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Zhang MY, Xiao F, Han XF, Hou J, Gong HX, Shen YY, Huang HH. Transient hepatic portal venous gas secondary to acute ischemic necrotic colitis in a lymphoma patient during chemotherapy: A case report and review. J Dig Dis 2023; 24:434-436. [PMID: 37503941 DOI: 10.1111/1751-2980.13212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 07/21/2023] [Accepted: 07/25/2023] [Indexed: 07/29/2023]
Affiliation(s)
- Min Yue Zhang
- Division of Hematology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Fei Xiao
- Division of Hematology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Xiao Feng Han
- Division of Hematology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Jian Hou
- Division of Hematology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Hong Xia Gong
- Division of Radiology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Yan Ying Shen
- Division of Pathology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Hong Hui Huang
- Division of Hematology, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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Reginelli A, Sangiovanni A, Vacca G, Belfiore MP, Pignatiello M, Viscardi G, Clemente A, Urraro F, Cappabianca S. Chemotherapy-induced bowel ischemia: diagnostic imaging overview. Abdom Radiol (NY) 2022; 47:1556-1564. [PMID: 33811514 PMCID: PMC9038829 DOI: 10.1007/s00261-021-03024-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 02/19/2021] [Accepted: 02/25/2021] [Indexed: 12/19/2022]
Abstract
Cancer patients need multimodal therapies to treat their disease increasingly. In particular, drug treatment, as chemotherapy, immunotherapy, or various associations between them are commonly used to increase efficacy. However, the use of drugs predisposes a percentage of patients to develop toxicity in multiple organs and systems. Principle chemotherapy drugs mechanism of action is cell replication inhibition, rapidly proliferating cells especially. Immunotherapy is another tumor therapy strategy based on antitumor immunity activation trough agents as CTLA4 inhibitors (ipilimumab) or PD-1/PD-L1 inhibitors as nivolumab. If, on the one hand, all these agents inhibit tumor growth, on the other, they can cause various degrees toxicity in several organs, due to their specific mechanism of action. Particularly interesting are bowel toxicity, which can be clinically heterogeneous (pain, nausea, diarrhea, enterocolitis, pneumocolitis), up to severe consequences, such as ischemia, a rare occurrence. However, this event can occur both in vessels that supply intestine and in submucosa microvessels. We report drug-related intestinal vascular damage main characteristics, showing the radiological aspect of these alterations. Interpretation of imaging in oncologic patients has become progressively more complicated in the context of “target therapy” and thanks to the increasing number and types of therapies provided. Radiologists should know this variety of antiangiogenic treatments and immunotherapy regimens first because they can determine atypical features of tumor response and then also because of their eventual bowel toxicity.
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Affiliation(s)
- Alfonso Reginelli
- Department of Precision Medicine, University of Campania "L. Vanvitelli,", 80138, Naples, Italy.
| | - Angelo Sangiovanni
- Department of Precision Medicine, University of Campania "L. Vanvitelli,", 80138, Naples, Italy
| | - Giovanna Vacca
- Department of Precision Medicine, University of Campania "L. Vanvitelli,", 80138, Naples, Italy
| | - Maria Paola Belfiore
- Department of Precision Medicine, University of Campania "L. Vanvitelli,", 80138, Naples, Italy
| | - Maria Pignatiello
- Department of Precision Medicine, University of Campania "L. Vanvitelli,", 80138, Naples, Italy
| | - Giuseppe Viscardi
- Department of Precision Medicine, University of Campania "L. Vanvitelli,", 80138, Naples, Italy
| | - Alfredo Clemente
- Department of Precision Medicine, University of Campania "L. Vanvitelli,", 80138, Naples, Italy
| | - Fabrizio Urraro
- Department of Precision Medicine, University of Campania "L. Vanvitelli,", 80138, Naples, Italy
| | - Salvatore Cappabianca
- Department of Precision Medicine, University of Campania "L. Vanvitelli,", 80138, Naples, Italy
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Gazzaniga G, Villa F, Tosi F, Pizzutilo EG, Colla S, D’onghia S, Di Sanza G, Fornasier G, Gringeri M, Lucatelli MV, Mosini G, Pani A, Siena S, Scaglione F, Sartore-bianchi A. Pneumatosis Intestinalis Induced by Anticancer Treatment: A Systematic Review. Cancers (Basel) 2022; 14:1666. [PMID: 35406436 PMCID: PMC8996919 DOI: 10.3390/cancers14071666] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Revised: 03/16/2022] [Accepted: 03/22/2022] [Indexed: 02/06/2023] Open
Abstract
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.
