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Ito N, Masuda T, Yamaguchi K, Sakamoto S, Horimasu Y, Nakashima T, Miyamoto S, Iwamoto H, Fujitaka K, Hamada H, Hattori N. Pneumatosis Intestinalis following Radiation Esophagitis during Chemoradiotherapy for Lung Cancer: A Case Report. Case Rep Oncol 2021; 14:1454-1459. [PMID: 34899236 PMCID: PMC8613634 DOI: 10.1159/000518315] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Accepted: 07/05/2021] [Indexed: 11/19/2022] Open
Abstract
Pneumatosis intestinalis (PI) is a rare disease that forms emphysema lesions under the mucosa and serosa of the gastrointestinal tract. We present the first case of PI following radiation-induced esophagitis during chemoradiotherapy (CRT) for lung cancer. A 74-year-old man with severe chronic obstructive pulmonary disease (COPD) was treated with CRT for lung cancer. During the treatment, he presented with vomiting and abdominal distention. CT showed pneumatosis from the esophagus to the small intestine. Severe radiation-induced esophagitis was observed, and gastrointestinal endoscopy revealed a circumferential esophageal ulcer. From these observations, this case was diagnosed as PI following severe esophagitis. A nasogastric tube was inserted, and conservative treatment with fasting, fluid replacement, and antibiotic was performed. Four days after the onset of PI, CT showed marked improvement of the pneumatosis. When CRT is performed for lung cancer patients, we should not only consider esophagitis but also PI. The presence of COPD may be considered a specific factor for the development of severe esophagitis and the consequent PI in this case.
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Affiliation(s)
- Noriaki Ito
- Department of Respiratory Medicine, Hiroshima University Hospital, Hiroshima, Japan
| | - Takeshi Masuda
- Department of Respiratory Medicine, Hiroshima University Hospital, Hiroshima, Japan
| | - Kakuhiro Yamaguchi
- Department of Respiratory Medicine, Hiroshima University Hospital, Hiroshima, Japan
| | - Shinjiro Sakamoto
- Department of Respiratory Medicine, Hiroshima University Hospital, Hiroshima, Japan
| | - Yasushi Horimasu
- Department of Respiratory Medicine, Hiroshima University Hospital, Hiroshima, Japan
| | - Taku Nakashima
- Department of Respiratory Medicine, Hiroshima University Hospital, Hiroshima, Japan
| | - Shintaro Miyamoto
- Department of Respiratory Medicine, Hiroshima University Hospital, Hiroshima, Japan
| | - Hiroshi Iwamoto
- Department of Molecular and Internal Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Kazunori Fujitaka
- Department of Molecular and Internal Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Hironobu Hamada
- Department of Physical Analysis and Therapeutic Sciences, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Noboru Hattori
- Department of Molecular and Internal Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
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Miyara SJ, Becker LB, Guevara S, Kirsch C, Metz CN, Shoaib M, Grodstein E, Nair VV, Jandovitz N, McCann-Molmenti A, Hayashida K, Takegawa R, Shinozaki K, Yagi T, Aoki T, Nishikimi M, Choudhary RC, Cho YM, Zanos S, Zafeiropoulos S, Hoffman HB, Watt S, Lumermann CM, Aronsohn J, Shore-Lesserson L, Molmenti EP. Pneumatosis Intestinalis in the Setting of COVID-19: A Single Center Case Series From New York. Front Med (Lausanne) 2021; 8:638075. [PMID: 34150792 PMCID: PMC8212022 DOI: 10.3389/fmed.2021.638075] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Accepted: 03/08/2021] [Indexed: 12/18/2022] Open
Abstract
This case series reviews four critically ill patients infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) [coronavirus disease 2019 (COVID-19)] suffering from pneumatosis intestinalis (PI) during their hospital admission. All patients received the biological agent tocilizumab (TCZ), an interleukin (IL)-6 antagonist, as an experimental treatment for COVID-19 before developing PI. COVID-19 and TCZ have been independently linked to PI risk, yet the cause of this relationship is unknown and under speculation. PI is a rare condition, defined as the presence of gas in the intestinal wall, and although its pathogenesis is poorly understood, intestinal ischemia is one of its causative agents. Based on COVID-19's association with vasculopathic and ischemic insults, and IL-6's protective role in intestinal epithelial ischemia-reperfusion injury, an adverse synergistic association of COVID-19 and TCZ can be proposed in the setting of PI. To our knowledge, this is the first published, single center, case series of pneumatosis intestinalis in COVID-19 patients who received tocilizumab therapy.
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Affiliation(s)
- Santiago J. Miyara
- Elmezzi Graduate School of Molecular Medicine, Manhasset, NY, United States
- Feinstein Institutes for Medical Research, Manhasset, NY, United States
| | - Lance B. Becker
- Elmezzi Graduate School of Molecular Medicine, Manhasset, NY, United States
- Feinstein Institutes for Medical Research, Manhasset, NY, United States
- Department of Surgery, North Shore University Hospital, Manhasset, NY, United States
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY, United States
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
| | - Sara Guevara
- Department of Surgery, North Shore University Hospital, Manhasset, NY, United States
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY, United States
| | - Claudia Kirsch
- Department of Radiology, North Shore University Hospital, Manhasset, NY, United States
| | - Christine N. Metz
- Elmezzi Graduate School of Molecular Medicine, Manhasset, NY, United States
- Feinstein Institutes for Medical Research, Manhasset, NY, United States
| | - Muhammad Shoaib
- Feinstein Institutes for Medical Research, Manhasset, NY, United States
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY, United States
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
| | - Elliot Grodstein
- Department of Surgery, North Shore University Hospital, Manhasset, NY, United States
| | - Vinay V. Nair
- Department of Medicine, North Shore University Hospital, Manhasset, NY, United States
| | - Nicholas Jandovitz
- Department of Surgery, North Shore University Hospital, Manhasset, NY, United States
- Department of Pharmacy, North Shore University Hospital, Manhasset, NY, United States
| | | | - Kei Hayashida
- Feinstein Institutes for Medical Research, Manhasset, NY, United States
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY, United States
| | - Ryosuke Takegawa
- Feinstein Institutes for Medical Research, Manhasset, NY, United States
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY, United States
| | - Koichiro Shinozaki
- Feinstein Institutes for Medical Research, Manhasset, NY, United States
