(s)
- Paul Lebert
- Department of Digestive Diagnostic and Interventional Radiology, Lille University Hospital, 59037 Lille Cedex, France.
| | - Olivier Ernst
- Department of Digestive Diagnostic and Interventional Radiology, Lille University Hospital, 59037 Lille Cedex, France
| | - Marc Zins
- Department of Radiology, Fondation Hôpital Saint-Joseph, 75014 Paris, France
| | - Marie Lanchou
- Department of Digestive Diagnostic and Interventional Radiology, Lille University Hospital, 59037 Lille Cedex, France
| | - Jean-Robert Nzamushe
- Department of Emergency Surgery, Lille University Hospital, 59037 Lille Cedex, France
| | - Mathilde Vermersch
- Department of Digestive Diagnostic and Interventional Radiology, Lille University Hospital, 59037 Lille Cedex, France
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Fujii M, Yamashita S, Tashiro J, Tanaka M, Takenaka Y, Yamasaki K, Masaki Y. Clinical characteristics of patients with pneumatosis intestinalis. ANZ J Surg 2021; 91:1826-1831. [PMID: 33825311 DOI: 10.1111/ans.16772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 03/09/2021] [Accepted: 03/10/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Several theories explaining the development of pneumatosis intestinalis (PI) have been reported, but a substantial portion of cases have been idiopathic. Additionally, predictors of bowel ischaemia in PI have not been fully investigated, while PI with bowel ischaemia has deteriorated overall outcomes of PI. METHODS Sixty-four patients diagnosed with PI (2009-2019) were allocated to two groups: with (group 1; n = 15 (23%)) and without (group 2; n = 49 (77%)) bowel ischaemia. Fourteen patients underwent emergency surgery, and bowel ischaemia was identified in nine (64%). Six patients in group 1 were diagnosed with bowel ischaemia, and were treated palliatively. On medical charts, we determined underlying conditions of PI, compared the characteristics and outcomes between the groups, and identified the predictors of bowel ischaemia. RESULTS Group 1 patients more commonly showed abdominal pain, lower base excess, higher C-reactive protein concentrations, higher white blood cell counts and higher neutrophil-to-lymphocyte ratios, and more frequent comorbid ascites, free air and hepatic portal vein gas. Of nine bowel ischaemia surgery patients, three (33%) died; all because of anastomotic leak. All except three patients in group 2, who presented with aspiration pneumonia, responded to treatment. Only one patient had an unknown cause (1/64, 1.6%), and various underlying conditions in secondary PI were confirmed. CONCLUSION Idiopathic PI may be identified rarely using current imaging and knowledge, but outcomes in PI patients with bowel ischaemia remain unsatisfactory. Earlier identification of bowel ischaemia by various specialists in accordance with predictors of bowel ischaemia could improve overall outcomes in PI patients.
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Affiliation(s)
- Manato Fujii
- Department of Surgery, Ome Municipal General Hospital, Tokyo, Japan
| | - Suguru Yamashita
- Department of Surgery, Ome Municipal General Hospital, Tokyo, Japan
| | - Jo Tashiro
- Department of Surgery, St. Luke's International Hospital, Tokyo, Japan
| | - Mayuko Tanaka
- Department of Radiology, Ome Municipal General Hospital, Tokyo, Japan
| | | | - Kazuki Yamasaki
- Department of Surgery, Ome Municipal General Hospital, Tokyo, Japan
| | - Yukiyoshi Masaki
- Department of Surgery, Ome Municipal General Hospital, Tokyo, Japan
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Rieser CJ, Dadashzadeh ER, Handzel RM, Clancy KJ, Kaltenmeier CT, Moses JB, Forsythe RM, Wu S, Rosengart MR. Development and validation of a five-factor score for prediction of pathologic pneumatosis. J Trauma Acute Care Surg 2021; 90:477-483. [PMID: 33075028 PMCID: PMC7927914 DOI: 10.1097/ta.0000000000002989] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The significance of pneumatosis intestinalis (PI) remains challenging. While certain clinical scenarios are predictive of transmural ischemia, risk models to assess the presence of pathologic PI are needed. The aim of this study was to determine what patient factors at the time of radiographic diagnosis of PI predict the risk for pathologic PI. METHODS We conducted a retrospective cohort study examining patients with PI from 2010 to 2016 at a multicenter hospital network. Multivariate logistic regression was used to develop a predictive model for pathologic PI in a derivation cohort. Using regression-coefficient-based methods, the final multivariate model was converted into a five-factor-based score. Calibration and discrimination of the score were then assessed in a validation cohort. RESULTS Of 305 patients analyzed, 102 (33.4%) had pathologic PI. We identified five factors associated with pathologic PI at the time of radiographic diagnosis: small bowel PI, age 70 years or older, heart rate 110 bpm or greater, lactate of 2 mmol/L or greater, and neutrophil-lymphocyte ratio 10 or greater. Using this model, patients in the validation cohort were assigned risk scores ranging from 0 to 11. Low-risk patients were categorized when scores are 0 to 4; intermediate, score of 5 to 6; high, score of 7 to 8; and very high risk, 9+. In the validation cohort, very high-risk patients (n = 17; 18.1%) had predicted rates of pathologic pneumatosis of 88.9% and an observed rate of 82.4%. In contrast, patients labeled as low risk (n = 37; 39.4%) had expected rates of pathologic pneumatosis of 1.3% and an observed rate of 0%. The model showed excellent discrimination (area under the curve, 0.90) and good calibration (Hosmer-Lemeshow goodness-of-fit, p = 0.37). CONCLUSION Our score accurately stratifies patient risk of pathologic pneumatosis. This score has the potential to target high-risk individuals for expedient operation and spare low-risk individuals invasive interventions. LEVEL OF EVIDENCE Prognostic Study, Level III.
