The role of computed tomography in the evaluation of pneumatosis intestinalis

The spectrum of pneumatosis intestinalis in the adult. A surgical dilemma

Pneumatosis intestinalis (PI) is a striking radiological diagnosis. Formerly a rare diagnostic finding, it is becoming more frequently diagnosed due to the wider availability and improvement of computed tomography scan imaging. Once associated only with poor outcome, its clinical and prognostic significance nowadays has to be cross-referenced to the nature of the underlying condition. Multiple mechanisms of pathogenesis have been debated and multiple causes have been detected during the years. All this contributes to creating a broad range of clinical and radiological presentations. The management of patients presenting PI is related to the determining cause if it is identified. Otherwise, in particular if an association with portal venous gas and/or pneumoperitoneum is present, the eventual decision between surgery and non-operative management is challenging, even for stable patients, since this clinical condition is traditionally associated to intestinal ischemia and consequently to pending clinical collapse if not treated. Considering the wide variety of origin and outcomes, PI still remains for surgeons a demanding clinical entity. The manuscript is an updated narrative review and gives some suggestions that may help make the decisional process easier, identifying patients who can benefit from surgical intervention and those who can benefit from non-operative management avoiding unnecessary procedures.

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.

[Clinical Course of Three Cases of Pneumatosis Intestinalis]

Pneumatosis cystoides intestinalis (PCI) is a rare condition characterized by multiple gas-filled cysts of varying size in the wall of gastrointestinal tract. PCI may idiopathic or secondary to various disorders. The etiology and pathogenesis of PCI are unclear. Treatment is usually conservative, and includes oxygen and antibiotics therapy. Surgery is reserved for cases of suspected inconvertible intestinal obstruction or perforation. Eleven patients who were diagnosed with PI between 2005 and 2015 were reviewed. We report three cases of PCI and describe causes and complications. The most important point in the treatment of PCI is to determine whether the patient needs surgery. Conservative care should be considered first if the patient is stable. If any complication is observed, such as ischemia in the intestine, surgery is needed. It is important to choose the best treatment based on prognostic factors and CT findings.

Asymptomatic pneumatosis intestinalis following chemotherapy for B lymphoblastic leukemia with recurrent genetic abnormalities in an adolescent patient

Pneumatosis intestinalis (PI) is a rare condition characterized by multiple pneumocysts in the submucosa or subserosa of the bowel. Here, we report a rare case of asymptomatic PI after chemotherapy induction in an 18-yr-old man with B lymphoblastic leukemia with recurrent genetic abnormalities. The patient was treated conservatively and recovered without complications. The possibility of PI should be considered as a complication during or after chemotherapy for hematologic malignancies. Conservative treatment should be considered unless there are complications, including peritonitis, bowel perforation, and severe sepsis.

Medical management of pneumatosis intestinalis in patients undergoing allogeneic blood and marrow transplantation

Pneumatosis intestinalis (PI) occurs when gastrointestinal (GI) wall disruption, increased wall permeability or necrosis leads to wall infiltration by gas. It is associated with a spectrum of causal factors, including GI disease in allogeneic blood and marrow transplant patients. Traditionally, PI has been managed surgically with high morbidity and mortality. We describe our experience managing allogeneic blood and marrow transplant patients with PI. From January 1998 to May 2008, 320 patients underwent allogeneic blood and marrow transplant of whom 10 were identified with PI. PI diagnosis was established by computed tomography scan (n=7), plain film (n=2) or colonoscopy (n=1). A total of 9 of 10 patients had ongoing GI GvHD or received recent treatment for GI GvHD. Before April 2002, two patients underwent subtotal colectomy with ileostomy (n=1) and sigmoid colectomy with colostomy (n=1). One patient was managed with bowel rest and total parental nutrition (TPN) only. These three patients died 0.4, 1.1 and 3.9 years after PI diagnosis owing to GI GvHD (n=2) and surgical complications (n=1). Seven patients, diagnosed after September 2006, were treated with GI rest, TPN and antibiotics. PI treated with GI rest, TPN and antibiotics will resolve without surgical intervention. AlloBMT-associated PI is often a non-critical finding that does not represent true GI tract ischemia and/or GI tract perforation.

