A Rare Case of Benign Pneumatosis Intestinalis with Portal Venous Gas and Pneumoperitoneum Induced by Acarbose

The Challenge of Pneumatosis Intestinalis: A Contemporary Systematic Review

PURPOSE

Pneumatosis intestinalis is a radiological finding with incompletely understood pathogenesis. To date, there are no protocols to guide surgical intervention.

METHODS

A systematic review of literature, according to PRISMA criteria, was performed. Medline and PubMed were consulted to identify articles reporting on the items "emergency surgery, pneumatosis coli, and pneumatosis intestinalis" from January 2010 up to March 2022. This study has not been registered in relevant databases.

RESULTS

A total of 1673 patients were included. The average age was 67.1 ± 17.6 years. The etiology was unknown in 802 (47.9%) patients. Hemodynamic instability (246/1673-14.7% of the patients) was associated with bowel ischemia, necrosis, or perforation (p = 0.019). Conservative management was performed in 824 (49.2%) patients. Surgery was performed 619 (36.9%) times, especially in unstable patients with bowel ischemia signs, lactate levels greater than 2 mmol/L, and PVG (p = 0.0026). In 155 cases, surgery was performed without pathological findings.

CONCLUSIONS

Many variables should be considered in the approach to patients with pneumatosis intestinalis. The challenge facing the surgeons is in truly identifying those who really would benefit and need surgical intervention. The watch and wait policy as a first step seems reasonable, reserving surgery only for patients who are unstable or with high suspicion of bowel ischemia, necrosis, or perforation.

Pneumatosis cystoides intestinalis in dermatomyositis: a case series report and literature review

Pneumatosis cystoides intestinalis (PCI) in adult dermatomyositis (DM) is rarely described. This report aimed to describe the clinical features and prognosis of PCI in six adult patients with DM (four with anti-MDA5 antibodies, one with anti-SAE antibodies, and one with anti-TIF-1γ antibodies). Except for one patient with transient abdominal pain, the remaining five patients were asymptomatic. PCI occurred in the ascending colon in all patients, of whom five had free gas in the abdominal cavity. No patients received excessive treatment, and PCI disappeared in four patients during the follow-up. Additionally, we reviewed previous studies on this complication.

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.

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.

Pneumatosis cystoides intestinalis: six case reports and a review of the literature

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.

Pneumatosis intestinalis with a benign clinical course: a report of two cases

Background

Pneumatosis intestinalis (PI) is a rare condition characterized by the presence of gas within the gastrointestinal tract wall. Most cases of PI have a benign clinical course, although some have serious outcomes. Mechanical stress on or bacterial infection of the gastrointestinal tract wall may be responsible for the onset of PI, but the detailed mechanism of PI pathogenesis is still unclear. Here, we describe two Japanese patients presenting with benign PI.

Case presentation

Case 1, a 37-year-old previously healthy male patient, had a 1-week history of abdominal pain, and case 2, a 78-year-old female diabetic patient, had a 2-week history of voglibose treatment and abdominal pain. Intramural gas was mainly distributed in the colon in case 1 and in the small intestine in case 2. Interestingly, neither patient showed obvious inflammatory signs upon admission and recovered spontaneously with conservative treatment, including fasting and fluid infusion without antibiotics. Voglibose treatment was terminated in case 2. Recent studies have shown the presence of nonpathogenic bacteria, such as Clostridium spp., in PI lesions, which usually play an important role in modulating the tolerance of the gastrointestinal immune responses. The benign clinical course and spontaneous resolution of PI in these patients, without specific treatment, suggests that nonpathogenic indigenous bacteria in the gastrointestinal tract participate in the pathogenesis of PI.

Conclusion

In patients with benign PI, the absence of an inflammatory response and the spontaneous resolution of the disease without specific treatment suggest the participation of nonpathogenic indigenous bacteria of the gastrointestinal tract.

Pneumatosis intestinalis after etoposide-based chemotherapy in a patient with metastatic small cell lung cancer: successful conservative management of a rare condition

A 69-year-old male patient, smoker, was diagnosed with small cell lung cancer metastatic to lung, liver and central nervous system. He received chemotherapy with carboplatin AUC 5 on day 1 and etoposide 100mg/m² on days 1, 2 and 3. During the first cycle, the patient presented with febrile neutropenia and abdominal distension. Chest, abdomen and pelvis computed tomography scan was performed and detected gas dissecting the wall of sigmoid colon extending to the mesosigmoid. Patient had no abdominal pain, nausea, vomiting, and on physical examination he had no peritoneal irritation, tachycardia or hemodynamic instability compatible with perforation or acute abdomen. Therefore, the radiological finding was interpreted as pneumatosis intestinalis caused by chemotherapy with etoposide. Pneumatosis resolved after continuous oxygen therapy. The second cycle was administered after a complete resolution of the clinical condition and etoposide dose was reduced by 30%. The patient experienced a remarkable evolution.