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Affiliation(s)
- Caroline J. Rieser
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | | | - Robert M. Handzel
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Kadie J. Clancy
- Department of Computer Science, University of Pittsburgh, Pittsburgh, PA, USA
| | | | - JB Moses
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Raquel M. Forsythe
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Shandong Wu
- Departments of Radiology, Biomedical Informatics, and Bioengineering, University of Pittsburgh, Pittsburgh, PA, USA
| | - Matthew R. Rosengart
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Alpuim Costa D, Modas Daniel P, Vieira Branco J. The Role of Hyperbaric Oxygen Therapy in Pneumatosis Cystoides Intestinalis-A Scoping Review. Front Med (Lausanne) 2021; 8:601872. [PMID: 33681242 PMCID: PMC7926085 DOI: 10.3389/fmed.2021.601872] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 01/28/2021] [Indexed: 12/24/2022] Open
Abstract
Pneumatosis cystoides intestinalis (PCI) is characterized by gas-filled cysts within gastrointestinal tract wall from esophagus to rectum, with preferential involvement of large and small intestine. PCI is rare with an estimated incidence of 0.03 to 0-2% in general population. PCI can be distinguished into idiopathic (15%) or secondary (85%) and the clinical picture ranges from completely asymptomatic to life-threatening intraabdominal complications. Although etiology of PCI appears to be multifactorial, the exact pathophysiology is poorly understood and two main theories have been proposed (mechanical and bacterial). Over the last decades, an enormous therapeutic armamentarium was considered in PCI's management, including hyperbaric oxygen therapy (HBOT). Treatment comprises conservative treatment in mild cases to surgery in highly symptomatic and complicated PCI. In the late 70s, HBOT started to be used in selected cases of PCI not responding to conservative measures. Since then, several case reports, case series, and reviews have been published in the literature with variable outcomes. The overall response rate and complete response were 92.1% (n = 82/89) and 65.2% (n = 58/89), respectively, with a median follow-up of 7 months. Furthermore, HBOT is extremely safe, with few reported complications in the literature when used for PCI. Nevertheless, a randomized, controlled, and double-blind clinical trial is unlikely to occur given the rarity of PCI, logistical issues of HBOT, and methodological considerations related to adequate blinding with a sham-controlled group. HBOT in combination with personalized diet and antibiotics may be beneficial for moderate to severe PCI in patients with no indication for emergency exploratory laparotomy. The purpose of this article is to synthesize the existing data, analyse results of previous studies, identify gaps in knowledge, and discuss PCI' management, including the proposal of an algorithm, with a special focus on HBOT.
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Affiliation(s)
- Diogo Alpuim Costa
- Centro de Medicina Subaquática e Hiperbárica (CMSH), Portuguese Navy, Lisbon, Portugal
- Centro de Investigação Naval (CINAV), Base Naval Do Alfeite, Portuguese Navy, Almada, Portugal
- CUF Oncology, Haematology and Oncology Department, Lisbon, Portugal
- NOVA Medical School, Faculdade de Ciências Médicas, Lisbon, Portugal
| | - Pedro Modas Daniel
- Centro de Medicina Subaquática e Hiperbárica (CMSH), Portuguese Navy, Lisbon, Portugal
- Centro de Investigação Naval (CINAV), Base Naval Do Alfeite, Portuguese Navy, Almada, Portugal
| | - João Vieira Branco
- Centro de Medicina Subaquática e Hiperbárica (CMSH), Portuguese Navy, Lisbon, Portugal
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27
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Aiello P, Johnson S, Ramos Mercado A, Hussein S. Pneumatosis intestinalis in a patient with COVID-19. BMJ Case Rep 2020; 13:e237564. [PMID: 32900750 PMCID: PMC7478032 DOI: 10.1136/bcr-2020-237564] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/17/2020] [Indexed: 12/24/2022] Open
Abstract
A 73-year-old man with significant medical history including renal transplantation and chronic immunosuppression presented to the hospital with acute respiratory failure. His initial treatment included steroids for concern for Pneumocystis jiroveci pneumonia, although this was later excluded as the diagnosis. The patient's illness was consistent with COVID-19; however, he was not diagnosed with the virus until late in his course. The patient was found to have pneumatosis intestinalis that was successfully managed conservatively. Despite his multiple medical comorbidities, the patient had a positive outcome following COVID-19 infection. We discuss the association of pneumatosis intestinalis and COVID-19, and we investigate the various factors, including immunosuppression, that could play a role in this patient's successful recovery from the virus.
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Affiliation(s)
- Paige Aiello
- Department of Surgery, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Samuel Johnson
- Department of Radiology, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Abdiel Ramos Mercado
- Department of Infectious Disease, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Shakir Hussein
- Department of Surgery, Wayne State University School of Medicine, Detroit, Michigan, USA
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Dibra R, Picciariello A, Trigiante G, Labellarte G, Tota G, Papagni V, Martines G, Altomare DF. Pneumatosis Intestinalis and Hepatic Portal Venous Gas: Watch and Wait or Emergency Surgery? A Case Report and Literature Review. AMERICAN JOURNAL OF CASE REPORTS 2020; 21:e923831. [PMID: 32653891 PMCID: PMC7377522 DOI: 10.12659/ajcr.923831] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Patient: Female, 60-year-old Final Diagnosis: Pneumatosis intestinalis Symptoms: Abdominal pain Medication:— Clinical Procedure: — Specialty: Surgery
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Affiliation(s)
- Rigers Dibra
- Department of Emergency and Organ Transplantation, University "Aldo Moro" of Bari, Bari, Italy
| | - Arcangelo Picciariello
- Department of Emergency and Organ Transplantation, University "Aldo Moro" of Bari, Bari, Italy
| | - Giuseppe Trigiante
- Department of Emergency and Organ Transplantation, University "Aldo Moro" of Bari, Bari, Italy
| | - Grazia Labellarte
- Department of Emergency and Organ Transplantation, University "Aldo Moro" of Bari, Bari, Italy
| | - Giovanni Tota
- Department of Emergency and Organ Transplantation, University "Aldo Moro" of Bari, Bari, Italy
| | - Vincenzo Papagni
- Department of Emergency and Organ Transplantation, University "Aldo Moro" of Bari, Bari, Italy
| | - Gennaro Martines
- Department of Emergency and Organ Transplantation, University "Aldo Moro" of Bari, Bari, Italy
| | - Donato F Altomare