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY, United States
| | - Tsukasa Yagi
- Feinstein Institutes for Medical Research, Manhasset, NY, United States
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY, United States
| | - Tomoaki Aoki
- Feinstein Institutes for Medical Research, Manhasset, NY, United States
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY, United States
| | - Mitsuaki Nishikimi
- Feinstein Institutes for Medical Research, Manhasset, NY, United States
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY, United States
| | - Rishabh C. Choudhary
- Feinstein Institutes for Medical Research, Manhasset, NY, United States
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY, United States
| | - Young Min Cho
- Department of Surgery, North Shore University Hospital, Manhasset, NY, United States
| | - Stavros Zanos
- Elmezzi Graduate School of Molecular Medicine, Manhasset, NY, United States
- Feinstein Institutes for Medical Research, Manhasset, NY, United States
| | - Stefanos Zafeiropoulos
- Elmezzi Graduate School of Molecular Medicine, Manhasset, NY, United States
- Feinstein Institutes for Medical Research, Manhasset, NY, United States
| | - Hannah B. Hoffman
- Department of Surgery, North Shore University Hospital, Manhasset, NY, United States
| | - Stacey Watt
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, United States
| | - Claudio M. Lumermann
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
- Department of Anesthesiology, North Shore University Hospital, Manhasset, NY, United States
| | - Judith Aronsohn
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
- Department of Anesthesiology, North Shore University Hospital, Manhasset, NY, United States
| | - Linda Shore-Lesserson
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
- Department of Anesthesiology, North Shore University Hospital, Manhasset, NY, United States
| | - Ernesto P. Molmenti
- Department of Surgery, North Shore University Hospital, Manhasset, NY, United States
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY, United States
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
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Roy J, Kang M, Stern B, Riley T, Schreibman I. Lactulose-induced pneumatosis intestinalis following colonoscopy: a case report. Clin J Gastroenterol 2021; 14:1152-1156. [PMID: 33772734 DOI: 10.1007/s12328-021-01392-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 03/17/2021] [Indexed: 01/13/2023]
Abstract
Pneumatosis intestinalis (PI) occurs when gas is discovered in the intestinal wall and is categorized into two types: primary PI which is idiopathic and mainly occurs in the colon, and secondary PI which occurs more often in the small bowel but has variable presentation and etiology. We report a case of a patient status post-orthotopic deceased liver transplantation complicated by a portal vein thrombus on chronic lactulose for portosystemic encephalopathy who presented due to pyelonephritis and persistent diarrhea. The patient underwent colonoscopy with random biopsies and subsequently developed acute sepsis with Escherichia coli bacteremia. The findings of PI were noted on computed tomography imaging obtained 5 days post-colonoscopy, due to persistent post-procedure abdominal pain. The patient was treated with discontinuation of lactulose, supportive care, and antibiotics for her bacteremia with resolution of her PI 3 days later. This suggests that a combination of factors may lead to the development of PI, and while some cases require emergent intervention including surgery, others may be treated conservatively. Awareness of risk factors that may precipitate PI and specific clinical predictors may help to both mitigate and manage PI appropriately.
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Affiliation(s)
- Justin Roy
- Department of Internal Medicine, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA.
| | - Mitchell Kang
- Division of Gastroenterology and Hepatology, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Benjamin Stern
- Division of Gastroenterology and Hepatology, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Thomas Riley
- Division of Gastroenterology and Hepatology, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
| | - Ian Schreibman
- Division of Gastroenterology and Hepatology, Penn State Milton S. Hershey Medical Center, Hershey, PA, USA
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Alpuim Costa D, Modas Daniel P, Vieira Branco J. The Role of Hyperbaric Oxygen Therapy in Pneumatosis Cystoides Intestinalis-A Scoping Review. Front Med (Lausanne) 2021; 8:601872. [PMID: 33681242 PMCID: PMC7926085 DOI: 10.3389/fmed.2021.601872] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 01/28/2021] [Indexed: 12/24/2022] Open
Abstract
Pneumatosis cystoides intestinalis (PCI) is characterized by gas-filled cysts within gastrointestinal tract wall from esophagus to rectum, with preferential involvement of large and small intestine. PCI is rare with an estimated incidence of 0.03 to 0-2% in general population. PCI can be distinguished into idiopathic (15%) or secondary (85%) and the clinical picture ranges from completely asymptomatic to life-threatening intraabdominal complications. Although etiology of PCI appears to be multifactorial, the exact pathophysiology is poorly understood and two main theories have been proposed (mechanical and bacterial). Over the last decades, an enormous therapeutic armamentarium was considered in PCI's management, including hyperbaric oxygen therapy (HBOT). Treatment comprises conservative treatment in mild cases to surgery in highly symptomatic and complicated PCI. In the late 70s, HBOT started to be used in selected cases of PCI not responding to conservative measures. Since then, several case reports, case series, and reviews have been published in the literature with variable outcomes. The overall response rate and complete response were 92.1% (n = 82/89) and 65.2% (n = 58/89), respectively, with a median follow-up of 7 months. Furthermore, HBOT is extremely safe, with few reported complications in the literature when used for PCI. Nevertheless, a randomized, controlled, and double-blind clinical trial is unlikely to occur given the rarity of PCI, logistical issues of HBOT, and methodological considerations related to adequate blinding with a sham-controlled group. HBOT in combination with personalized diet and antibiotics may be beneficial for moderate to severe PCI in patients with no indication for emergency exploratory laparotomy. The purpose of this article is to synthesize the existing data, analyse results of previous studies, identify gaps in knowledge, and discuss PCI' management, including the proposal of an algorithm, with a special focus on HBOT.