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Abstract
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.
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Affiliation(s)
- Keiko Nunomiya
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University Faculty of Medicine, Japan
| | - Sumito Inoue
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University Faculty of Medicine, Japan
| | - Kento Sato
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University Faculty of Medicine, Japan
| | - Akira Igarashi
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University Faculty of Medicine, Japan
| | - Keiko Yamauchi
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University Faculty of Medicine, Japan
| | - Yuki Abe
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University Faculty of Medicine, Japan
| | - Masafumi Watanabe
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University Faculty of Medicine, Japan
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5
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Bitar ZI, Elhabibi ME, Maadarani OS, Albirami AK, Elzoueiry MM, Zaalouk TM. Hepatic portal vein gas detected by point of care ultrasound. Int J Surg Case Rep 2021; 83:105974. [PMID: 34022761 PMCID: PMC8164028 DOI: 10.1016/j.ijscr.2021.105974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 05/07/2021] [Accepted: 05/08/2021] [Indexed: 11/14/2022] Open
Abstract
Introduction Portal venous gas is a rare finding in adults and is typically associated with underlying intestinal ischemia. Portal venous gas can be detected by a bedside point of care ultrasound (POCUS) examination in adult patients in critical care units (CCU). Findings include echogenic bubbles flowing centrifugally throughout the portal venous system. Case presentation We present the case of a 73-year-old female with advanced ischemic cardiomyopathy and cardiorenal syndrome who was managed in the CCU. She developed vague abdominal pain and respiratory depression requiring intubation and dialysis during her course of treatment in the CCU. Her findings were consistent with portal venous gas upon POCUS, prompting computed tomography of her abdomen and surgical consultation. She was ultimately found to have nonobstructive mesenteric ischemia. Clinical discussion PVG is an ominous radiological sign and reflects intestinal ischemia in up to 72% of cases. Acute mesenteric ischemia of the small bowel could be due to occlusive or nonocclusive obstruction of the arterial blood supply or obstruction of venous outflow. Nonocclusive obstruction accounts for 5% to 15% of patients with acute mesenteric ischemia. Conclusion With the increasing use of POCUS, critical care physicians should be aware of findings consistent with portal venous gas as a bedside tool for directing the treating physician toward an ominous diagnosis in patients with shock. Portal vein gas detected by point-of-care ultrasound in situations of unidentified shock indicates a high likelihood of underlying intestinal ischemia. Point-of-care ultrasound plays an important role in detecting the sources of surgical emergencies. Nonobstructive mesenteric ischemia can present with nonspecific symptoms in critically ill patients, leading to a delay in diagnosis.
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Affiliation(s)
| | | | - Ossama Sajeh Maadarani
- Critical Care Unit, Ahmadi Hospital, Kuwait Oil Company, PO BOx 46468, 64015, Fahahil, Kuwait.
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Chen CC, Chen Y, Zhang YX, Chen ZH, Yang K. Case Report: A Rare Condition of Abdominal Pain: Chemotherapy Induced Portal Vein Pneumatosis Mimicking the Bowel Necrosis. Front Surg 2021; 8:620908. [PMID: 33693027 PMCID: PMC7938891 DOI: 10.3389/fsurg.2021.620908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 01/05/2021] [Indexed: 02/05/2023] Open
Abstract
Portal vein pneumatosis is the presence of air in the portal venous system, which is one of the classic radiologic features of bowel ischemia or necrosis. However, there are several other morbidities that can have portal vein pneumatosis as a complication. This is a case of a 44-year-old man who suffered from severe abdominal pain after chemotherapy for soft tissue sarcoma of his left hip. The physical signs, laboratory findings, as well as the portal venous pneumatosis sign of the CT scan strongly indicated the probability of bowel necrosis and subjected the treatment decision of the patient finally to laparotomy. However, nothing abnormal except a segment of swollen small intestine was detected. Caution should be kept in mind when encountering a patient with suspected bowel necrosis following chemotherapy since several chemotherapeutic agents could cause portal vein pneumatosis. Diagnostic laparoscopy might be a better option for such cases.