- Department of Emergency and Organ Transplantation, University "Aldo Moro" of Bari, Bari, Italy
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Selander C, Pullatt R, Esnaola N, Camp ER. Pneumatosis Intestinalis after Open Jejunostomy Tube Placement. Am Surg 2020. [DOI: 10.1177/000313481307900210] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Craig Selander
- Department of Surgery Medical University of South Carolina Charleston, South Carolina
| | - Rana Pullatt
- Department of Surgery Medical University of South Carolina Charleston, South Carolina
- Ralph H. Johnson VA Medical Center Charleston, South Carolina
| | - Nestor Esnaola
- Department of Surgery Medical University of South Carolina Charleston, South Carolina
| | - E. Ramsay Camp
- Department of Surgery Medical University of South Carolina Charleston, South Carolina
- Ralph H. Johnson VA Medical Center Charleston, South Carolina
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Varelas LJ, Klinge MJ, Malik SM, Borhani AA, Neal M. Idiopathic pneumatosis intestinalis secondary to lactulose use in patients with cirrhosis. J Gastroenterol Hepatol 2020; 35:1065-1068. [PMID: 31692099 DOI: 10.1111/jgh.14920] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2019] [Revised: 10/23/2019] [Accepted: 10/26/2019] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIM Few case reports exist that link lactulose use with pneumatosis intestinalis in cirrhotics. This study investigates the relationship between lactulose use and idiopathic pneumatosis intestinalis in a cohort of cirrhotic patients. METHODS This case series considers several notable cases of patients with idiopathic pneumatosis intestinalis and concurrent lactulose use. Idiopathic pneumatosis intestinalis was defined as pneumatosis intestinalis with no identifiable etiology. A cohort of 119 patients with cirrhosis and pneumatosis intestinalis were identified in a tertiary care setting, via chart review by a multidisciplinary team. Eleven of these patients were found to have idiopathic pneumatosis intestinalis. Nine of these patients were being treated with lactulose. RESULTS Six out of 9 patients with idiopathic pneumatosis intestinalis that were being treated with lactulose saw resolution of pneumatosis intestinalis following discontinuation of treatment. CONCLUSIONS The etiology of idiopathic pneumatosis intestinalis is likely multifactorial, but lactulose might play a preventable role in its formation.
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Affiliation(s)
- Lee J Varelas
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh School of Medicine
| | - Matthew J Klinge
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Shahid M Malik
- Division of Gastroenterology, Hepatology and Nutrition, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Amir A Borhani
- Department of Radiology, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Matthew Neal
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Ribolla M, Conti L, Baldini E, Palmieri G, Grassi C, Banchini F, Dacco' MD, Capelli P. Asymptomatic pneumoperitoneum in pneumatosis coli: A misleading operative indication. Int J Surg Case Rep 2020; 69:92-95. [PMID: 32305029 PMCID: PMC7163289 DOI: 10.1016/j.ijscr.2020.03.042] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 03/14/2020] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Pneumatosis cystoides intestinalis (PCI) is a rare clinical pathology characterized by sub-mucosal and/or sub-serous cysts of free gas, forming cystic lesions usually ranging from 0.5 to 2.0 cm in size within the gastrointestinal tract. About 3% of patients with PCI develop complications such as pneumoperitoneum, intestinal volvulus, obstruction, or hemorrhage, these cases need immediate surgical intervention. Cyst rupture can produce peritoneal irritation and pneumoperitoneum. PRESENTATION OF CASE A 65-years-old woman was admitted to the Emergency Department for epileptiform convulsions. Her medical hystory included epilepsy, diabetes, lichenoid dermatitis, hypothyroidism, severe cognitive impairment. Abdominal CT scan revealed a dilated large intestine with parietal pneumatosis from the appendix to the transverse colon associated to extensive pneumoperitoneum. The patient underwent emergency laparotomy which revealed the presence of gas within the wall of right and transverse colon and distension of great omentum. No resection was needed as normal blood supply to the bowel present. DISCUSSION Pneumatosis coli can be both asymptomatic or life-threatening condition associated to bowel infarction; this situation can mimic a bowel perforation causing pneumoperitoneum - that sometimes is a non-surgical pneumoperitoneum - and it could be a misleading indication to surgical exploration especially in the case of uncertain origin of a septic shock. CONCLUSIONS We report a case of pneuomoperitoneum due to PCI. Surgical intervention was required for patient's conditions and unclear origin of the sepsis.
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Affiliation(s)
- Marta Ribolla
- Department of Medicine and Surgery, AOU Parma, Via Gramsci 14, Parma, Italy
| | - Luigi Conti
- Department of Surgery, AUSL Piacenza, Via Taverna 49, 29121 Piacenza, Italy.
| | - Edoardo Baldini
- Department of Surgery, AUSL Piacenza, Via Taverna 49, 29121 Piacenza, Italy
| | - Gerardo Palmieri
- Department of Medicine and Surgery, AOU Parma, Via Gramsci 14, Parma, Italy
| | - Carmine Grassi
- Department of Surgery, AUSL Piacenza, Via Taverna 49, 29121 Piacenza, Italy
| | - Filippo Banchini
- Department of Surgery, AUSL Piacenza, Via Taverna 49, 29121 Piacenza, Italy
| | | | - Patrizio Capelli
- Department of Surgery, AUSL Piacenza, Via Taverna 49, 29121 Piacenza, Italy
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Muhammad Nawawi KN, Abd Samat AH, Nik Fuad NF, Yi LL. Pneumatosis intestinalis: An important radiological clue in a case of missed perforated appendicitis. Turk J Emerg Med 2020; 20:86-89. [PMID: 32587928 PMCID: PMC7305666 DOI: 10.4103/2452-2473.278560] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 12/07/2019] [Indexed: 01/17/2023] Open
Abstract
Pneumatosis intestinalis (PI) is a rare radiological finding, characterized by the presence of gas in the bowel wall. It has a wide spectrum of possible underlying diagnosis ranging from benign to life-threatening conditions. We present a case of a previously healthy male who was initially presented with missed diagnosis of acute appendicitis which had led to perforated appendix. Failure to recognize the significance of PI and its correlation with other clinical information had caused the delay in his surgical intervention. Fortunately, the patient made a steady recovery and was discharged well. It is important to have a high clinical suspicion of life-threatening conditions whenever patients presented with a radiological clue of PI. Failure to incorporate this finding with other clinical clues might lead to devastating consequences and delay the necessary treatment.