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Affiliation(s)
- Diogo Alpuim Costa
- Centro de Medicina Subaquática e Hiperbárica (CMSH), Portuguese Navy, Lisbon, Portugal
- Centro de Investigação Naval (CINAV), Base Naval Do Alfeite, Portuguese Navy, Almada, Portugal
- CUF Oncology, Haematology and Oncology Department, Lisbon, Portugal
- NOVA Medical School, Faculdade de Ciências Médicas, Lisbon, Portugal
| | - Pedro Modas Daniel
- Centro de Medicina Subaquática e Hiperbárica (CMSH), Portuguese Navy, Lisbon, Portugal
- Centro de Investigação Naval (CINAV), Base Naval Do Alfeite, Portuguese Navy, Almada, Portugal
| | - João Vieira Branco
- Centro de Medicina Subaquática e Hiperbárica (CMSH), Portuguese Navy, Lisbon, Portugal
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Sato T, Ohbe H, Fujita M, Kushimoto S. Clinical characteristics and prediction of the asymptomatic phenotype of pneumatosis intestinalis in critically ill patients: a retrospective observational study. Acute Med Surg 2020; 7:e556. [PMID: 32995016 PMCID: PMC7507103 DOI: 10.1002/ams2.556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 07/11/2020] [Accepted: 07/20/2020] [Indexed: 11/07/2022] Open
Abstract
Aim The differences in clinical characteristics between benign asymptomatic and symptomatic pneumatosis intestinalis (PI) remain unknown. This study aimed to reveal the clinical characteristics of PI in critically ill patients. Methods This was a retrospective observational study undertaken between 2013 and 2017 in a single facility. Patients with PI were enrolled. Pneumatosis intestinalis was diagnosed using computed tomography, and clinical data were collected. Pathologic PI refers to PI with bowel ischemia. Asymptomatic PI refers to PI with a benign etiology. Results There were 17 patients with pathologic PI and 31 with asymptomatic PI. Pathologic PI was detected at day 4 of hospital stay, and asymptomatic PI was detected at day 30 of hospital stay (P < 0.01). The symptoms that were different between pathologic and asymptomatic PI were acute diarrhea (18% and 65%, P = 0.01), C‐reactive protein level elevation (9.9 and 2.1 mg/dL, P = 0.01), and systemic inflammatory reaction syndrome (100% and 13%, P < 0.01). Computed tomography findings showed a difference in the occurrence of ascites collection (94% versus 23%, P < 0.01) and PI of the ascending colon (47% versus 80%, P = 0.02). Hospital mortality of pathologic PI was 88%, whereas all patients with benign PI survived. The positive likelihood ratio of acute diarrhea with PI of the ascending colon to diagnose benign PI was 7.33 (1.11–48.5). Conclusions Pneumatosis intestinalis of the ascending colon that occurs in the post‐intensive care phase with a poor inflammatory reaction, acute diarrhea, and no ascites collection could be benign. In other cases, bowel ischemia should be promptly ruled out.
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Affiliation(s)
- Takeaki Sato
- Department of Emergency and Critical Care Medicine Tohoku University Hospital Sendai Japan
| | - Hiroyuki Ohbe
- Department of Clinical Epidemiology and Health Economics The University of Tokyo Sendai Japan
| | - Motoo Fujita
- Division of Emergency and Critical Care Medicine Tohoku University Graduate School of Medicine Sendai Japan
| | - Shigeki Kushimoto
- Division of Emergency and Critical Care Medicine Tohoku University Graduate School of Medicine Sendai Japan
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Abstract
BACKGROUND Pneumatosis cystoides intestinalis (PCI) is a low-incidence disease that confuses many doctors. A vast number of factors are suspected to contribute to its pathogenesis, such as Crohn's disease, intestinal stenosis, ulcerative colitis, drug use, extra-gastrointestinal diseases, and chronic obstructive pulmonary disease. Most consider its pathogenesis interrelated to an increase in intra-intestinal pressure and the accumulation of gas produced by aerogenic bacteria, and patients with atypical symptoms and imaging manifestations tend to be misdiagnosed. CASE PRESENTATION A 64-year-old man complained of a 3-month history of bloody stool without mucopurulent discharge, abdominal pain, or diarrhea. Colonoscopy revealed multiple nodular projections into the segmental mucosa of the sigmoid colon. Crohn's disease and malignant disease ware suspected first according to the patient's history, but laboratory examinations did not confirm either. Endoscopic ultrasound (EUS) revealed multiple cystic lesions in the submucosa. Moreover, computer tomography scan showed multiple bubble-like cysts. Combined with ultrasonography, computed tomography, and pathology findings, we ultimately made a diagnosis of PCI. Instead of surgery, we recommended conservative treatment consisting of endoscopy and oral drug administration. His symptoms improved with drug therapy after discharge, and no recurrence was noted on follow-up. CONCLUSIONS The incidence of PCI is low. Due to a lack of specificity in clinical manifestations and endoscopic findings, it often misdiagnosed as intestinal polyps, tumors, inflammatory bowel disease, or other conditions. Colonoscopy, computed tomography, and ultrasonography have demonstrated benefit in patients with multiple nodular projections in colon. Compared to the treatment of the above diseases, PCI treatment is effective and convenient, and the prognosis is optimistic. Therefore, clinicians should increase their awareness of PCI to avoid unnecessary misdiagnosis.
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Affiliation(s)
- Fangmei Ling
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, No.1277, Jiefang Avenue, Wuhan, Hubei province, China
| | - Di Guo
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, No.1277, Jiefang Avenue, Wuhan, Hubei province, China
| | - Liangru Zhu
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, No.1277, Jiefang Avenue, Wuhan, Hubei province, China.
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Ling F, Guo D, Zhu L. Pneumatosis cystoides intestinalis: a case report and literature review. BMC Gastroenterol 2019; 19:176. [PMID: 31694581 PMCID: PMC6836417 DOI: 10.1186/s12876-019-1087-9] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 10/02/2019] [Indexed: 01/05/2023] Open
Abstract
Background Pneumatosis cystoides intestinalis (PCI) is a low-incidence disease that confuses many doctors. A vast number of factors are suspected to contribute to its pathogenesis, such as Crohn’s disease, intestinal stenosis, ulcerative colitis, drug use, extra-gastrointestinal diseases, and chronic obstructive pulmonary disease. Most consider its pathogenesis interrelated to an increase in intra-intestinal pressure and the accumulation of gas produced by aerogenic bacteria, and patients with atypical symptoms and imaging manifestations tend to be misdiagnosed. Case presentation A 64-year-old man complained of a 3-month history of bloody stool without mucopurulent discharge, abdominal pain, or diarrhea. Colonoscopy revealed multiple nodular projections into the segmental mucosa of the sigmoid colon. Crohn’s disease and malignant disease ware suspected first according to the patient’s history, but laboratory examinations did not confirm either. Endoscopic ultrasound (EUS) revealed multiple cystic lesions in the submucosa. Moreover, computer tomography scan showed multiple bubble-like cysts. Combined with ultrasonography, computed tomography, and pathology findings, we ultimately made a diagnosis of PCI. Instead of surgery, we recommended conservative treatment consisting of endoscopy and oral drug administration. His symptoms improved with drug therapy after discharge, and no recurrence was noted on follow-up. Conclusions The incidence of PCI is low. Due to a lack of specificity in clinical manifestations and endoscopic findings, it often misdiagnosed as intestinal polyps, tumors, inflammatory bowel disease, or other conditions. Colonoscopy, computed tomography, and ultrasonography have demonstrated benefit in patients with multiple nodular projections in colon. Compared to the treatment of the above diseases, PCI treatment is effective and convenient, and the prognosis is optimistic. Therefore, clinicians should increase their awareness of PCI to avoid unnecessary misdiagnosis.