[Linear or bubbly: a pictorial review of CT features of intestinal pneumatosis in adults]

Pneumatosis intestinalis is a rare condition, which is defined by the presence of gas within the bowel wall. In adult patients, pneumatosis intestinalis can be depicted in various circumstances. Owing to the routine use of CT to investigate patients with abdominal pain, pneumatosis intestinalis can be seen as an incidental finding or can be observed in association with a life-threatening disease such as bowel infarction. On CT images, pneumatosis intestinalis can display two different appearances; one that has a cystic or bubbly appearance can be considered as a chronic pneumatosis and is suggestive for a benign cause while the other, which has a linear appearance can be considered as a symptom and is more frequently secondary to a life-threatening cause. However, none of these two CT characteristics can be considered pathognomonic for any of these two categories of causes. In such situations, the analysis of the location, extent and, if any, associated findings may help to differentiate between benign and life-threatening causes. In these patients who present with abdominal signs that mimic symptoms that would warrant surgical exploration, the analysis of associated findings is critical to rule out a life-threatening cause of pneumatosis intestinalis and to obviate the need for unnecessary laparotomy. In adult patients with a known specific disease such as celiac disease, chronic pseudointestinal obstruction or other chronic diseases, even with accompanying pneumoperitoneum, pneumatosis intestinalis does not uniformly mandate surgical exploration. This pictorial review presents the more and the less common pneumatosis intestinalis CT features in adult patients, with the aim of making the reader more familiar with this potentially misleading sign.

Pneumatosis cystoides intestinalis following alpha-glucosidase inhibitor treatment: A case report and review of the literature

A 69-year-old man was diagnosed as having myasthenia gravis (MG) in September 2004, and treated with thymectomy and prednisolone. He was then diagnosed as having steroid-induced diabetes mellitus, and received sulfonylurea (SU) therapy in May 2005. An alpha- glucosidase inhibitor (αGI) was added in March 2006, resulting in good glycemic control. He experienced symptoms of abdominal distention, increased flatus, and constipation in October 2007, and was admitted into our hospital in late November with hematochezia. Plain abdominal radiography revealed small linear radiolucent clusters in the wall of the colon. Computed tomography (CT) showed intramural air in the sigmoid colon. Colonoscopy revealed multiple smooth surfaced hemispherical protrusions in the sigmoid colon. The diagnosis of pneumatosis cystoides intestinalis (PCI) was made on the basis of these findings. As the αGI voglibose was suspected as the cause of this patient’s PCI, treatment was conservative, ceasing voglibose, with fasting and fluid supplementation. The patient progressed well, and was discharged 2 wk later. Recently, several reports of PCI associated with αGI therapy have been published, predominantly in Japan where αGIs are commonly used. If the use of αGIs becomes more widespread, we can expect more reports of this condition on a global scale. The possibility of PCI should be considered in diabetic patients complaining of gastrointestinal symptoms, and the gastrointestinal tract should be thoroughly investigated in these patients.

Computed tomography colonographic findings of pneumatosis cystoides coli

Pneumatosis cystoides coli (PCC) is an uncommon condition in which multiple gas-filled cysts in the walls of the colon. Patients with PCC initially complain of various symptoms including abdominal discomfort, constipation, diarrhea, hematochezia, vomiting, and fever. We recently diagnosed PCC by computed tomography (CT) colonography in 2 patients. Two patients visited the outpatient clinic presenting with hematochezia, diarrhea, or abdominal pain. No underlying cause of PCC was found. Colonoscopy revealed multiple submucosal nodules covered with normal mucosa in the colon. However, CT colonography showed multiple gas-filled cysts within the walls of colon.