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Affiliation(s)
- Chong-Cheng Chen
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China
| | - Yi Chen
- Department of Nephrology, West China Hospital, Sichuan University, Chengdu, China
| | - Yue-Xin Zhang
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Ze-Hua Chen
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Kun Yang
- Department of Gastrointestinal Surgery, West China Hospital, Sichuan University, Chengdu, China
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7
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Affiliation(s)
- M Laharwal
- Department of Medicine, Saint Barnabas Medical Center, Livingston, NJ 07039, USA
| | - E Orosz
- Division of Gastroenterology & Hepatology, Rutgers Robert Wood Johnson Medical School, Medical Education Building, New Brunswick, NJ 08901, USA
| | - C Law
- Division of Gastroenterology & Hepatology, Rutgers Robert Wood Johnson Medical School, Medical Education Building, New Brunswick, NJ 08901, USA
| | - A V Patel
- Division of Gastroenterology & Hepatology, Rutgers Robert Wood Johnson Medical School, Medical Education Building, New Brunswick, NJ 08901, USA
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Torres US, Fortes CD, Salvadori PS, Tiferes DA, D′Ippolito G. Pneumatosis From Esophagus to Rectum: A Comprehensive Review Focusing on Clinico-Radiological Differentiation Between Benign and Life-Threatening Causes. Semin Ultrasound CT MR 2018; 39:167-182. [DOI: 10.1053/j.sult.2017.09.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Kouzu K, Tsujimoto H, Hiraki S, Takahata R, Yaguchi Y, Kumano I, Horiguchi H, Nomura S, Nagata K, Harada M, Nagata H, Sugihara T, Ishibashi Y, Itazaki Y, Tsuchiya S, Aosasa S, Hase K, Yamamoto J, Ueno H. A case of pneumatosis intestinalis during neoadjuvant chemotherapy with cisplatin and 5-fluorouracil for esophageal cancer †. J Surg Case Rep 2017; 2017:rjx227. [PMID: 29181149 PMCID: PMC5697399 DOI: 10.1093/jscr/rjx227] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Revised: 10/02/2017] [Accepted: 11/06/2017] [Indexed: 12/27/2022] Open
Abstract
Pneumatosis intestinalis (PI) is a relatively rare disease. A 70-year-old man with stage II squamous cell carcinoma of the middle thoracic esophagus was administered cisplatin plus 5-fluorouracil (CF) therapy as neoadjuvant chemotherapy. On Day 14 of the first course of CF therapy, he complained of acute abdominal pain. Computed tomography (CT) revealed PI of the entire colon and a small air bubble in the mesentery. A colonoscopy revealed that there was no finding suggestive of ischemia. Because there was no sign of peritoneal irritation, conservative treatment was selected. On Day 7 after PI diagnosis, CT indicated the disappearance of PI. The patient underwent a radical esophagectomy. Intraoperative laparoscopic findings showed the serosa of the colon to be intact. The patient was discharged without any complications. It is important to take into account that CF therapy may cause PI and that PI can be treated conservatively.
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Affiliation(s)
- Keita Kouzu
- Department of Surgery, National Defense Medical College, 3-2 Namiki, Tokorozawa 359-8513, Japan
| | - Hironori Tsujimoto
- Department of Surgery, National Defense Medical College, 3-2 Namiki, Tokorozawa 359-8513, Japan
| | - Shuichi Hiraki
- Department of Surgery, National Defense Medical College, 3-2 Namiki, Tokorozawa 359-8513, Japan
| | - Risa Takahata
- Department of Surgery, National Defense Medical College, 3-2 Namiki, Tokorozawa 359-8513, Japan
| | - Yoshihisa Yaguchi
- Department of Surgery, National Defense Medical College, 3-2 Namiki, Tokorozawa 359-8513, Japan
| | - Isao Kumano
- Department of Surgery, National Defense Medical College, 3-2 Namiki, Tokorozawa 359-8513, Japan
| | - Hiroyuki Horiguchi
- Department of Surgery, National Defense Medical College, 3-2 Namiki, Tokorozawa 359-8513, Japan
| | - Shinsuke Nomura
- Department of Surgery, National Defense Medical College, 3-2 Namiki, Tokorozawa 359-8513, Japan
| | - Ken Nagata
- Department of Surgery, National Defense Medical College, 3-2 Namiki, Tokorozawa 359-8513, Japan
| | - Manabu Harada
- Department of Surgery, National Defense Medical College, 3-2 Namiki, Tokorozawa 359-8513, Japan
| | - Hiromi Nagata
- Department of Surgery, National Defense Medical College, 3-2 Namiki, Tokorozawa 359-8513, Japan
| | - Takao Sugihara
- Department of Surgery, National Defense Medical College, 3-2 Namiki, Tokorozawa 359-8513, Japan
| | - Yusuke Ishibashi
- Department of Surgery, National Defense Medical College, 3-2 Namiki, Tokorozawa 359-8513, Japan