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Affiliation(s)
- Fangmei Ling
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, No.1277, Jiefang Avenue, Wuhan, Hubei province, China
| | - Di Guo
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, No.1277, Jiefang Avenue, Wuhan, Hubei province, China
| | - Liangru Zhu
- Division of Gastroenterology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, No.1277, Jiefang Avenue, Wuhan, Hubei province, China.
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Abstract
Pneumatosis cystoides intestinalis is a rare disease characterized by presence of multilocular cysts in the gastrointestinal wall. Idiopatic and secondary forms of the disease can be distinguished. There are presented several theories explaining pneumatogenesis in this article. The specific and non-specific symptoms are described. Attention is drawn to the pneumoperitoneum without signs of peritoneal irritation, what is a typical complication of this disease. The suspition of pneumatosis cystoides intestinalis may be based on plain abdominal X-ray, and is usually confirmed by computer tomography or magnetic resonance imaging. The therapy can be conservative or surgical. In conclusion, although pneumatosis cystoides intestinalis is a rare disease, it may represent a problem in differential diagnosis of abdominal pain.
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9
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Cystic intestinal pneumatosis revealed by peritonitis in perforated peptic ulcer: A case report. JOURNAL OF SURGERY AND MEDICINE 2018. [DOI: 10.28982/josam.426196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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10
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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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Muhammad MN, Sadough M, King R, Singh G. Pneumatosis of the esophagus and intestines with portal venous air: a rare presentation. J Community Hosp Intern Med Perspect 2017; 7:255-257. [PMID: 29046756 PMCID: PMC5637708 DOI: 10.1080/20009666.2017.1356188] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Accepted: 07/11/2017] [Indexed: 01/04/2023] Open
Abstract
Pneumatosis intestinalis is a radiographic finding that represents a spectrum of conditions ranging from benign disease to abdominal sepsis and death. Along with portal venous gas, it is generally considered an ominous sign prompting emergency operative intervention. We report a rare case showing that nonoperative therapy can be considered in a seriously ill patient with esophageal, gastric and portal venous air.
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Affiliation(s)
| | - Maryam Sadough
- Internal Medicine, Greater Baltimore Medical Center, Baltimore, MD, USA
| | - Robert King
- Department of Medicine, Ross University School of Medicine, Chicago, IL, USA
| | - Gurkeerat Singh
- Internal Medicine, Greater Baltimore Medical Center, Baltimore, MD, USA
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Cavalea AC, Heidel RE, Daley BJ, Lawson CM, Benton DA, Mcloughlin JM. Pneumatosis Intestinalis in Patients Receiving Tube Feeds. Am Surg 2017. [DOI: 10.1177/000313481708300830] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Pneumatosis intestinalis (PI) identified on computed tomography (CT) suggests an underlying pathology including bowel ischemia. Patients receiving tube feeds can develop PI, potentially requiring surgical intervention. We identify clinical factors in PI to predict those that may be safe to observe versus those that need immediate intervention. We retrospectively reviewed patients from a single institution from 2008 to 2016 with CT findings of PI and an enteric feeding tube. Patients who had not received tube feeds within one week of the CT were excluded. We analyzed clinical, operative, and outcome data to differentiate benign from pathologic outcomes. P values < 0.05 were set as significant. Forty patients were identified. We classified 24 as benign (no intervention) and 16 as pathologic (requiring intervention). A pathologic outcome was demonstrated for free fluid on CT [odds ratio (OR) = 5.00, confidence interval (CI) 1.23-20.30, P = 0.03)], blood urea nitrogen (BUN) elevation (OR = 8.27, CI 1.53-44.62, P = 0.01), creatinine (Cr) elevation (OR = 5.00, CI 1.27-19.62, P = 0.02), BUN/Cr ratio >30 (OR = 8.57, CI 1.79-40.98, P = 0.006), and vomiting/ feeding intolerance (OR = 9.38, CI 1.64-53.62, P = 0.01). Bowel function within 24 hours of the CT, bowel dilatation (small ≥ 3 cm; large ≥6 cm), and lactic acidemia were not significant. Peritonitis was only seen in pathologic states, but this did not reach statistical significance (P = 0.06). This represents the largest single-center retrospective analysis of tube feeding-induced PI to date. The presence of free fluid on CT, BUN and Cr elevation, BUN/Cr >30, vomiting/feeding intolerance and peritonitis were predictive of a pathologic etiology of PI.
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Affiliation(s)
- Alexander C. Cavalea
- Department of Surgery, University of Tennessee Graduate School of Medicine, Knoxville, Tennesssee
| | - Robert E. Heidel
- Department of Surgery, University of Tennessee Graduate School of Medicine, Knoxville, Tennesssee
| | - Brian J. Daley
- Department of Surgery, University of Tennessee Graduate School of Medicine, Knoxville, Tennesssee
| | - Christy M. Lawson
- Department of Surgery, University of Tennessee Graduate School of Medicine, Knoxville, Tennesssee
| | - Darrell A. Benton
- Department of Surgery, University of Tennessee Graduate School of Medicine, Knoxville, Tennesssee
| | - James M. Mcloughlin
- Department of Surgery, University of Tennessee Graduate School of Medicine, Knoxville, Tennesssee
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13
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Calabrese E, Ceponis PJ, Derrick BJ, Moon RE. Successful treatment of pneumatosis intestinalis with associated pneumoperitoneum and ileus with hyperbaric oxygen therapy. BMJ Case Rep 2017; 2017:bcr-2017-219209. [PMID: 28559286 DOI: 10.1136/bcr-2017-219209] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Pneumatosis intestinalis (PI), or the presence of air in the bowel wall, is a rare disorder that is associated with a variety of underlying diseases, including connective tissue disorders. PI presents on a spectrum from asymptomatic to bowel obstruction and acute abdomen. In general, treatment of PI consists of treating the underlying disease. Both normobaric and hyperbaric oxygen have been used to treat PI directly. Here we report a symptomatic scleroderma-related case of PI that responded clinically to hyperbaric oxygen therapy. This report adds to a growing body of literature supporting a role for hyperbaric oxygen therapy in symptomatic PI.