Pneumatosis intestinalis: a challenging biopsy diagnosis

BACKGROUND

Pneumatosis intestinalis is characterized by the accumulation of gas in the gastrointestinal wall. The histopathologic diagnosis is easily made on resection specimens in which the presence of submucosal or subserosal empty spaces lined by histiocytes and giant cells presents little diagnostic dilemma. In biopsy material, though, the diagnosis is more challenging, as giant cells and histiocytes can be interpreted as granulomatous inflammation indicative of other conditions such as infection or Crohn disease.

DESIGN

Nine gastrointestinal biopsies diagnosed as pneumatosis intestinalis from 7 patients were reviewed. Clinical history, radiologic features, and endoscopic findings were obtained from patient records.

RESULTS

Five patients presented with blood in the stool (one also with diarrhea) and 2 patients were diagnosed after screening colonoscopies. The endoscopist frequently described polyps or raised mucosal folds (6 cases). In all biopsies submucosal cystic spaces lined by giant cells could be observed. The cysts were intact (2 biopsies), partially intact (5 biopsies), or collapsed (5 biopsies), with 3 biopsies showing 2 cyst architectural conformations. The arrangement of the giant cells lining a rounded or cleft-like space was the most helpful feature in distinguishing pneumatosis intestinalis from granulomatous colitis. Additional useful features included the recognition of "pseudolipomatosis" (n=4) and the presence of round empty spaces in the submucosa resembling fat (n=3). Nonspecific findings included variable inflammation, eosinophilia, mild gland disarray, vascular ectasia and edema, and mild melanosis coli. Two cases were initially given a diagnosis of granulomatous inflammation. One patient with acquired immunodeficiency syndrome and positive cytomegalovirus antigenemia assay had ischemic colitis on the biopsy and another had a subsequent resection with ischemic colitis. A third patient was treated for cytomegalovirus colitis. None had a history of or developed Crohn disease.

CONCLUSIONS

Pneumatosis intestinalis remains a challenging diagnosis on biopsy material, particularly because endoscopy usually does not suggest that diagnosis. The presence of giant cells in the submucosa, variable inflammation, and crypt disarray can be easily confused with Crohn disease. Attention to the arrangement of the giant cells lining intact, partial, or collapsed cysts is crucial to making the correct diagnosis. Although nonspecific by itself, pseudolipomatosis may also indicate the presence of gas within the tissue and suggest the diagnosis.

Pneumatosis intestinalis in the adult: benign to life-threatening causes

OBJECTIVE

The frequency of detection of pneumatosis intestinalis (PI) appears to be increasing. This increase may be the result of increased CT use. New medications and surgical procedures have been reported to be associated with an increase in the incidence of PI. The purpose of this review is to provide an update on the imaging features and clinical conditions associated with PI.

CONCLUSION

This article illustrates the imaging findings of PI due to benign and life-threatening causes, with emphasis placed on describing newly associated conditions and also the imaging appearance on CT.

Emphysematous Gastritis: A Case Report and a Review of Literature

Introduction: Gas is rarely found within the viscera outside the lumen of the gastrointestinal tract. Emphysematous gastritis is a rare form of infection of the stomach wall by gas producing organisms. Clinical Picture: A 45-year-old Chinese lady underwent hepatectomy for hepatocellular carcinoma. Postoperatively, she turned septic and encephalopathic with worsening liver function. Computed tomography scan revealed a thickened, oedematous stomach wall with air pockets within. Treatment: The patient was started on a course of broad spectrum antibiotics. Outcome: She responded and was discharged well. Conclusion: Emphysematous gastritis is a rare condition with high mortality. There is however, still no preferable approach of treatment despite therapeutic advances. Key words: gas, stomach wall, gastric emphysema

Serum Lactic Acid Determines the Outcomes of CT Diagnosis of Pneumatosis of the Gastrointestinal Tract