| | - Yujiro Itazaki
- Department of Surgery, National Defense Medical College, 3-2 Namiki, Tokorozawa 359-8513, Japan
| | - Satoshi Tsuchiya
- Department of Surgery, National Defense Medical College, 3-2 Namiki, Tokorozawa 359-8513, Japan
| | - Suefumi Aosasa
- Department of Surgery, National Defense Medical College, 3-2 Namiki, Tokorozawa 359-8513, Japan
| | - Kazuo Hase
- Department of Surgery, National Defense Medical College, 3-2 Namiki, Tokorozawa 359-8513, Japan
| | - Junji Yamamoto
- Department of Surgery, National Defense Medical College, 3-2 Namiki, Tokorozawa 359-8513, Japan
| | - Hideki Ueno
- Department of Surgery, National Defense Medical College, 3-2 Namiki, Tokorozawa 359-8513, Japan
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Tan EW, Smith MD. A rare occurrence of hepatic portal venous gas in a patient with chemotherapy-induced enterocolitis: the rise of benign aetiologies. J Surg Case Rep 2015; 2015:rjv114. [PMID: 26362212 PMCID: PMC4566040 DOI: 10.1093/jscr/rjv114] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Hepatic portal venous gas (HPVG) is often viewed as an ominous imaging finding with a poor prognosis and a high mortality rate. We recently encountered a case of HPVG in a patient with advanced metastatic prostate cancer previously treated with chemotherapy and radiotherapy. A laparotomy was performed, which was negative. Although HPVG secondary to chemotherapy is extremely rare, we as clinicians need to consider this aetiology and other benign aetiologies. With the increased rate of benign aetiologies and their successful conservative management, the role of emergency laparotomies needs to be re-considered.
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Affiliation(s)
- Elizabeth W Tan
- General Surgery Department, Bunbury Regional Hospital, Bunbury, Western Australia, Australia
| | - Mark D Smith
- General Surgery Department, Bunbury Regional Hospital, Bunbury, Western Australia, Australia
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Kawaguchi Y, Fujita T, Hanaoka J, Hayashi K. A Case of Hepatic Portal Venous Gas in a Patient Treated with Pemetrexed and Carboplatin for Lung Cancer. Chemotherapy 2015; 60:88-90. [PMID: 25720567 DOI: 10.1159/000371440] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Accepted: 12/08/2014] [Indexed: 11/19/2022]
Abstract
Hepatic portal venous gas (HPVG) has rarely been reported in patients undergoing chemotherapy. We encountered a case of a 64-year-old man with stage IIIA lung adenocarcinoma who received adjuvant chemotherapy with pemetrexed and carboplatin and developed HPVG 1 day after the second chemotherapy. An emergency operation was performed, but the patient died 2 days after the operation because of multiple organ failure caused by sepsis. Since the patient had complained of alternating abdominal bloating and diarrhea during chemotherapy, we considered that the cause of HPVG was intestinal mucosal disruption and increased intraluminal pressure due to the chemotherapy.
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Sedlaczek O, Grüllich C, Röthke M, Schlemmer HP, Kauczor HU. [Organ toxicity of medicinal tumor therapy: morphological correlates]. Radiologe 2013; 53:329-35. [PMID: 23536030 DOI: 10.1007/s00117-012-2428-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
UNLABELLED CLINICAL/METHODOLOGICAL ISSUE: In antineoplastic chemotherapy classical cytostatic drugs are increasingly being supplemented by antibodies and so-called targeted therapies. In addition to the antineoplastic effect and general intolerance quite characteristic morphological changes can often be found and identified by the radiologist. The distinction between findings indicating side effects versus tumor progression or an infectious etiology is essential. FACTS AND CIRCUMSTANCES Classical antineoplastic chemotherapy interacts with DNA and RNA synthesis, DNA repair or the mitosis process. In contrast modern targeted anticancer therapies act at the level of signal transduction pathways.Localized, organ-related changes are related to the metabolic characteristics of organs or anatomical features such as the properties of the local blood-tissue barrier. Toxicity associated findings often resemble fulminant tumor progression. EVALUATION In new targeted anti-cancer therapies toxicity often occurs in a non-cumulative way; therefore, morphological changes are often precursors of the manifestation of clinical toxicity. PRACTICAL RECOMMENDATIONS Oncological radiology requires increasingly active interdisciplinary dialogue in order to delineate morphological correlates of organ toxicity against tumor progression and initiate appropriate therapeutic measures.
