Gastric pneumatosis intestinalis associated with malignancy: An unusual case report

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.

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.

Gastric Pneumatosis: An Atypical Presentation of Desmoid Tumor

Case presentation

A middle-aged woman presented to the emergency department with a chief complaint of abdominal pain, fever, vomiting, and diarrhea. Abdominal computed tomography revealed gastric pneumatosis and air in the portal system. The patient had an unfavorable clinical course with pneumoperitoneum and septic shock due to secondary peritonitis. She underwent emergency laparotomy where neoformation of the mesentery root was found with infiltration of the small intestine and jejunal perforation. The anatomopathological study of the tumor revealed that it was a desmoid tumor.

Discussion

To our knowledge this is the first report in the literature of gastric pneumatosis as the initial presentation of a mesenteric desmoid tumor. Although it usually has a benign clinical course, its locally invasive characteristics can lead to critical illness. Physicians shouldn’t overlook these types of complications, as early identification and surgical intervention can modify the prognosis and shorten hospital stay.

Gastrointestinal malignant neoplasms disguised as pneumatosis cystoids intestinalis: A case report and literature review

RATIONALE

Pneumatosis cystoids intestinalis (PCI) is a rare disease in which gas develops in the mucosa or submucosa of the digestive tract. The etiology and pathogenesis of this disease, at present, remain unclear, and gastrointestinal malignant neoplasms may be a potentially important cause. Herein, we report a case of mantle cell lymphoma presenting as PCI as well as present a literature review of cases of suspect PCI that was definitively diagnosed as gastrointestinal neoplasms. In doing so, we highlighted cases of neoplastic pathogenesis that present as PCI.

PATIENT CONCERNS

A 55-year-old man was referred to our gastrointestinal department with complaints of intermittent abdominal pain, distention, diarrhea, and occasional melena that persisted for 2 months. He has a history of nasopharyngeal carcinoma.

DIAGNOSES

Intensive, translucent, grape-like cystoids of the whole colon and small intestine were disguised as PCI upon colonoscopy and capsule endoscopy.

INTERVENTIONS

Right hemicolectomy and ileocecectomy were performed for intussusception and to confirm the diagnosis. Final pathology indicated that the mass was mantle cell lymphoma.

OUTCOMES

After surgery and subsequent chemotherapy, the patient showed good recovery and no abnormal lesions were detected on colonoscopy.

LESSONS

As shown through this case and a literature review of similar cases of apparent PCI that was definitively diagnosed as gastrointestinal neoplasm, gastrointestinal malignant neoplasms might rarely present as PCI and neoplastic etiologies should also be considered once PCI is detected. Because most patients with malignant PCIs might inevitably experience severe complications, abdominal surgery should be considered and applied timely after unsuccessful resolution by conservative medical therapies and symptomatic treatments.

Pneumatosis cystoides intestinalis: A single center experience

AIM: To share our experience of the management and outcomes of patients with pneumatosis cystoides intestinalis (PCI).

METHODS: The charts of seven patients who underwent surgery for PCI between 2001 and 2009 were reviewed retrospectively. Clinical features, diagnoses and surgical interventions of patients with PCI are discussed.

RESULTS: Seven patients with PCI (3 males, 4 females; mean age, 50 ± 16.1 years; range, 29-74 years) were analyzed. In three of the patients, abdominal pain was the only complaint, whereas additional vomiting and/or constipation occurred in four. Leukocytosis was detected in four patients, whereas it was within normal limits in three. Subdiaphragmatic free air was observed radiologically in four patients but not in three. Six of the patients underwent an applied laparotomy, whereas one underwent an applied explorative laparoscopy. PCI localized to the small intestine only was detected in four patients, whereas it was localized to the small intestine and the colon in three. Three patients underwent a partial small intestine resection and four did not after PCI was diagnosed. Five patients were diagnosed with secondary PCI and two with primary PCI when the surgical findings and medical history were assessed together. Gastric atony developed in one case only, as a complication during a postoperative follow-up of 5-14 d.

CONCLUSION: Although rare, PCI should be considered in the differential diagnosis of acute abdomen. Diagnostic laparoscopy and preoperative radiological tests, including computed tomography, play an important role in confirming the diagnosis.