Clinical characteristics of patients with pneumatosis intestinalis

Radiological diagnosis of acute mesenteric ischemia in adult patients: a systematic review and meta-analysis

Computed tomography (CT) is widely used in diagnosing acute mesenteric ischemia (AMI), but robust identification of distinctive subtypes and stages of progression is lacking. Systematic literature search in PubMed, Cochrane Library, Web of Science and Scopus was conducted in May 2024. Studies including at least 10 adult patients and reporting radiological diagnosis of AMI versus no AMI or transmural ischemia versus no transmural ischemia were included. Meta-analyses on sensitivity and specificity of different radiological features in diagnosing AMI were conducted. From 2628 titles, 490 studies underwent full text review, and 81 were included in 14 meta-analyses. Diagnostic accuracy of CT angiography (CTA) was high - sensitivity of 92.0% and specificity of 98.8% (I2 45% and 79%, respectively), but lower for other CT protocols (sensitivity 75.8 and specificity 90.5; I2 83%). In most included studies, distinction of subtypes and severity of AMI (non-transmural or transmural) was not possible. Amongst the non-vascular features, absent/reduced bowel wall enhancement provided the best prognostic value (sensitivity 57.9 and specificity 90.1). CTA is the method of choice for diagnosing AMI with high diagnostic accuracy. None of the non-vascular features alone is sufficiently reliable to diagnose AMI or its progression to transmural necrosis, whereas a combination of different radiological features conveys a potential.

Is Pneumatosis and Portal Venous Air an Indication for Surgical Intervention: A Systematic Review

Pneumatosis and portal venous gas are radiological findings that have been historically associated with 70% mortality, and usually trigger surgical intervention. This is due to their association with acute mesenteric ischemia. As cross-sectional imaging usage has increased in recent years, these findings have also been observed in patients with indolent symptoms, the true mortality among patients with pneumatosis or portal venous gas is now theorized to be significantly lower than previously stated. This systematic review was designed to assess the mortality rate among patients with pneumatosis and portal venous gas on initial imaging. We systematically searched Embase, Web of Science, PubMed, and Scopus. Eleven articles were included for final analysis. Ten articles assessed mortality, and included a total of 308 patients, with an overall mortality rate of 31%. Eight articles reported on both ischemia and mortality (n = 233). Of the patients with confirmed ischemia (n = 74), a mortality rate of 69% (n = 51) was noted. Of those without ischemia (n = 159), a mortality rate of 14% (n = 22) was seen. Four studies reported pneumatosis and ischemia (n = 45), in which 64% (n = 29) had ischemia. Four articles reported on portal venous air and ischemia (n = 78). Ischemia was confirmed in 44% of these patients (n = 34). Given an overall mortality of 31% vs prior estimates of 70% for patients with these findings, the decision for surgery on patients with these imaging findings should be made utilizing the overall clinical picture of the patient.

Portal vein gas is a sign of intestinal necrosis after pesticide poisoning: a case report

Portal vein gas accumulation and intestinal pneumatosis are uncommon signs indicating a high mortality risk in cases of intestinal ischemic necrosis. However, the widespread use of computed tomography has led to an increase in detection of benign lesions. We report a case of portal vein gas accumulation resulting from organophosphorus pesticide poisoning. A male patient was brought to the hospital in a comatose state with bilateral pupils that measured 1.0 mm, and he showed shortness of breath and wet rattles in the lungs. A cholinesterase concentration of 214 U/L was detected on an auxiliary examination. The patient was diagnosed with organophosphorus pesticide poisoning and underwent mechanical ventilation, hemoperfusion, and continuous renal replacement therapy according to the poisoning guidelines. On the fifth day, considerable abdominal distension was observed. An abdominal computed tomography scan revealed dilation of the small bowel and ascending colon with fluid and gas accumulation, as well as gas within the intestinal wall and hepatic veins. Although portal vein gas and intestinal pneumatosis are a sign of mortality requiring immediate surgical intervention, an increasing number of benign cases suggests potential benefits of conservative treatment approaches.

[Pneumatosis cystoides intestinalis: a case report and literature review]

Pneumatosis cystoides was first described by Du Vernay in 1783. This is a fairly rare disease with nonspecific symptoms and CT data on pneumoperitoneum. The authors present pneumatosis intestinalis in a patient with systemic connective tissue disorder. Free gas in abdominal cavity and dilated intestinal loops were an indication for emergency surgery with subsequent resection of intestine due to signs of ischemic damage. A review of clinical cases allows us to conclude that pneumoperitoneum requires careful differential diagnosis. Free gas in abdominal cavity in patients with cystic pneumatosis is an indication for emergency surgery only in case of complicated course of disease.

Palliative Emergency General Surgery

Acute care surgeons encounter patients experiencing surgical emergencies related to advanced malignancy, catastrophic vascular events, or associated with multisystem organ failure. The acute nature is a factor in establishing a relationship between surgeon, patient, and family. Surgeons must use effective communication skills, empathy, and a knowledge of legal and ethical foundations. Training in palliative care principles is limited in many medical school and residency curricula. We offer examples of clinical situations facing acute care surgeons and discuss evidence-based recommendations to facilitate successful treatment and outcomes.