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Affiliation(s)
- O Sedlaczek
- Diagnostische und Interventionelle Radiologie, Universitätsklinik Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland.
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Rahim H, Khan M, Hudgins J, Lee K, Du L, Amorosa L. Gastrointestinal sarcoidosis associated with pneumatosis cystoides intestinalis. World J Gastroenterol 2013; 19:1135-1139. [PMID: 23467442 PMCID: PMC3582003 DOI: 10.3748/wjg.v19.i7.1135] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2012] [Revised: 11/19/2012] [Accepted: 12/17/2012] [Indexed: 02/06/2023] Open
Abstract
A 39-year-old male reported fevers, weight loss, watery loose stools, and decreased visual acuity in his right eye over the prior five years. He was pancytopenic, had an elevated American council on exercise level, total bilirubin, and alkaline phosphatase. Computed tomography revealed massive hepatosplenomegaly and emphysematous lung changes. Liver biopsy showed non caseating granulomas. The patient was diagnosed with extrapulmonary sarcoidosis and was treated with prednisone. The patient symptomatically improved but 5 mo later presented with abdominal pain caused by perforation of the cecum. He underwent a cecectomy and pathology revealed pneumatosis cystoides intestinalis. This represents the first reported association between pneumatosis cystoides intestinalis and sarcoidosis. The etiology of pneumatosis cystoides intestinalis in this case was likely multifactorial and involved both effects of the corticosteroids as well as the advanced nature of the gastrointestinal sarcoidosis. Furthermore this case has the unique features of emphysematous lung changes and pancytopenia which are uncommon with sarcoidosis.
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Shinagare AB, Howard SA, Krajewski KM, Zukotynski KA, Jagannathan JP, Ramaiya NH. Pneumatosis intestinalis and bowel perforation associated with molecular targeted therapy: an emerging problem and the role of radiologists in its management. AJR Am J Roentgenol. 2012;199:1259-1265. [PMID: 23169717 DOI: 10.2214/ajr.12.8782] [Citation(s) in RCA: 82] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE The purpose of this article is to study the imaging features, management, and outcome of pneumatosis intestinalis and bowel perforation associated with molecular targeted therapy. MATERIALS AND METHODS In this retrospective study, 48 patients with cancer who developed pneumatosis or intestinal perforation were found by searching a radiology database. Of these patients, 24 patients (13 women and 11 men; mean age, 61 years; range, 39-83 years) receiving molecular targeted therapy without any confounding factors for pneumatosis or perforation were selected. Initial and follow-up CT scans were evaluated by two radiologists; medical records were reviewed to note clinical features, management, and outcome. RESULTS Seventeen (70.8%) patients were asymptomatic. Colorectal cancer (n = 10) and renal cell carcinoma (n = 5) were the most common malignancies; bevacizumab (n = 14) and sunitinib (n = 6) were the most common associated drugs. Imaging findings included intestinal perforation (20 sites in 18 patients), pneumatosis (n = 10), ascites (n = 8), pneumoperitoneum (n = 7), fistula formation (n = 7), and fluid collections (six collections in five patients). Fifteen (62.5%) patients were treated conservatively, seven (29.2%) underwent surgery, and two (8.3%) underwent percutaneous drainage. Molecular targeted therapy was discontinued in 22 of 24 patients; findings resolved in 19 patients, remained stable in one, and worsened in one. One patient died after surgery. In both instances where the drug was continued, the abnormality worsened. Findings recurred in three of four patients in whom the drug was restarted after initial resolution. CONCLUSION Radiologists should be aware of intestinal complications associated with molecular targeted therapy, including pneumatosis, bowel perforation, and fistula formation. Most patients can be treated conservatively after discontinuation of molecular targeted therapy. Continuing or restarting molecular targeted therapy can cause worsening or recurrent pneumatosis or perforation.