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Affiliation(s)
- Khairul Najmi Muhammad Nawawi
- Department of Medicine, Gastroenterology Unit,The National University of Malaysia Medical Centre, Cheras, Kuala Lumpur, Malaysia
| | - Azlan Helmy Abd Samat
- Department of Emergency, Faculty of Medicine, The National University of Malaysia Medical Centre, Cheras, Kuala Lumpur, Malaysia
| | - Nik Farhan Nik Fuad
- Department of Radiology, Faculty of Medicine, The National University of Malaysia Medical Centre, Cheras, Kuala Lumpur, Malaysia
| | - Lim Li Yi
- Department of Surgery, Faculty of Medicine, The National University of Malaysia Medical Centre, Cheras, Kuala Lumpur, Malaysia
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Kim DJ, Choi YJ, Yoo YS. Pneumatosis Intestinalis Presenting as Small Bowel Obstruction without Bowel Ischemia after Mechanical Ventilation. Acute Crit Care 2019; 34:81-85. [PMID: 31723909 PMCID: PMC6849051 DOI: 10.4266/acc.2016.00311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Revised: 09/12/2016] [Accepted: 09/28/2016] [Indexed: 11/30/2022] Open
Abstract
Pneumatosis intestinalis (PI) is a rare condition of the presence of gas within the bowel walls. PI is associated with numerous underlying diseases, ranging from life-threatening to innocuous conditions. PI is believed to be secondary to coexisting disorders in approximately 85% of all cases. This paper reviews the case of a patient who was diagnosed 7 years prior with pneumoperitoneum from unknown causes without any symptoms. The patient was admitted to the intensive care unit for the management of aspiration pneumonia and developed extensive PI after mechanical ventilation, presenting as small bowel obstruction with mesenteric torsion. Although the exact mechanism and etiology of PI are unclear, this case provides an update on the imaging features of and the clinical conditions associated with PI, as well as the management of this condition.
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Affiliation(s)
- Dong Joon Kim
- Department of Anesthesiology and Pain Medicine, Chosun University Hospital, Gwangju, Korea
| | - Yong Joon Choi
- Department of Anesthesiology and Pain Medicine, Chosun University Hospital, Gwangju, Korea
| | - Young Sun Yoo
- Department of Surgery, Chosun University Hospital, Gwangju, Korea
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Abstract
BACKGROUND Pneumatosis cystoides intestinalis (PCI) is a low-incidence disease that confuses many doctors. A vast number of factors are suspected to contribute to its pathogenesis, such as Crohn's disease, intestinal stenosis, ulcerative colitis, drug use, extra-gastrointestinal diseases, and chronic obstructive pulmonary disease. Most consider its pathogenesis interrelated to an increase in intra-intestinal pressure and the accumulation of gas produced by aerogenic bacteria, and patients with atypical symptoms and imaging manifestations tend to be misdiagnosed. CASE PRESENTATION A 64-year-old man complained of a 3-month history of bloody stool without mucopurulent discharge, abdominal pain, or diarrhea. Colonoscopy revealed multiple nodular projections into the segmental mucosa of the sigmoid colon. Crohn's disease and malignant disease ware suspected first according to the patient's history, but laboratory examinations did not confirm either. Endoscopic ultrasound (EUS) revealed multiple cystic lesions in the submucosa. Moreover, computer tomography scan showed multiple bubble-like cysts. Combined with ultrasonography, computed tomography, and pathology findings, we ultimately made a diagnosis of PCI. Instead of surgery, we recommended conservative treatment consisting of endoscopy and oral drug administration. His symptoms improved with drug therapy after discharge, and no recurrence was noted on follow-up. CONCLUSIONS The incidence of PCI is low. Due to a lack of specificity in clinical manifestations and endoscopic findings, it often misdiagnosed as intestinal polyps, tumors, inflammatory bowel disease, or other conditions. Colonoscopy, computed tomography, and ultrasonography have demonstrated benefit in patients with multiple nodular projections in colon. Compared to the treatment of the above diseases, PCI treatment is effective and convenient, and the prognosis is optimistic. Therefore, clinicians should increase their awareness of PCI to avoid unnecessary misdiagnosis.
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Affiliation(s)
- Fangmei Ling
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, No.1277, Jiefang Avenue, Wuhan, Hubei province, China
| | - Di Guo
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, No.1277, Jiefang Avenue, Wuhan, Hubei province, China
| | - Liangru Zhu
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, No.1277, Jiefang Avenue, Wuhan, Hubei province, China.
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Ling F, Guo D, Zhu L. Pneumatosis cystoides intestinalis: a case report and literature review. BMC Gastroenterol 2019; 19:176. [PMID: 31694581 PMCID: PMC6836417 DOI: 10.1186/s12876-019-1087-9] [Citation(s) in RCA: 39] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 10/02/2019] [Indexed: 01/05/2023] Open
Abstract
Background Pneumatosis cystoides intestinalis (PCI) is a low-incidence disease that confuses many doctors. A vast number of factors are suspected to contribute to its pathogenesis, such as Crohn’s disease, intestinal stenosis, ulcerative colitis, drug use, extra-gastrointestinal diseases, and chronic obstructive pulmonary disease. Most consider its pathogenesis interrelated to an increase in intra-intestinal pressure and the accumulation of gas produced by aerogenic bacteria, and patients with atypical symptoms and imaging manifestations tend to be misdiagnosed. Case presentation A 64-year-old man complained of a 3-month history of bloody stool without mucopurulent discharge, abdominal pain, or diarrhea. Colonoscopy revealed multiple nodular projections into the segmental mucosa of the sigmoid colon. Crohn’s disease and malignant disease ware suspected first according to the patient’s history, but laboratory examinations did not confirm either. Endoscopic ultrasound (EUS) revealed multiple cystic lesions in the submucosa. Moreover, computer tomography scan showed multiple bubble-like cysts. Combined with ultrasonography, computed tomography, and pathology findings, we ultimately made a diagnosis of PCI. Instead of surgery, we recommended conservative treatment consisting of endoscopy and oral drug administration. His symptoms improved with drug therapy after discharge, and no recurrence was noted on follow-up. Conclusions The incidence of PCI is low. Due to a lack of specificity in clinical manifestations and endoscopic findings, it often misdiagnosed as intestinal polyps, tumors, inflammatory bowel disease, or other conditions. Colonoscopy, computed tomography, and ultrasonography have demonstrated benefit in patients with multiple nodular projections in colon. Compared to the treatment of the above diseases, PCI treatment is effective and convenient, and the prognosis is optimistic. Therefore, clinicians should increase their awareness of PCI to avoid unnecessary misdiagnosis.
