Pneumatosis cystoides intestinalis after chemotherapy for hematological malignancies: report of 4 cases

Benign Pneumatosis Intestinalis: A Case Report and Review of the Literature

BACKGROUND

Pneumatosis intestinalis is the presence of gas within the walls of the intestine on imaging and has variable clinical significance, ranging from an incidental finding to a harbinger of intra-abdominal catastrophe. There are multiple mechanisms by which this radiographic finding develops, including bacterial gas production, increased intraluminal pressure within the gastrointestinal tract, mechanical disruption of the gut mucosa, and tracking of pulmonary gas along the mesenteric vasculature.

CASE PRESENTATION

We present the case of a 61-year-old male veteran who had sustained a remote anoxic brain injury resulting in chronic dependence on a gastrostomy tube for enteral nutrition, found incidentally to have pneumatosis intestinalis without signs of intra-abdominal catastrophe.

CONCLUSIONS

Appropriate interpretation of this finding can lead to life-saving interventions and avoid unnecessary surgical procedures.

Pneumatosis cystoides intestinalis associated with etoposide in hematological malignancies: a case report and a literature review

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.

Pneumatosis Intestinalis Induced by Anticancer Treatment: A Systematic Review

Simple Summary

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

Abstract

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

Pneumatosis Intestinalis in Lung Cancer Induced Twice by Different Drugs: Bevacizumab and Pemetrexed

A 72-year-old man diagnosed with stage 4 lung adenocarcinoma developed asymptomatic pneumatosis intestinalis while undergoing treatment with first-line chemotherapy, which included carboplatin, paclitaxel, and bevacizumab (BEV). He was treated conservatively. The pneumatosis recurred while the patient was undergoing treatment with the third-line chemotherapy, which included pemetrexed (PEM). His condition resolved after 4 weeks of supportive therapy. To our knowledge, this is the first case in which pneumatosis intestinalis was induced twice by two drugs in a patient with lung cancer. BEV and PEM are often administered to patients with lung cancer; thus, it should be noted that pneumatosis intestinalis may occur as an adverse event in patients treated with these drugs.

Unique Case of Gastroenteritis Presenting as Pneumatosis Intestinalis With Emphysematous Gastritis and Portal Vein Gas: Do Not Take Gastroenteritis Lightly

Pneumatosis intestinalis (PI) consists of multiple, thin, gas-filled cysts in the wall of the gastrointestinal (GI) tract. It is an uncommon entity that can involve any gastrointestinal site from the stomach to the rectum. Isolated stomach involvement is rare. PI can represent a broad spectrum of diseases with variable prognoses. We present the case of a patient who was admitted with gastroenteritis-like symptoms. He remained hemodynamically stable, and on further imaging with contrast-enhanced computed tomography of the abdomen and pelvis, air was found in the portal vein and gastric wall, with minimal thickening of the proximal small bowel concerning for emphysematous gastroenteritis. Further workup results were negative, including blood cultures, stool studies, Clostridium difficile toxins, and lactic acid levels. The patient was managed nonoperatively and recovered without serious complications. Our case is unique in terms of the presence of air in the portal vein, which would otherwise suggest the possible spread of infection across the bowel wall.

Pneumatosis cystoides intestinalis: case report and review of literature

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

Pneumatosis cystoides intestinalis: case report and review of literature

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

[Gastrointestinal tract diseases induced by medications]

Gastrointestinal symptoms are common side effects of medical drugs. They are usually mild but sometimes require diagnostic endoscopy and histologic evaluation. Due to the rapidly increasing number of drugs developed especially for cancer treatment, pathologists are faced with a spectrum of different drug-associated histologies in all segments of the gastrointestinal tract. Some medication-induced mucosal damage features may mimic classical pathologies of nondrug-associated diseases, while others result in novel phenotypes. The present article focusses on the histologic presentations of gastrointestinal diseases induced by medications that either compromise or induce immune response.

Primary pneumatosis intestinalis of small bowel: a case of a rare disease

Pneumatosis intestinalis (PI) is a condition in which multiple gas-filled cysts are located in the bowel wall; it can represent a wide spectrum of diseases and a variety of underlying diagnoses. The present report describes the case of an 86-year-old man with symptomatic primary PI of small bowel treated with surgical approach after periodic episodes of cysts rupture and superimposed inflammation revealed on the basis of a clinical suspicion thanks to abdominal computed tomography. Moreover, after one year of followup, there has been no recurrence of digestive symptoms.

Improvement of pneumatosis cystoides intestinalis after steroid tapering in a patient with bronchial asthma: a case report

INTRODUCTION

We report the case of a patient who was diagnosed as having pneumatosis cystoides intestinalis while being treated with prednisolone for bronchial asthma. Even before we had experienced a case of this, the relationship between pneumatosis cystoides intestinalis and prednisolone was unclear. In this case, pneumatosis cystoides intestinalis was improved with the reduction of prednisolone, and therefore we thought a direct relationship between pneumatosis cystoides intestinalis and prednisolone might become clear, such as whether it is dose dependent.