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Sakamoto A, Matsumoto N, Arimura Y, Yanagi S, Iiboshi H, Tokojima M, Yamashita S, Nakazato M. Hepatic portal venous gas in a patient undergoing chemotherapy for non-small cell lung cancer. Int Cancer Conf J 2013; 2:14-16. [DOI: 10.1007/s13691-012-0055-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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Shin DK, Oh J, Yoon H, Kim JE, Chong SY, Oh D. Asymptomatic pneumatosis intestinalis following chemotherapy for B lymphoblastic leukemia with recurrent genetic abnormalities in an adolescent patient. Korean J Hematol 2012; 47:74-6. [PMID: 22479281 PMCID: PMC3317476 DOI: 10.5045/kjh.2012.47.1.74] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/17/2011] [Revised: 09/16/2011] [Accepted: 02/20/2012] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- Dae-Kyu Shin
- Department of Internal Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Korea
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Lee JY, Han HS, Lim SN, Shim YK, Choi YH, Lee OJ, Lee KH, Kim ST. Pneumatosis intestinalis and portal venous gas secondary to Gefitinib therapy for lung adenocarcinoma. BMC Cancer 2012; 12:87. [PMID: 22405425 PMCID: PMC3314573 DOI: 10.1186/1471-2407-12-87] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2011] [Accepted: 03/10/2012] [Indexed: 12/13/2022] Open
Abstract
Background Pneumatosis intestinalis (PI), defined as the presence of gas in the bowel wall, and portal venous gas (PVG) are relatively rare radiological findings. Although several chemotherapeutic agents and anti-vascular endothelial growth factor agents are reported to be associated with PI and PVG, an association with anti-epidermal growth factor receptor (EGFR) agents has not been described previously. Case presentation The present report describes a case of PI and PVG secondary to treatment with an EGFR tyrosine kinase inhibitor. A 66-year-old woman who had been diagnosed with metastatic lung adenocarcinoma presented with nausea, vomiting and abdominal distension after commencing gefitinib. A computed tomography (CT) scan of the abdomen revealed PI extending from the ascending colon to the rectum, hepatic PVG, and infarction of the liver. Gefitinib therapy was discontinued immediately and the patient was managed conservatively. A follow-up CT scan 2 weeks later revealed that the PI and hepatic PVG had completely resolved. Conclusion This is the first report of PI and PVG caused by EGFR tyrosine kinase inhibitor. Although these complications are extremely rare, clinicians should be aware of the risk of PI and PVG in patients undergoing targeted molecular therapy.
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Affiliation(s)
- Joo Young Lee
- Department of Internal Medicine College of Medicine, Chungbuk National University, 410 Seongbong-ro, Heungduk-Gu, Cheongju 361-711, South Korea
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Naguib N, Mekhail P, Gupta V, Naguib N, Masoud A. Portal venous gas and pneumatosis intestinalis; radiologic signs with wide range of significance in surgery. J Surg Educ 2012; 69:47-51. [PMID: 22208832 DOI: 10.1016/j.jsurg.2011.07.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/07/2011] [Accepted: 07/20/2011] [Indexed: 05/31/2023]
Abstract
BACKGROUND Portal vein gas (PVG) was described as an uncommon ominous radiologic sign usually harboring an intra-abdominal catastrophe. When accompanied by pneumatosis intestinalis (PI), it is more predictive of bowel ischemia. Since the wide use of computed tomography (CT), both signs could also be viewed as incidental findings during routine radiologic investigations. METHODS We present a series of 12 cases that showed either or both signs, collected in a district general hospital between 1991 and 2011. RESULTS The diagnoses in these cases varied between fatal bowel ischemia and the mere presence of radiologic signs in the absence of significant pathology. CONCLUSION PVG and PI are radiologic signs that can represent a wide range of pathology.
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Affiliation(s)
- Nader Naguib
- Department of Surgery, Prince Charles Hospital, Merthyr Tydfil, United Kingdom.
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19
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Arredondo J, Pastor C, Amoza S, Oronoz B, Arbea L, Hernández-Lizoain JL. Portal pneumatosis as a complication of neoadjuvant chemoradiotherapy for rectal cancer: a case report. Colorectal Dis 2011; 13:e383-4. [PMID: 21689357 DOI: 10.1111/j.1463-1318.2011.02690.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- J Arredondo
- Department of General Surgery, Clínica Universidad de Navarra, Pamplona, Spain.