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Affiliation(s)
- Fangmei Ling
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, No.1277, Jiefang Avenue, Wuhan, Hubei province, China
| | - Di Guo
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, No.1277, Jiefang Avenue, Wuhan, Hubei province, China
| | - Liangru Zhu
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, No.1277, Jiefang Avenue, Wuhan, Hubei province, China.
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Gao Y, Uffenheimer M, Ashamallah M, Grimaldi G, Swaminath A, Sultan K. Presentation and outcomes among inflammatory bowel disease patients with concurrent pneumatosis intestinalis: a case series and systematic review. Intest Res 2019; 18:289-296. [PMID: 31671928 PMCID: PMC7385580 DOI: 10.5217/ir.2019.00073] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 08/29/2019] [Indexed: 12/11/2022] Open
Abstract
Background/Aims Inflammatory bowel disease (IBD) involves chronic inflammation of the colon with ulcerative colitis (UC), and the colon and/or small intestine with Crohn’s disease (CD). Pneumatosis intestinalis (PI), characterized by compromise of the intestinal wall with gas-filled cysts, has rarely been reported with IBD. The presentation, best management and outcomes of PI with IBD are poorly defined. Methods We conducted a search for PI in all abdominal computed tomography (CT) reports at 2 large tertiary care hospitals from January 1, 2010 to December 31, 2017, cross referenced to ICD codes for IBD. CT and chart review was performed to confirm PI and IBD respectively. A systematic review excluding case reports was performed for PI with IBD for comparison. Results Of 5,990 patients with a CT abdomen report mentioning PI, we identified 11 cases of PI with IBD, 4 UC, 6 CD, and 1 indeterminate colitis. PI was limited to the small bowel in 5 patients, the right colon in 5, and small bowel and colonic in 1. All 3 mortalities had CD, small intestinal PI and portal/mesenteric venous gas. The systematic literature search identified 9 articles describing 58 patients with IBD and PI. These cases were mostly included in larger cohorts of PI patients without extractable data on presentation or outcomes in the IBD subpopulation. Conclusions Ours appears to be the first reporting of presentations and outcomes, outside of case reports, for those with PI and IBD. The high mortality for those with CD and PI of the small bowel appears to define a group requiring more than supportive medical care.
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Affiliation(s)
- Youran Gao
- Division of Gastroenterology, North Shore University Hospital and Long Island Jewish Medical Center, Manhasset, NY, USA
| | - Meka Uffenheimer
- Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Michael Ashamallah
- Department of Medicine, North Shore University Hospital and Long Island Jewish Medical Center, Manhasset, NY, USA
| | - Gregory Grimaldi
- Department of Radiology, North Shore University Hospital and Long Island Jewish Medical Center, Manhasset, NY, USA
| | - Arun Swaminath
- Division of Gastroenterology, Lenox Hill Hospital, New York, NY, USA
| | - Keith Sultan
- Division of Gastroenterology, North Shore University Hospital and Long Island Jewish Medical Center, Manhasset, NY, USA
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Management of Pneumatosis Intestinalis in Neutropenic Acute Leukemia Patients. INFECTIOUS DISEASES IN CLINICAL PRACTICE 2019. [DOI: 10.1097/ipc.0000000000000718] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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38
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Date Y, Katoh H, Abe T, Nagamine H, Hara H, Kawase Y. Effective kissing stent to severe stenosis of the superior mesenteric artery replacing the common hepatic artery. CVIR Endovasc 2019; 1:18. [PMID: 30652149 PMCID: PMC6319509 DOI: 10.1186/s42155-018-0025-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2018] [Accepted: 08/06/2018] [Indexed: 11/10/2022] Open
Abstract
Background Endovascular therapy (ET) for chronic mesenteric ischemia (CMI) is a effective treatment to relieve the symptoms, such as postprandial abdominal pain, food fear, and progressive weight loss. CMI is not known to be caused by rare anatomical variation of severe stenosis of the superior mesenteric artery (SMA), with replaced the common hepatic artery to the SMA. The treatment of such a rare anatomical variation using ET technique has not been discribed. ET with kissing stent technique can be applied to the CMI accompanied with a rare anatomical variation. Case presentation An 80-year-old woman presented with a history of intermittent, severe epigastric pain. Over the preceding 5 months, she had less severe and self-resolving epigastric pain 15-30 min after every meal. Abdominal computed tomography (CT) showed severe calcification of the SMA origin and bubble-like intramural gas of the small bowel with the contrasted wall pneumoperitoneum. As the patient did not have peritonitis, a conservative approach was used. Angiography performed after symptom resolution showed severe stenosis of the SMA origin with calcification, and the SMA had replaced the common hepatic artery. ET with the kissing stent technique, namely stenting to the SMA and common hepatic artery, was successfully performed and relieved the patient's symptoms. Conclusions CMI cause the symptoms of Pneumatosis intestinalis (PI) and pneumoperitoneum. Severe stenosis of the SMA origin replacing the common hepatic artery is a rare anatomic variation, which can cause CMI symptoms. ET with a kissing stent is the effective treatment option for the mesenteric artery stenosis accompanied with such rare anatomical variation.