Computed tomography (CT) diagnosis of pneumatosis involving the gastrointestinal tract can represent a broad range of clinical entities from a benign process to ischemic bowel. The purpose of this study is to define the significance and outcome of pneumatosis intestinalis (PI). All CT scans from 5/93 to 12/01 with the finding of PI were reviewed. Eighty-six CT scans had the finding of PI, with the colon being the most frequent location (51%), followed by small bowel (36%) and gastric (9%). Forty per cent of patients underwent surgery, with an overall mortality rate of 42 per cent and a surgical mortality rate of 47 per cent. Univariate analysis demonstrated significant correlation between serum lactic acid (LA) >2.0 mmol/L [odds ratio (OR) = 23.4; 95% confidence interval (C.I.), 7.21–75.92] and serum creatinine >1.5 mg/dL (OR = 3.05; 95% C.I., 1.25–7.42) with mortality. Age was suggestive but not a significant risk factor for mortality ( P = 0.09). Multivariate analysis found serum LA >2.0 (OR = 30.37; 95% CI., 7.31–126.2) to be the only significant predictor of mortality. CT diagnosis of PI is associated with significant in-hospital mortality, especially in the elderly. Serum LA level >2.0 mmol/L at time of diagnosis is associated with a greater than 80 per cent mortality. Surgical consultation is necessary to determine which patients need urgent surgical intervention.

Gas within the wall of the stomach due to emphysematous gastritis: case report and review

Emphysematous gastritis is a rare variant of phlegmonous gastritis due to invasion of the stomach wall by gas-forming bacteria. We present a case of emphysematous gastritis in a 66-year-old woman admitted with septicaemia, and a review of gas in the wall of the stomach is given with focus on emphysematous gastritis.

Pneumatosis intestinalis. Two case reports and a retrospective review of the literature from 1985 to 1995

Pneumatosis intestinalis (PI) is characterized by subserosal or submucosal gas-filled cysts of the gastrointestinal tract. The course may be benign or may lead to the need for urgent surgery. Knowledge of the differential diagnosis, course, and treatment modalities are key in providing optimal care to patients who present with this entity. In this article, two cases of "benign" pneumatosis seen at our institution over a one-month period are presented, along with a retrospective review of the English literature from January 1985 to March 1995. Incidence, symptoms, gross and microscopic appearance, radiographic appearance, etiology, differential diagnosis and therapy are reviewed.

Pneumatosis intestinalis. Appearance on MR examination

We describe the magnetic resonance (MR) appearance of pneumatosis intestinalis in two patients. Pneumatosis is suggested by the finding of circumferential collections of air adherent or within the bowel wall. This air is more apparent on gradient-echo images due to "blooming" associated with magnetic field inhomogeneities at air-tissue interfaces. While MR is not routinely indicated as a diagnostic tool for the detection of pneumatosis, the radiologist should nevertheless be familiar with its appearance on MR examination.

Pneumatosis cystoides intestinalis: CT findings

Two patients with primary pneumatosis cystoides intestinalis are presented. In both cases, the sigmoid colon was involved and there were no major complications. On computed tomography (CT), at lung window settings, the gas cysts in the colonic wall were clearly delineated. CT was useful in confirming the intramural gas cysts in patients with primary pneumatosis cystoides intestinalis.

Pneumatosis cystoides intestinalis (PCI)

Pneumatosis cystoides intestinalis (PCI) is a rare disease usually occurring in association with a large variety of gastrointestinal (GI) and non GI conditions in the majority of cases, although idiopathic PCI is also known to occur. There are two theories regarding the development of these intramural gas cysts--the mechanical and bacterial theories. PCI usually runs a benign course, although fulminant PCI can be present both in infants and adults. The importance of this condition for the surgeon lies in its early recognition, in order to prevent unnecessary surgical intervention, especially when pneumoperitoneum without clinical evidence of peritonitis is encountered. Oxygen therapy has been shown to lead to regression of PCI, although recurrences have been reported. Elemental diets and antimicrobial agents have provided symptomatic relief in a few reported cases. The association of PCI with a wide variety of conditions leads us to conclude that PCI may not be a disease in itself, but a sequel to these varied conditions.