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Torrisi JM, Schwartz LH, Gollub MJ, Ginsberg MS, Bosl GJ, Hricak H. CT Findings of Chemotherapy-induced Toxicity: What Radiologists Need to Know about the Clinical and Radiologic Manifestations of Chemotherapy Toxicity. Radiology 2011; 258:41-56. [DOI: 10.1148/radiol.10092129] [Citation(s) in RCA: 153] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
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Clemente G, Chiarla C, Giovannini I, De Rose AM, Astone A, Barone C, Nuzzo G. Gas in portal circulation and pneumatosis cystoides intestinalis during chemotherapy for advanced rectal cancer. Curr Med Res Opin 2010; 26:707-11. [PMID: 20078321 DOI: 10.1185/03007990903566798] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES Acute abdominal symptoms with CT scan evidence of intramural gas in bowel walls (pneumatosis cystoides intestinalis, PCI) and of gas in the portal venous blood (PBG) in patients undergoing chemotherapy may represent a worrisome picture, suggestive of bowel necrosis. This picture remains a major clinical clue and the reporting of new cases may help to share awareness and experience on management. We describe a patient with acute abdominal symptoms and evidence of PCI with PBG under cetuximab, oxaliplatin, tegafur-uracil and folinic acid chemotherapy for metastatic adenocarcinoma of the rectosigmoid junction. METHODS After admission for mucositis with diarrhea and profound dehydration, and subsequent emergency laparotomy for derotation of an intestinal volvulus, on the tenth postoperative day the patient developed fever and abdominal pain, with CT scan evidence of PCI with PBG. The exam of the abdomen did not suggest major problems requiring emergency surgery, and antibiotic treatment with close monitoring were performed, followed by rapid improvement. RESULTS Twelve days later, after resumption of oral diet, the patient unexpectedly suffered a spontaneous jejunal microperforation, requiring emergency laparotomy and bowel resection. Pathology showed that the perforation was within an area of ulceration involving the inner superficial layer of the bowel. Subsequently recovery was normal and at present, after 15 months, the patient is well and continuing chemotherapy. CONCLUSIONS This is probably the first report of PCI with PBG related to intestinal toxicity during cetuximab, oxaliplatin, tegafur-uracil and folinic acid chemotherapy in a patient with advanced rectal carcinoma, followed by delayed small bowel perforation. It provides an example of the challenges involved in the management of this type of patient.
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Affiliation(s)
- G Clemente
- Catholic University of Sacred Heart, Agostino Gemelli Medical School, Rome, Italy.
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22
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Chou CT, Su WW, Chen RC. Successful conservative treatment of pneumatosis intestinalis and portomesenteric venous gas in a patient with septic shock. Kaohsiung J Med Sci 2010; 26:105-8. [PMID: 20123600 DOI: 10.1016/s1607-551x(10)70016-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
Pneumatosis intestinalis (PI) and portomesenteric venous gas (PMVG) are alarming radiological findings that signify bowel ischemia. The management of PI and PMVG remain a challenging task because clinicians must balance the potential morbidity associated with unnecessary surgery with inevitable mortality if the necrotic bowel is not resected. The combination of PI, portal venous gas, and acidosis typically indicates bowel ischemia and, inevitably, necrosis. We report a patient with PI and PMVG caused by septic shock who completely recovered after conservative treatment.
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Affiliation(s)
- Chen-Te Chou
- Department of Radiology, Changhua Christian Hospital, Er-Lin branch, Taipei, Taiwan
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Ortega J, Hayes JM, Antonia S. Hepatic portal venous gas in a patient with metastatic non-small cell lung cancer on bevacizumab therapy: a case report and review of the literature. Cancer Chemother Pharmacol 2009; 65:187-90. [PMID: 19697030 DOI: 10.1007/s00280-009-1104-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2009] [Accepted: 07/29/2009] [Indexed: 10/20/2022]
Abstract
BACKGROUND The presence of hepatic portal venous gas (HPVG) is a rare finding. It is most commonly caused by bowel necrosis and typically carries a grave prognosis. Bevacizumab has emerged as an effective standard therapy in the frontline management of advanced non-small cell lung cancer (NSCLC). Although bevacizumab is associated with gastrointestinal perforation, it has not been shown to cause HPVG. CASE A 75-year-old man, diagnosed with metastatic NSCLC, was treated with palliative chemotherapy consisting of paclitaxel, carboplatin, and bevacizumab for six cycles. He continued on maintenance bevacizumab after that for a total of six doses, given every 3 weeks, with continued stable disease. During a surveillance CT scan 4 weeks after the last dose of bevacizumab, HPVG was shown. CONCLUSION This is the first case of HPVG associated with bevacizumab therapy in a patient with metastatic NSCLC. The HPVG may have been an early warning sign of impending bowel perforation, and bevacizumab was immediately discontinued, with HPVG completely resolving on follow-up CT scan 2 weeks later. We recommend that bevacizumab therapy be immediately and permanently discontinued whenever HPVG is observed, as this may help avoid a potentially catastrophic outcome.