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Affiliation(s)
- Yusuke Date
- Department of Cardiovascular Surgery and Department of Cardiology, Yokohama Sakae Kyosai Hospital, 132, Katsuracho, Sakae-ku Yokohama-shi, Kanagawa 247-8581 Japan
| | - Hiromasa Katoh
- Department of Cardiovascular Surgery and Department of Cardiology, Yokohama Sakae Kyosai Hospital, 132, Katsuracho, Sakae-ku Yokohama-shi, Kanagawa 247-8581 Japan
| | - Takatoshi Abe
- Department of Cardiovascular Surgery and Department of Cardiology, Yokohama Sakae Kyosai Hospital, 132, Katsuracho, Sakae-ku Yokohama-shi, Kanagawa 247-8581 Japan
| | - Hirhoshi Nagamine
- Department of Cardiovascular Surgery and Department of Cardiology, Yokohama Sakae Kyosai Hospital, 132, Katsuracho, Sakae-ku Yokohama-shi, Kanagawa 247-8581 Japan
| | - Hiroiku Hara
- Department of Cardiovascular Surgery and Department of Cardiology, Yokohama Sakae Kyosai Hospital, 132, Katsuracho, Sakae-ku Yokohama-shi, Kanagawa 247-8581 Japan
| | - Yushi Kawase
- Department of Cardiovascular Surgery and Department of Cardiology, Yokohama Sakae Kyosai Hospital, 132, Katsuracho, Sakae-ku Yokohama-shi, Kanagawa 247-8581 Japan
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Singh G, Johnson C, Gill R, De Cruz P. Pneumatosis cystoides intestinalis (PCI) in a patient with undiagnosed systemic sclerosis. BMJ Case Rep 2018; 2018:bcr-2018-225175. [PMID: 30269087 DOI: 10.1136/bcr-2018-225175] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Pneumatosis cystoides intestinalis (PCI) refers to the presence of gas within the wall of the small or large intestine. The pathophysiology is incompletely understood and is probably multifactorial in nature. PCI is a known but rare complication of systemic scleroderma, and the aetiology of PCI in patients with scleroderma is not fully understood. We present the case of a patient who was referred to gastroenterology clinic by her general practitioner for investigation of 8 months of weight loss, urgency, diarrhoea, bloating and crampy abdominal pain. Extensive investigations were performed to exclude infective, inflammatory or malignant aetiologies for these symptoms. She was diagnosed with PCI on her colonoscopy and was subsequently screened for secondary causes. Our patient was diagnosed with the limited cutaneous (CREST) variant of systemic scleroderma. This case report illustrates that PCI could be an uncommon presentation of systemic sclerosis, therefore clinicians should be aware of the association between these conditions.
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Affiliation(s)
- Gurpreet Singh
- Department of Gastroenterology, Austin Hospital, Heidelberg, Victoria, Australia
| | - Christopher Johnson
- Department of Gastroenterology, Austin Hospital, Heidelberg, Victoria, Australia
| | - Rosie Gill
- Department of Rheumatology, Austin Hospital, Melbourne, Victoria, Australia
| | - Peter De Cruz
- Department of Gastroenterology, Austin Hospital, Heidelberg, Victoria, Australia
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Wang YJ, Wang YM, Zheng YM, Jiang HQ, Zhang J. Pneumatosis cystoides intestinalis: six case reports and a review of the literature. BMC Gastroenterol 2018; 18:100. [PMID: 29954324 PMCID: PMC6022295 DOI: 10.1186/s12876-018-0794-y] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2017] [Accepted: 05/03/2018] [Indexed: 01/05/2023] Open
Abstract
Background Pneumatosis cystoides intestinalis (PCI) is characterized by gas-filled cysts in the intestinal submucosa and subserosa. There are few reports of PCI occurring in duodenum and rectum. Here we demonstrated four different endoscopic manifestations of PCI and three cases with intestinal stricture all were successfully managed by medical conservative treatment. Case presentation There are 6 cases of PCI with varied causes encountered, in which the etiology, endoscopic features, treatment methods and prognosis of patients were studied. One case was idiopathic, while the other one case was caused by exposing to trichloroethylene (TCE), and the remaining four cases were secondary to diabetes, emphysema, therioma and diseases of immune system. Of the six patients, all complained of abdominal distention or diarrhea, three (50%) reported muco-bloody stools, two (33.3%) complained of abdominal pain. In four other patients, PCI occurred in the colon, especially the sigmoid colon, while in the other two patients, it occurred in duodenum and rectum. Endoscopic findings were divided into bubble-like pattern, grape or beaded circular forms, linear or cobblestone gas formation and irregular forms. After combination of medicine and endoscopic treatment, the symptoms of five patients were relieved, while one patient died of malignant tumors. Conclusion PCI endoscopic manifestations were varied, and radiology combined with endoscopy can avoid misdiagnosis. The primary bubble-like pattern can be cured by endoscopic resection, while removal of etiology combined with drug therapy can resolve majority of secondary cases, thereby avoiding the adverse risks of surgery.
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Affiliation(s)
- Yong Juan Wang
- Department of Gastroenterology and Hepatology, The Second Affiliated Hospital of Hebei Medical University, Hebei, China
| | - Yu Ming Wang
- Department of Gastroenterology and Hepatology, The General Hospital of Tianjin Medical University, Tianjin, China
| | - Yan Min Zheng
- Department of Gastroenterology and Hepatology, The General Hospital of Tianjin Medical University, Tianjin, China
| | - Hui Qing Jiang
- Department of Gastroenterology and Hepatology, The Second Affiliated Hospital of Hebei Medical University, Hebei, China
| | - Jie Zhang
- Department of Gastroenterology and Hepatology, The General Hospital of Tianjin Medical University, Tianjin, China.