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Affiliation(s)
- Evan Calabrese
- Center for In Vivo Microscopy, Duke University, Durham, North Carolina, USA
| | - Peter Jm Ceponis
- Center for Hyperbaric Medicine, Duke University, Durham, North Carolina, USA
| | - Bruce J Derrick
- Center for Hyperbaric Medicine, Duke University, Durham, North Carolina, USA
| | - Richard E Moon
- Center for Hyperbaric Medicine, Duke University, Durham, North Carolina, USA.,Department of Anesthesia, Duke University Medical Center, Durham, North Carolina, USA
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Itazaki Y, Tsujimoto H, Ito N, Horiguchi H, Nomura S, Kanematsu K, Hiraki S, Aosasa S, Yamamoto J, Hase K. Pneumatosis intestinalis with obstructing intussusception: A case report and literature review. World J Gastrointest Surg 2016; 8:173-178. [PMID: 26981192 PMCID: PMC4770172 DOI: 10.4240/wjgs.v8.i2.173] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Revised: 08/19/2015] [Accepted: 10/19/2015] [Indexed: 02/06/2023] Open
Abstract
Pneumatosis intestinalis (PI) often represents a benign condition that should not be considered as an argument for surgery. We report a patient with PI and obstructing intussusception who underwent urgent colectomy and review the literatures regarding PI with intussusception. A 20-year-old man presented at our hospital with a 3-d intermittent lower abdominal pain history. He underwent steroid therapy for membranoproliferative glomerulonephritis for 4 years. Computed tomography revealed ascending colon intussusception with air within the wall. Intraoperative colonoscopy revealed numerous soft polypoid masses with normal overlying mucosa and right hemicolectomy was performed. Histological examination of colonic wall sections revealed large cysts in the submucosal layer. The pathological diagnosis was PI. Nine cases of intussusception associated with primary PI have been reported. Although primary PI often represents a benign condition that should not be considered as an argument for surgery, if the case involves intussusception and obstruction, emergent laparotomy should be considered.
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Ooi SMS. Pneumoperitoneum in a non-acute abdomen-pneumatosis cystoides intestinalis. Surg Case Rep 2015; 1:44. [PMID: 26943409 PMCID: PMC4747943 DOI: 10.1186/s40792-015-0046-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2015] [Accepted: 05/22/2015] [Indexed: 11/10/2022] Open
Abstract
Aim The aim of this study is to increase the understanding of pneumatosis cystoides intestinalis (PCI) and its incidents. Method We report here a case of PCI in an 88-year-old man with a provisional diagnosis of perforated viscus and possible ischaemic bowels based on CT findings of pneumoperitoneum. The patient was found to have extensive PCI on his small bowels. We then systematically search the PubMed database for case reports for articles containing ‘pneumatosis intestinalis’ in their titles or key words. Results The study group consisted of 52 cases on PCI from the period of 2010–2014 with the focus on the adult population. The youngest patient was 18 years old and the oldest was 91 years old. The mean age was 60.4 years (range, 18–91 years old). There were 27 (52 %) females and 25 (48 %) males. The most common symptoms were abdominal pain (79 %) followed by nausea/vomiting (27 %) and abdominal distension (19 %). CT imaging was the most common investigation modality used (94 %). Three (6 %) of the patients had laparoscopic treatment while 20 (38 %) had laparotomy. Thirty-six (69 %) of them recovered uneventfully while 9 (17 %) of the patients died. Conclusion Although there have been more case reports published on PCI in the recent years, the understanding of this condition remains in the infancy stage. PCI can be difficult to diagnose and can be easily misdiagnosed as pneumoperitoneum in an acute abdomen. Often it is identified incidentally during operation. Asymptomatic PCI should be treated conservatively, while emergency laparotomy should be reserved for life threatening abdominal pathology.
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Hassani KIM, Yazough I, Laalim SA, Toughrai I, Mazaz K. [Intestinal cystic pneumatosis secondary to a peptic ulcer: report of three cases]. Pan Afr Med J 2015; 20:150. [PMID: 27386026 PMCID: PMC4919673 DOI: 10.11604/pamj.2015.20.150.3017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2013] [Accepted: 08/22/2013] [Indexed: 12/03/2022] Open
Abstract
La pneumatose kystique intestinale (PNK) est une pathologie rare qui se caractérise par la présence de kystes gazeux dans la paroi intestinale. Elle est asymptomatique ou pauci symptomatique, et le plus souvent découverte lors d'un examen d'imagerie ou d'endoscopie. Nous rapportons une série de trois cas de pneumatose kystique secondaire à un ulcère peptique. A travers ce travail nous essayons de mettre la lumière sur les différents aspects cliniques, radiologiques et thérapeutiques de cette pathologie.
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Affiliation(s)
- Karim Ibn Majdoub Hassani
- Faculté de Médecine et de Pharmacie de Fès, Université Sidi Mohammed Ben Abdellah, Département de Chirurgie, CHU Hassan II, Fès, Maroc
| | - Issam Yazough
- Faculté de Médecine et de Pharmacie de Fès, Université Sidi Mohammed Ben Abdellah, Département de Chirurgie, CHU Hassan II, Fès, Maroc
| | - Said Ait Laalim
- Faculté de Médecine et de Pharmacie de Fès, Université Sidi Mohammed Ben Abdellah, Département de Chirurgie, CHU Hassan II, Fès, Maroc
| | - Imane Toughrai
- Faculté de Médecine et de Pharmacie de Fès, Université Sidi Mohammed Ben Abdellah, Département de Chirurgie, CHU Hassan II, Fès, Maroc
| | - Khalid Mazaz
- Faculté de Médecine et de Pharmacie de Fès, Université Sidi Mohammed Ben Abdellah, Département de Chirurgie, CHU Hassan II, Fès, Maroc
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Tahiri M, Levy J, Alzaid S, Anderson D. An approach to pneumatosis intestinalis: Factors affecting your management. Int J Surg Case Rep 2014; 6C:133-7. [PMID: 25531306 PMCID: PMC4334205 DOI: 10.1016/j.ijscr.2014.12.007] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2014] [Revised: 10/31/2014] [Accepted: 12/06/2014] [Indexed: 12/28/2022] Open
Abstract
Surgical intervention is necessary in patients that are unstable or in the presence of probable bowel wall compromise. Medical management of PI includes antibiotics, elemental diet and oxygen therapy. We propose a management algorithm for the treatment of PI based on clinical, laboratory and radiological findings.
Pneumatosis Intestinalis (PI) is defined as the presence of extra-luminal gas confined to the bowel wall. PI is an ominous condition often requiring emergent surgery. The management can be challenging in some circumstances, as the choice of surgery versus medical treatment can be difficult. In this study, we first report the case of a seventy-seven year old woman presenting to the emergency department with the presence of PI on computed tomography of the abdomen. Secondly, we review the existing literature regarding the management of PI and we suggest a treatment algorithm based on clinical, laboratory and radiological findings.