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Abstract
Hepatic portal venous gas (HPVG), an ominous radiologic sign, is associated in some cases with a severe underlying abdominal disease requiring urgent operative intervention. HPVG has been reported with increasing frequency in medical literature and usually accompanies severe or lethal conditions. The diagnosis of HPVG is usually made by plain abdominal radiography, sonography, color Doppler flow imaging or computed tomography (CT) scan. Currently, the increased use of CT scan and ultrasound in the inpatient setting allows early and highly sensitive detection of such severe illnesses and also the recognition of an increasing number of benign and non-life threatening causes of HPVG. HPVG is not by itself a surgical indication and the treatment depends mainly on the underlying disease. The prognosis is related to the pathology itself and is not influenced by the presence of HPVG. Based on a review of the literature, we discuss in this paper the pathophysiology, risk factors, radiographic findings, management, and prognosis of pathologies associated with HPVG.
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Zalinski S, Scatton O, Jacqmin S, Tacher V, Brézault C, Soubrane O. Portal venous gas following chemotherapy for colorectal cancer liver metastasis. Eur J Surg Oncol 2008; 35:557-60. [PMID: 18950980 DOI: 10.1016/j.ejso.2008.09.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2008] [Revised: 08/29/2008] [Accepted: 09/02/2008] [Indexed: 01/02/2023] Open
Abstract
The standard of care for patients with colorectal liver metastases is a combination of chemotherapy and surgery. New chemotherapy regimens with biologic agents (cetuximab, bevacizumab) have been shown to increase tumor response rates. Although this might be beneficial and this is an expected endpoint, it should be noted that patients with synchronous colorectal and liver metastases are at risk of septic complications. We recently encountered a case of hepatic portal venous gas after two cycles of chemotherapy in a patient with right colon cancer liver metastases. Complete necrosis of the liver metastasis subsequently turned into a liver abscess, which fistulized in the right portal vein. Infection of the necrotized metastasis was thought to be promoted by the colic tumor. Although this is a dramatic situation, it does not contraindicate a curative surgical resection.
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Affiliation(s)
- S Zalinski
- Department of Hepatobiliary Surgery and Liver Transplantation, Cochin Hospital, Paris, France
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Abstract
Background Portal vein gas is an ominous radiological sign, which indicates a serious gastrointestinal problem in the majority of patients. Many causes have been identified and the most important was bowel ischemia and mesenteric vascular accident. The presentation of patients is varied and the diagnosis of the underlying problem depends mainly on the radiological findings and clinical signs. The aim of this article is to show the clinical importance of portal vein gas and its management in emergency surgery. Methods A computerised search was made of the Medline for publications discussing portal vein gas through March 2008. Sixty articles were identified and selected for this review because of their relevance. These articles cover a period from 1975–2008. Results Two hundreds and seventy-five patients with gas in the portal venous system were reported. The commonest cause for portal vein gas was bowel ischemia and mesenteric vascular pathology (61.44%). This was followed by inflammation of the gastrointestinal tract (16.26%), obstruction and dilatation (9.03%), sepsis (6.6%), iatrogenic injury and trauma (3.01%) and cancer (1.8%). Idiopathic portal vein gas was also reported (1.8%). Conclusion Portal vein gas is a diagnostic sign, which indicates a serious intra-abdominal pathology requiring emergency surgery in the majority of patients. Portal vein gas due to simple and benign cause can be treated conservatively. Correlation between clinical and diagnostic findings is important to set the management plan.
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Affiliation(s)
- Abdulzahra Hussain
- General surgery department, Princess Royal University Hospital, Greater London, UK.
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Mimatsu K, Oida T, Kawasaki A, Kano H, Kuboi Y, Aramaki O, Amano S. Pneumatosis cystoides intestinalis after fluorouracil chemotherapy for rectal cancer. World J Gastroenterol 2008; 14:3273-5. [PMID: 18506940 PMCID: PMC2712867 DOI: 10.3748/wjg.14.3273] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
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.
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