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Walczak R, Paek M, Suran J, Amory JT, Specchi S, Sanchez M. Radiography and ultrasonography of pneumatosis intestinalis in a cat. Vet Radiol Ultrasound 2018; 61:E26-E30. [DOI: 10.1111/vru.12635] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 01/14/2018] [Accepted: 02/21/2018] [Indexed: 12/22/2022] Open
Affiliation(s)
- Raelyn Walczak
- Department of RadiologyGulf Coast Veterinary Specialists Houston TX 77027
| | - Matthew Paek
- Department of RadiologySynergy Veterinary Imaging Partners Rockville MD 21029
| | - Jantra Suran
- Section of RadiologyUniversity of Pennsylvania Philadelphia PA 19104
| | - Joseph T. Amory
- Department of RadiologyIDEXX Telemedicine Consultants Clackamas OR 97015
| | - Swan Specchi
- Department of Clinical SciencesIstituto Veterinario di Novara Strada Provinciale 9 Granozzo con Monticello Italy
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Torres US, Fortes CD, Salvadori PS, Tiferes DA, D′Ippolito G. Pneumatosis From Esophagus to Rectum: A Comprehensive Review Focusing on Clinico-Radiological Differentiation Between Benign and Life-Threatening Causes. Semin Ultrasound CT MR 2018; 39:167-182. [DOI: 10.1053/j.sult.2017.09.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Mareth K, Alsaad AA, Roy A. Pneumatosis intestinalis in small bowel obstruction. BMJ Case Rep 2018; 2018:bcr-2018-224684. [DOI: 10.1136/bcr-2018-224684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Okuda Y, Mizuno S, Koide T, Suzaki M, Isaji S. Surgical treatment of pneumatosis cystoides intestinalis with pneumoperitoneum secondary. TURKISH JOURNAL OF GASTROENTEROLOGY 2018; 29:131-133. [PMID: 29391321 DOI: 10.5152/tjg.2018.17519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
| | - Shugo Mizuno
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Mie, Japan
| | - Taihei Koide
- Department of Surgery, Kinan Hospital, Mie, Japan
| | | | - Shuji Isaji
- Department of Hepatobiliary Pancreatic and Transplant Surgery, Mie University Graduate School of Medicine, Mie, Japan
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Recurrent Benign Pneumatosis Intestinalis in a Patient With Mixed Connective Tissue Disease. Arch Rheumatol 2018; 33:478-481. [PMID: 30874243 DOI: 10.5606/archrheumatol.2018.6589] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Accepted: 12/03/2017] [Indexed: 11/21/2022] Open
Abstract
Connective tissue diseases can be associated with rare gastrointestinal complications such as pneumatosis intestinalis and pneumoperitoneum. In this article, we report a unique case of recurrent pneumatosis intestinalis and spontaneous pneumoperitoneum without evidence of peritonitis in a patient with long-standing mixed connective tissue disease. Computed tomography scan of the abdomen and pelvis revealed pneumatosis of the jejunum and intra-abdominal free air, without evidence of perforation. The patient was managed non-operatively. Prior to discharge, on post-admission day two, imaging revealed resolution of the pneumatosis but persistent large volume pneumoperitoneum. It is important for clinicians to recognize pneumatosis and pneumoperitoneum as a possible benign complication in patients with mixed connective tissue disease and differentiate it from ruptured viscous. The management of benign spontaneous pneumoperitoneum can be supportive, thereby avoiding unnecessary investigations and surgery.
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Mesaki K, Sugimoto S, Otani S, Kurosaki T, Miyoshi K, Yamane M, Oto T. Pneumatosis intestinalis after lung transplantation for pulmonary graft-versus-host disease. J Thorac Dis 2018; 10:E42-E45. [PMID: 29600102 DOI: 10.21037/jtd.2017.11.121] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Pneumatosis intestinalis, which could complicate a spectrum of clinical conditions ranging from benign to life-threatening, is a rarely encountered complication after lung transplantation (LT). We describe two cases in which PI developed as a complication following LT for pulmonary graft-versus-host disease (GVHD) after hematopoietic stem cell transplantation (HSCT). In addition to the long-term immunosuppression administered for pulmonary GVHD, the intense immunosuppression needed after LT might increase the risk of PI in lung transplant recipients after HSCT. Conservative therapy should be considered for the treatment of PI developing after LT.
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Affiliation(s)
- Kumi Mesaki
- Department of General Thoracic Surgery, Okayama University Hospital, Okayama, Japan
| | - Seiichiro Sugimoto
- Department of General Thoracic Surgery, Okayama University Hospital, Okayama, Japan
| | - Shinji Otani
- Department of Organ Transplant Center, Okayama University Hospital, Okayama, Japan
| | - Takeshi Kurosaki
- Department of Organ Transplant Center, Okayama University Hospital, Okayama, Japan
| | - Kentaroh Miyoshi
- Department of General Thoracic Surgery, Okayama University Hospital, Okayama, Japan
| | - Masaomi Yamane
- Department of General Thoracic Surgery, Okayama University Hospital, Okayama, Japan
| | - Takahiro Oto
- Department of Organ Transplant Center, Okayama University Hospital, Okayama, Japan
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Chandola R, Laing B, Lien D, Mullen J. Pneumatosis Intestinalis and Its Association With Lung Transplant: Alberta Experience. EXP CLIN TRANSPLANT 2017; 16:75-80. [PMID: 29108518 DOI: 10.6002/ect.2016.0289] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
OBJECTIVES We evaluated the incidence, clinical presentation, laboratory findings, possible causes, and outcomes associated with pneumatosis intestinalis in the setting of lung transplant. MATERIALS AND METHODS A departmental database showed that, between October 2002 and August 2013, our institution performed 373 lung transplants. The database was queried for all patients who had pneumatosis intestinalis and/or pneumoperitoneum after lung transplant at our institution. For this retrospective chart review, information collected included demographics, baseline variables, symptoms, signs, laboratory parameters, radiologic work-up, medications, including immunosuppressants at presentation, progress and time to resolution, length of hospital stay, and postoperative complications, as well as short-term and midterm outcomes (up to 1 year). RESULTS The incidence of pneumatosis intestinalis was 2.68% (10/373 patients). Mean age of patients was 52.2 years (range, 34.9-67.9 y). Mean time for development of pneumatosis intestinalis after transplant was 352.8 days (range, 5-2495 d). Abdominal symptoms and signs were present in 6 patients (60%). The large bowel was the site of involvement in all but 1 patient, with predilection for ascending colon (80%) and transverse colon (90%) in most patients. High serum lactate levels were found in 2 patients, and both underwent bowel resection, with surgical specimens revealing evidence of ischemic changes in the gut. Mean dose of prednisone was 22 mg at the time of presentation (range, 0-60 mg). Mean hospital length of stay was 16.9 days (range, 0-40 d). Short-term survival was 100%. Midterm survival at the end of 1 year was 80%. Mean time for pneumatosis to resolve was 18 days (range, 14-35 d). CONCLUSIONS Pneumatosis intestinalis in bilateral lung transplant recipients can be treated with a minimal amount of imaging, and most patients can be treated conservatively. Survival outcomes are quite good, with 100% during the short term and 80% at 1 year in our series.