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Affiliation(s)
- Mehdi Tahiri
- Saint Mary's Hospital, Division of General Surgery, McGill University, Montreal, Quebec, Canada; Lady Davis Institute for Medical Research, Jewish General Hospital, Canada.
| | - Jordan Levy
- Saint Mary's Hospital, Division of General Surgery, McGill University, Montreal, Quebec, Canada
| | - Saud Alzaid
- Saint Mary's Hospital, Division of General Surgery, McGill University, Montreal, Quebec, Canada
| | - Dawn Anderson
- Saint Mary's Hospital, Division of General Surgery, McGill University, Montreal, Quebec, Canada
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18
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Klimova K, Pérez Valderas M, Merino Rodríguez B, González Asanza C, Menchén Fernández-Pacheco P. Neumatosis quística intestinal como causa infrecuente de dolor abdominal crónico. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2014; 79:302-3. [DOI: 10.1016/j.rgmx.2014.09.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2014] [Revised: 08/16/2014] [Accepted: 09/26/2014] [Indexed: 10/24/2022]
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19
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Klimova K, Pérez Valderas M, Merino Rodríguez B, González Asanza C, Menchén Fernández-Pacheco P. Pneumatosis cystoides intestinalis as an infrequent cause of chronic abdominal pain. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2014. [DOI: 10.1016/j.rgmxen.2014.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
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20
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Feuerstein JD, White N, Berzin TM. Pneumatosis intestinalis with a focus on hyperbaric oxygen therapy. Mayo Clin Proc 2014; 89:697-703. [PMID: 24797647 DOI: 10.1016/j.mayocp.2014.01.026] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2013] [Revised: 01/12/2014] [Accepted: 01/14/2014] [Indexed: 12/16/2022]
Abstract
Pneumatosis intestinalis is a rare condition of air in the bowel wall. Pneumatosis intestinalis is most often secondary to another medical condition. The diagnosis is most often made radiologically with a computed tomography scan. The disease severity ranges from benign to life-threatening. Predictors of poor outcomes include pH less than 7.3, bicarbonate level of less than 20 mEq/L, lactate level of more than 2 mmol/L, amylase level of more than 200 U/L, and portal venous gas on imaging. Early recognition of life-threatening signs and symptoms is critical. Treatment options include bowel rest, antibiotics, surgery, and, more recently, the use of hyperbaric oxygen therapy. Hyperbaric oxygen therapy is extremely safe, with no reported complications in the literature when used for pneumatosis intestinalis. When surgery is not emergently needed, symptomatic pneumatosis intestinalis can be safely treated with hyperbaric oxygen with a high likelihood of success without any considerable adverse effects.
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Affiliation(s)
- Joseph D Feuerstein
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, and Harvard Medical School, Boston, MA.
| | - Nicole White
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, and Harvard Medical School, Boston, MA
| | - Tyler M Berzin
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, and Harvard Medical School, Boston, MA
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21
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El Matiallah MA, El Bouhaddouti H, Mouaqit O, Benjelloun EB, Ousadden A, Taleb KA. [Intestinal cystic pneumatosis revealed by stenosis of a gastrointestinal anastomosis: report of a case]. Pan Afr Med J 2013; 15:125. [PMID: 24255731 PMCID: PMC3830468 DOI: 10.11604/pamj.2013.15.125.2727] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2013] [Accepted: 07/15/2013] [Indexed: 11/15/2022] Open
Abstract
La pneumatose kystique intestinale est la présence de bulles gazeuses dans la paroi et les séreuses du tube digestif. Il s'agit d'une pathologie bénigne, rare, de diagnostic radiologique et de traitement médical. Nous rapportons le cas d'un homme âgé de 42ans, opéré il y a 6ans pour une sténose du bulbe duodénal d'origine ulcéreuse, il avait bénéficié d'une gastro-entéro-anastomose avec bivagotomie tronculaire. Il a été hospitalisé pour des vomissements associés à des épigastralgies. le patient a bénéficié d'une fibroscopie oeso-gastro-duodénale qui a trouvé une stase gastrique gênant toute exploration, ce qui a conduit à la réalisation d'une tomodensitométrie abdominale qui a objectivé un énorme estomac de stase en amont d'une sténose de l'anastomose gastro jéjunale, une pneumatose kystique intestinale et un pneumopéritoine. Le patient a été opéré et l'exploration a trouvé une ascite, un volumineux estomac de stase et des adhérences entre le grêle et le colon droit, sièges de la pneumatose, provoquant un tour de spire (volvulus) de l'ancienne anastomose gastro-jéjunale. L'estomac était atone. Une gastrectomie des 2/3 emportant l'ancienne anastomose suivie d'une anastomose type Finsterer manuelle a été réalisée. Les suites post opératoires étaient simples. La pneumatose kystique intestinale est une affection bénigne, de diagnostic radiologique. Le scanner permet d’étudier la diffusion des gaz dans les séreuses digestives. Son traitement est habituellement médical alors que ses complications peuvent relever d'un traitement chirurgical comme pour notre patient.
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Chelimilla H, Makker JS, Dev A. Incidental finding of esophageal pneumatosis. World J Gastrointest Endosc 2013; 5:74-78. [PMID: 23422740 PMCID: PMC3574616 DOI: 10.4253/wjge.v5.i2.74] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2012] [Revised: 11/20/2012] [Accepted: 11/28/2012] [Indexed: 02/05/2023] Open
Abstract
Pneumatosis of the gastrointestinal tract is a rare condition characterized by the presence of air filled cavities in the gastrointestinal tract wall. Its occurrence has been described throughout the gastrointestinal tract from the esophagus to the rectum, however it is most commonly reported in the small intestine. Despite multiple case reports in literature, its pathogenesis still remains unclear. Pneumatosis may be idiopathic or associated with a variety of disorders namely peptic ulcer disease, jejunoileal bypass, intestinal obstruction and non-gastrointestinal disorders like asthma, chronic obstructive pulmonary disease, systemic lupus erythematosus, infectious enteritis, etc. We here present a rare case of pneumatosis of the esophagus diagnosed incidentally at an esophagogastroduodenoscopy (EGD). A 78-year-old asymptomatic woman underwent EGD and colonoscopy at our hospital for evaluation of anemia. Few months prior to EGD, she had undergone excision of laryngocele at our hospital. EGD revealed extensive submucosal blebs distributed throughout the esophagus, otherwise unremarkable stomach and duodenum. Colonoscopy showed a tubular adenomatous polyp. Since our patient was asymptomatic she did not require any surgical intervention. Management of pneumatosis depends on the underlying cause.