CASE PRESENTATION

A 62-year-old Japanese woman had been treated for bronchial asthma for approximately 40 years. She presented with abdominal distension, and a radiographic examination showed intraperitoneal free gas and intramural gas, suggestive of pneumatosis cystoides intestinalis. However, when her prednisolone dose was decreased from 30 mg to 0 mg for approximately a year because of improvement in her asthma symptoms, her abdominal symptom resolved, and the frequency of her bowel movements returned to normal.

CONCLUSION

Amelioration of pneumatosis cystoides intestinalis was observed with tapering of the prednisolone, suggesting that prednisolone may have been involved in the pathogenesis of pneumatosis cystoides intestinalis in this patient.

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.

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

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

Natural history, clinical pattern, and surgical considerations of pneumatosis intestinalis

Objective

Pneumatosis intestinalis has been increasingly detected in recent years with the more frequent use of computed tomography for abdominal imaging of the intestine. The underlying causes of the gas found during radiographic studies of the bowel wall can vary widely and different hypotheses regarding its pathophysiology have been postulated. Pneumatosis intestinalis often represents a benign condition and should not be considered an argument for surgery. However, it can also require life-threatening surgery in some cases, and this can be a difficult decision in some patients.

Methods

The spectrum of pneumatosis intestinalis is discussed here based on various computed tomographic and surgical findings in patients who presented at our University Medical Centre in 2003-2008. We have also systematically reviewed the literature to establish the current understanding of its aetiology and pathophysiology, and the possible clinical conditions associated with pneumatosis intestinalis and their management.

Results

Pneumatosis intestinalis is a primary radiographic finding. After its diagnosis, its specific pathogenesis should be ascertained because the appropriate therapy is related to the underlying cause of pneumatosis intestinalis, and this is sometimes difficult to define. Surgical treatment should be considered urgent in symptomatic patients presenting with an acute abdomen, signs of ischemia, or bowel obstruction. In asymptomatic patients with otherwise inconspicuous findings, the underlying disease should be treated first, rather than urgent exploratory surgery considered. Extensive and comprehensive information on the pathophysiology and clinical findings of pneumatosis intestinalis is provided here and is incorporated into a treatment algorithm.

Conclusions

The information presented here allows a better understanding of the radiographic diagnosis and underlying aetiology of pneumatosis intestinalis, and may facilitate the decision-making process in this context, thus providing fast and adequate therapy to particular patients.

Pneumatosis cystoides intestinalis associated with massive free air mimicking perforated diffuse peritonitis

While pneumatosis cystoides intestinalis (PCI) is a rare disease entity associated with a wide variety of gastrointestinal and non-gastrointestinal disorders, PCI associated with massive intra- and retroperitoneal free air is extremely uncommon, and is difficult to diagnose differentially from perforated peritonitis. We present two cases of PCI associated with massive peritoneal free air and/or retroperitoneal air that mimicked perforated peritonitis. These cases highlight the clinical importance of PCI that mimics perforated peritonitis, which requires emergency surgery. Preoperative imaging modalities and diagnostic laparoscopy are useful to make an accurate diagnosis.

Pneumatosis cystoides intestinalis after fluorouracil chemotherapy for rectal cancer

Pneumatosis cystoides intestinalis (PCI) is a relatively rare condition characterized by intraluminal gas in the gastrointestinal tract. Several chemotherapeutic agents have been reported to be associated with PCI, although fluorouracil-related PCI is extremely rare. We report a case of a 76-year old man who received adjuvant chemotherapy for rectal cancer with fluorouracil (FU) and leucovorin (LV). After 1 cycle of the treatment, he presented with diarrhea and abdominal pain. Abdominal radiogram revealed the presence of free air under the diaphragm and intramural gas in the intestine. Laparotomy was performed, showing a suspected diagnosis of perforation in the gastrointestinal tract. Intraoperative findings revealed pneumatosis of the intestine without evidence of perforation. He was treated supportively and his symptoms improved. In conclusion, we should consider the possibility of PCI occurring in patients with malignancies during chemotherapy treatment.

Gastric pneumatosis following polychemotherapy

Lung cancer is the most frequent cause of cancer deaths in the western world today. In our case, we present the history of a 62-year-old man with the diagnosis of the uncommon complication of an acute gastric pneumatosis following his palliative chemotherapy. This rare condition was first described more than 100 years ago and has since been described in several distinctive clinical settings. To our knowledge, we present the first case of chemotherapy-related pneumatosis exclusively limited to the stomach wall but involving the portal veins and the spleen.