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Affiliation(s)
- Rahul Chandola
- From the Division of Cardiovascular Surgery, University of Alberta, University of Alberta, Edmonton, Alberta T6G 2B7, Canada
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Muhammad MN, Sadough M, King R, Singh G. Pneumatosis of the esophagus and intestines with portal venous air: a rare presentation. J Community Hosp Intern Med Perspect 2017; 7:255-257. [PMID: 29046756 PMCID: PMC5637708 DOI: 10.1080/20009666.2017.1356188] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Accepted: 07/11/2017] [Indexed: 01/04/2023] Open
Abstract
Pneumatosis intestinalis is a radiographic finding that represents a spectrum of conditions ranging from benign disease to abdominal sepsis and death. Along with portal venous gas, it is generally considered an ominous sign prompting emergency operative intervention. We report a rare case showing that nonoperative therapy can be considered in a seriously ill patient with esophageal, gastric and portal venous air.
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Affiliation(s)
| | - Maryam Sadough
- Internal Medicine, Greater Baltimore Medical Center, Baltimore, MD, USA
| | - Robert King
- Department of Medicine, Ross University School of Medicine, Chicago, IL, USA
| | - Gurkeerat Singh
- Internal Medicine, Greater Baltimore Medical Center, Baltimore, MD, USA
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Ito S, Masuda T, Harada N, Matsuyama A, Hamatake M, Maeda T, Tsutsui S, Matsuda H, Mimori K, Ishida T. Diagnostic laparoscopy for pneumatosis intestinalis in a very elderly patient: A case report. Ann Med Surg (Lond) 2017; 21:109-113. [PMID: 28861268 PMCID: PMC5567747 DOI: 10.1016/j.amsu.2017.07.058] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Revised: 07/25/2017] [Accepted: 07/25/2017] [Indexed: 02/08/2023] Open
Abstract
INTRODUCTION Pneumatosis intestinalis is rare but may be associated with life-threatening intra-abdominal conditions such as intestinal ischemia or perforation. However, it can be difficult, particularly in the very elderly, to identify candidates for immediate surgical intervention. PRESENTATION OF CASE A 94-year-old man with abdominal distension underwent abdominal computed tomography, which demonstrated accumulation of air bubbles within the intestinal wall and some free intraperitoneal air, suggestive of pneumatosis intestinalis. His vital signs showed evidence of systemic inflammatory response syndrome, and laboratory examination revealed inflammation and hypoxia. As the patient was frail, with his age and concomitant conditions which may have masked the symptoms and severity of his illness, immediate diagnostic laparoscopy was performed, which confirmed the diagnosis of pneumatosis intestinalis, with multiple gas-filled cysts seen within the subserosa of the small intestine. No additional surgical procedure was performed. His symptoms improved postoperatively. DISCUSSION Optimal management of pneumatosis intestinalis in a timely manner requires a comprehensive evaluation of factors in each individual. In patients with severe symptoms, PI might be a sign of a life-threatening intra-abdominal emergency. Despite the contrast-enhanced CT and prediction markers in previous reports, it considered to be difficult to completely rule out these fatal conditions without surgery, especially in very elderly patients with poor performance status. CONCLUSION Diagnostic laparoscopy may be a useful option for definitively ruling out the lethal conditions associated with pneumatosis intestinalis in frail elderly patients with severe conditions in the emergency setting.
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Affiliation(s)
- Shuhei Ito
- Department of Surgery, Hiroshima Red Cross Hospital and Atomic Bomb Survivors Hospital, Hiroshima, Japan.,Department of Surgery, Kyushu University Beppu Hospital, Beppu, Japan
| | - Takaaki Masuda
- Department of Surgery, Kyushu University Beppu Hospital, Beppu, Japan
| | - Noboru Harada
- Department of Surgery, Hiroshima Red Cross Hospital and Atomic Bomb Survivors Hospital, Hiroshima, Japan
| | - Ayumi Matsuyama
- Department of Surgery, Hiroshima Red Cross Hospital and Atomic Bomb Survivors Hospital, Hiroshima, Japan
| | - Motoharu Hamatake
- Department of Surgery, Hiroshima Red Cross Hospital and Atomic Bomb Survivors Hospital, Hiroshima, Japan
| | - Takashi Maeda
- Department of Surgery, Hiroshima Red Cross Hospital and Atomic Bomb Survivors Hospital, Hiroshima, Japan
| | - Shinichi Tsutsui
- Department of Surgery, Hiroshima Red Cross Hospital and Atomic Bomb Survivors Hospital, Hiroshima, Japan
| | - Hiroyuki Matsuda
- Department of Surgery, Hiroshima Red Cross Hospital and Atomic Bomb Survivors Hospital, Hiroshima, Japan
| | - Koshi Mimori
- Department of Surgery, Kyushu University Beppu Hospital, Beppu, Japan
| | - Teruyoshi Ishida
- Department of Surgery, Hiroshima Red Cross Hospital and Atomic Bomb Survivors Hospital, Hiroshima, Japan
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Martínez-Pérez A, Trullenque-Juan R, Santarrufina-Martínez S, Armañanzas-Villena E. Massive gastrointestinal pneumatosis in a patient with celiac disease and superior mesenteric artery syndrome. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2017; 107:709-10. [PMID: 26541666 DOI: 10.17235/reed.2015.3858/2015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Pneumatosis intestinalis (PI) is a radiological finding representing the presence of gas in the bowell, independently of the cause or location. We present the case of a 55-year-old man who was admitted presenting two-week history of intense vomiting. The patient was previously diagnosed with superior mesenteric artery syndrome and celiac disease. Plain x-ray and TC showed gastric and intestinal pneumatosis with important retropneumoperitoneum. Due to clinical stability the patient was managed conservatively, with a favorable outcome.
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