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23
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Pneumatosis intestinalis as the initial presentation of systemic sclerosis: a case report and review of the literature. Case Rep Med 2012; 2012:987410. [PMID: 23056057 PMCID: PMC3465941 DOI: 10.1155/2012/987410] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2012] [Accepted: 08/31/2012] [Indexed: 11/18/2022] Open
Abstract
Introduction. Pneumatosis intestinalis (PI) is an uncommon pathology characterised by the presence of gas within the intestinal wall. It has been associated with various conditions, including connective tissue diseases. This is the first report of PI being the initial presentation of systemic sclerosis. Case Presentation. The patient, a 75-year-old female, presented with an 8-month history of worsening dysphagia and epigastric pain, as well as other nonspecific symptoms. Initial investigations with an oesophagogastroduodenoscopy diagnosed Candida oesophagitis and also identified an extrinsic compression of the gastric antrum. Subsequently a CT scan of the abdomen and pelvis showed moderately dilated small bowel loops and PI. Due to the patient's stability, non-critical clinical condition, conservative management was instituted. More detailed investigations confirmed the diagnosis of systemic sclerosis with positive anticentromeric and antinuclear antibodies. The patient improved on methotrexate and was discharged with appropriate outpatient follow-up. Discussion. PI is a rare but well-documented pathology associated with connective tissue diseases, such as systemic sclerosis. In most cases, conservative management is preferable to surgical intervention, depending on the patient's clinical presentation and progress. This is the first report of PI being the initial presentation of a patient with systemic sclerosis responsive to conservative management.
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24
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Khor TS, Fujita H, Nagata K, Shimizu M, Lauwers GY. Biopsy interpretation of colonic biopsies when inflammatory bowel disease is excluded. J Gastroenterol 2012; 47:226-48. [PMID: 22322659 DOI: 10.1007/s00535-012-0539-6] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2012] [Accepted: 01/18/2012] [Indexed: 02/04/2023]
Abstract
The interpretation of colonic biopsies related to inflammatory conditions can be challenging because the colorectal mucosa has a limited repertoire of morphologic responses to various injurious agents. Only few processes have specific diagnostic features, and many of the various histological patterns reflect severity and duration of the disease. Importantly the correlation with endoscopic and clinical information is often cardinal to arrive at a specific diagnosis in many cases.
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Affiliation(s)
- Tze S Khor
- Gastrointestinal Pathology Service, Department of Pathology, Massachusetts General Hospital, Warren 219, Boston, MA, USA.
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25
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Azzaroli F, Turco L, Ceroni L, Galloni SS, Buonfiglioli F, Calvanese C, Mazzella G. Pneumatosis cystoides intestinalis. World J Gastroenterol 2011; 17:4932-6. [PMID: 22171137 PMCID: PMC3235639 DOI: 10.3748/wjg.v17.i44.4932] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2011] [Revised: 04/19/2011] [Accepted: 04/26/2011] [Indexed: 02/06/2023] Open
Abstract
Pneumatosis cystoides intestinalis (PCI) is a rare condition that may be associated with a variety of diseases. The presenting clinical picture may be very heterogeneous and represent a challenge for the clinician. In the present paper we describe both a common and an uncommon clinical presentation of PCI and review the pertaining literature. Our cases confirm that, apart from asymptomatic cases, the clinical presentation of PCI may be widely different and suggest that a new onset of stipsis might be the presenting symptom. Diagnosis might be suggested by a simple X-ray of the digestive tract showing a change in the characteristics of the intestinal wall in two-thirds of these patients. However, one third of the patients do not have a suggestive X-ray and require a computed tomography (CT) scan/nuclear magnetic resonance that may reveal a thickened bowel wall containing gas to confirm the diagnosis and distinguish PCI from intraluminal air or submucosal fat. CT also allows the detection of additional findings that may suggest an underlying, potentially worrisome cause of PCI such as bowel wall thickening, altered contrast mucosal enhancement, dilated bowel, soft tissue stranding, ascites and the presence of portal air. Our results also point out that clinicians and endoscopists should be aware of the possible presentations of PCI in order to correctly manage the patients affected with this disease and avoid unnecessary surgeries. The increasing number of colonoscopies performed for colon cancer screening makes PCI more frequently casually encountered and/or provoked, therefore the possible endoscopic appearances of this disease should be well known by endoscopists.
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26
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Vendryes C, Hunter CJ, Harlan SR, Ford HR, Stein J, Pierce JR. Pneumatosis intestinalis after laparoscopic appendectomy: case report and review of the literature. J Pediatr Surg 2011; 46:e21-4. [PMID: 22075367 DOI: 10.1016/j.jpedsurg.2011.07.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2011] [Revised: 07/15/2011] [Accepted: 07/19/2011] [Indexed: 12/13/2022]
Abstract
Pneumatosis intestinalis (PI) is the presence of intraluminal gas within the wall of the intestine. As a marker for bowel injury owing to mucosal injury, PI may herald a severe underlying disease process in patients without a significant medical history. In other cases, PI is a benign process, and expectant management is appropriate. Here, we present the first reported case of pneumatosis associated with postoperative abscess after appendectomy and its successful management. Then, we describe the pathophysiology of pneumatosis and review the literature regarding its origin and management.
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Affiliation(s)
- Chris Vendryes
- Department of Pediatric Surgery, Children's Hospital Los Angeles, Los Angeles, CA 90027, USA
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Hsueh KC, Tsou SS, Tan KT. Pneumatosis intestinalis and pneumoperitoneum on computed tomography: Beware of non-therapeutic laparotomy. World J Gastrointest Surg 2011; 3:86-8. [PMID: 21765972 PMCID: PMC3135874 DOI: 10.4240/wjgs.v3.i6.86] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2010] [Revised: 03/14/2011] [Accepted: 03/21/2011] [Indexed: 02/06/2023] Open
Abstract
Pneumatosis intestinalis (PI) is defined as gas within the gastrointestinal wall and is associated with a variety of disorders. As a concurrent occurrence with pneumoperitoneum, it can easily to be mistaken for bowel ischemia with perforated peritonitis. In fact, air dissection or rupture from subserosal cysts may be the cause of intraperitoneal and intraluminal free air, with clinical symptoms such as abdominal pain and fullness occurring as a result. We hereby report a case of an 82-year-old male with a history of chronic obstructive pulmonary disease who was diagnosed with bowel ischemia and received emergency laparotomy because of the appearance of PI and pneumoperitoneum on abdominal computed tomography scan. However, no perforated hollow organ or necrotic bowel segment was found, only diffusely distributed massive intraperitoneal air and PI of gastrointestinal tract. The laparotomy seemed non-therapeutic for this patient. This is significant warning for clinicians to differentiate the associated conditions of PI, and to evaluate whether or not emergency surgery is necessary.
