A case report and approach to management in pneumatosis intestinalis

Pneumatosis intestinalis in systemic sclerosis: navigating diagnostic and therapeutic challenges

BACKGROUND

Pneumatosis intestinalis, characterised by the presence of intramural bowel gas, is a radiological finding with varied clinical implications, ranging from incidental detection to severe underlying pathology, including bowel ischaemia or perforation. Its association with systemic sclerosis, a connective tissue disorder, remains rare and poorly understood, presenting unique diagnostic and therapeutic challenges.

METHODS

A comprehensive literature review was conducted, analysing 34 documented cases of pneumatosis intestinalis associated with systemic sclerosis, examining demographic profiles, clinical features, diagnostic findings, and outcomes of various management strategies.

RESULTS

Pneumatosis intestinalis in systemic sclerosis predominantly occurs in older female patients and is associated with gastrointestinal dysmotility and microvascular damage. Symptoms range from asymptomatic presentations to severe abdominal pain with obstructive symptoms, with the latter increasing the likelihood of surgical intervention. Non-operative management, encompassing antibiotic therapy, oxygen supplementation, and dietary modifications, was associated with favourable outcomes and the lowest mortality. In contrast, surgical intervention, often necessitated by suspected ischemia or perforation, was associated with significantly higher morbidity and mortality.

CONCLUSION

Pneumatosis intestinalis in systemic sclerosis is a complex clinical entity demanding a nuanced, multi-disciplinary approach to management. Non-operative management should remain the cornerstone of treatment for clinically stable presentations, with surgery reserved for those with clear indications. The absence of standardised guidelines underscores the need for further research to refine diagnostic criteria and therapeutic protocols, ultimately improving long-term outcomes in this complex intersection of gastrointestinal and systemic disease.

Pneumatosis Intestinalis Developed in a Patient with Giant Cell Arteritis While in a Clinically Sustained Remission Phase

We herein report a patient with giant cell arteritis (GCA) who developed pneumatosis intestinalis (PI) while she was in a clinically sustained remission phase. A 79-year-old woman with GCA involving the thoracic aorta and its first branches to the posterior tibial arteries had been treated with high-dose prednisolone. Nine weeks after initiating treatment and while in clinically sustained remission with a normal CRP level, PI and pneumoperitoneum were incidentally found during scheduled positron emission tomography-computed tomography, which also revealed slight residual inflammation of GCA. This is a very rare case of PI complicated by GCA, and we discuss the possible relationships.

Pneumatosis intestinalis after systemic chemotherapy for colorectal cancer: A case report

BACKGROUND

Pneumatosis intestinalis (PI), also known as intramural gas in the small intestine, is a rare condition encountered by patients with cancer after receiving chemotherapy.

CASE SUMMARY

A 78-year-old man with a history of colorectal cancer developed epigastric pain and diarrhea after receiving combination chemotherapy of fluorouracil, leucovorin, irinotecan, and cetuximab. Abdomen radiography revealed intramural air in the small intestinal wall. A computed tomography scan of the abdomen revealed the features of PI with air expanding into the mesentery. After surgery, the patient remained symptom-free throughout a 9 mo follow-up period during which he received chemotherapy of fluorouracil, leucovorin, and irinotecan.

CONCLUSION

Although chemotherapy-induced PI is rare among patients with cancer, the differential diagnosis of PI and fulminant complications (such as ischemia, infarction, and perforation of the gastrointestinal tract) should be conducted, in which case an urgent surgical intervention is required.

Intestinal pneumatosis: differential diagnosis

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.

OUP accepted manuscript

Pneumatosis cystoides intestinalis (PCI) is a rare condition, characterized by gas-filled cysts in the intestinal wall. The mesentery and intra-abdominal ligaments can be affected. PCI is classified as primary or secondary and associated with multiple predisposing factors. An asymptomatic 87-year-old man underwent an abdominal tomography for follow-up of bladder carcinoma. The examination revealed intestinal and mesenteric pneumatosis associated with pneumoperitoneum. At laparoscopy, intestinal and mesenteric pneumatosis without intestinal infarction was identified. He was discharged on the fifth postoperative day. PCI is a benign condition that can be confused with mesenteric ischemia. Treatment is conservative, with periodic clinical evaluations. Surgical procedure is unnecessary for its diagnosis or management.

Pseudo-pneumatosis of the gastrointestinal tract: its incidence and the accuracy of a checklist supported by artificial intelligence (AI) techniques to reduce the misinterpretation of pneumatosis

PURPOSE

To assess the incidence of erroneous diagnosis of pneumatosis (pseudo-pneumatosis) in patients who underwent an emergency abdominal CT and to verify the performance of imaging features, supported by artificial intelligence (AI) techniques, to reduce this misinterpretation.

METHODS

We selected 71 radiological reports where the presence of pneumatosis was considered definitive or suspected. Surgical findings, clinical outcomes, and reevaluation of the CT scans were used to assess the correct diagnosis of pneumatosis. We identified four imaging signs from literature, to differentiate pneumatosis from pseudo-pneumatosis: gas location, dissecting gas in the bowel wall, a circumferential gas pattern, and intramural gas beyond a gas-fluid/faecal level. Two radiologists reevaluated in consensus all the CT scans, assessing the four above-mentioned variables. Variable discriminative importance was assessed using the Fisher exact test. Accurate and statistically significant variables (p-value < 0.05, accuracy > 75%) were pooled using boosted Random Forests (RFs) executed using a Leave-One-Out cross-validation (LOO cv) strategy to obtain unbiased estimates of individual variable importance by permutation analysis. After the LOO cv, the comparison of the variable importance distribution was validated by one-sided Wilcoxon test.

RESULTS

Twenty-seven patients proved to have pseudo-pneumatosis (error: 38%). The most significant features to diagnose pneumatosis were presence of dissecting gas in the bowel wall (accuracy: 94%), presence of intramural gas beyond a gas-fluid/faecal level (accuracy: 86%), and a circumferential gas pattern (accuracy: 78%).

CONCLUSION

The incidence of pseudo-pneumatosis can be high. The use of a checklist which includes three imaging signs can be useful to reduce this overestimation.

Combination therapy for systemic sclerosis-associated pneumatosis intestinalis

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

Combination therapy for systemic sclerosis-associated pneumatosis intestinalis

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