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Affiliation(s)
- Kuan-Chun Hsueh
- Kuan-Chun Hsueh, Shung-Sheng Tsou, Kok-Tong Tan, Department of Surgery, Tungs' Taichung MetroHarbor Hospital, Taichung City 435, Taiwan, China
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Huzar TFM, Oh J, Renz EM, Wolf SE, King BT, Chung KK, White CE, Malin E, Lundy JB, Kim SH, Blackbourne LH, Cancio LC. Pneumatosis intestinalis in patients with severe thermal injury. J Burn Care Res 2011; 32:e37-44. [PMID: 21422942 DOI: 10.1097/bcr.0b013e318217f8f6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Severe thermal injury is associated with pronounced changes in intestinal physiology, which may cause ischemia, infarction, and pneumatosis intestinalis (PI). PI is a pathologic condition defined as infiltration of gas into the gastrointestinal tract wall. Historically, PI prompted urgent surgery, yet some surgeons "watch and wait" to avoid the risks of a negative laparotomy. The authors reviewed experience with PI at a single burn center. They retrospectively identified burn center intensive care unit patients with radiographic or pathologic evidence of PI. Data included demographics, injury severity score, TBSA burned, operative findings, length of stay, and mortality. From January 2003 through August 2009, 1129 patients were admitted to the authors' burn center intensive care unit. Fifteen had PI. Twelve had radiographic evidence of PI, and 10 had PI associated with intestinal infarction. Nonsurvivors had lower base deficits (P = .02), higher lactate levels (P = .05), and required vasopressor support (P = .02) within 24 hours of developing PI. Massive intestinal infarction (P = .004) and open abdomens (P = .004) were more common among nonsurvivors. PI can be identified by radiologic or pathologic findings. The authors' experience with PI among patients with burn injury revealed a high mortality rate. Because of the association of bowel ischemia with PI, exploratory laparotomy should be strongly considered in patients with burn injury with radiographic evidence of PI.
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Affiliation(s)
- Todd F M Huzar
- United States Army Institute of Surgical Research, Fort Sam Houston, Texas 78234-3611, USA
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Hepgur M, Ahluwalia MS, Anne N, Thomas J, Liu H, Schiff MD, Loud PA, Hahn TE, Bullard Dunn KM, McCarthy PL. Medical management of pneumatosis intestinalis in patients undergoing allogeneic blood and marrow transplantation. Bone Marrow Transplant 2010; 46:876-9. [PMID: 20871638 DOI: 10.1038/bmt.2010.208] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Pneumatosis intestinalis (PI) occurs when gastrointestinal (GI) wall disruption, increased wall permeability or necrosis leads to wall infiltration by gas. It is associated with a spectrum of causal factors, including GI disease in allogeneic blood and marrow transplant patients. Traditionally, PI has been managed surgically with high morbidity and mortality. We describe our experience managing allogeneic blood and marrow transplant patients with PI. From January 1998 to May 2008, 320 patients underwent allogeneic blood and marrow transplant of whom 10 were identified with PI. PI diagnosis was established by computed tomography scan (n=7), plain film (n=2) or colonoscopy (n=1). A total of 9 of 10 patients had ongoing GI GvHD or received recent treatment for GI GvHD. Before April 2002, two patients underwent subtotal colectomy with ileostomy (n=1) and sigmoid colectomy with colostomy (n=1). One patient was managed with bowel rest and total parental nutrition (TPN) only. These three patients died 0.4, 1.1 and 3.9 years after PI diagnosis owing to GI GvHD (n=2) and surgical complications (n=1). Seven patients, diagnosed after September 2006, were treated with GI rest, TPN and antibiotics. PI treated with GI rest, TPN and antibiotics will resolve without surgical intervention. AlloBMT-associated PI is often a non-critical finding that does not represent true GI tract ischemia and/or GI tract perforation.
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Affiliation(s)
- M Hepgur
- Department of Medicine, Roswell Park Cancer Institute, Buffalo, NY 14263, USA
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Abstract
Introduction Pneumatosis cystoides intestinalis is a rare disease characterized by presence of multilocular cysts in the gastrointestinal wall. Rarely, patients may experience symptoms secondary to the cysts. The pathogenesis of pneumatosis cystoides intestinalis is still unclear and many theories have been advocated to explain the exact origin. Complications occur in about 3% of cases and include obstruction, intussusception, volvulus, haemorrhage and intestinal perforation. Case presentation The author reported a male patient aged 56 years presented to the emergency department with acute upper abdominal pain. Widespread variable sized serosal intestinal air cysts were seen at the first look involving long segment of jejunum and ileum. Perforated duodenal ulcer, as the cause of generalized peritonitis, was repaired with direct closure and omental patch. A second laparotomy, was done and exploration was systematically performed and denoted hugely distended stomach with cicatrisation at the site of previous closure of perforated duodenal ulcer and the whole length of small gut was completely free from the already described pneumatosis cystoides intestinalis. Conclusion The pneumatosis cystoides intestinalis is a rare disease and suspicion of this disease process should be based on imaging and clinical finding. The therapy can be conservative or surgical in restricted situations.
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Portolani N, Baiocchi GL, Gadaldi S, Fisogni S, Villanacci V. Dysplasia in perforated intestinal pneumatosis complicating a previous jejuno-ileal bypass: A cautionary note. World J Gastroenterol 2009; 15:4189-92. [PMID: 19725155 PMCID: PMC2738817 DOI: 10.3748/wjg.15.4189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
We present the case of an elderly woman who developed a bowel perforation related to pneumatosis intestinalis, 33 years after a jejuno-ileal bypass for severe obesity. Final histological examination revealed the presence of dysplasia in the resected specimen. On the basis of our case and a review of the literature, we discuss the etiopathogenesis, the clinical aspects and the treatment of this rare condition.
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Khalil PN, Huber-Wagner S, Ladurner R, Kleespies A, Siebeck M, Mutschler W, Hallfeldt K, Kanz KG. Natural history, clinical pattern, and surgical considerations of pneumatosis intestinalis. Eur J Med Res 2009; 14:231-9. [PMID: 19541582 PMCID: PMC3352014 DOI: 10.1186/2047-783x-14-6-231] [Citation(s) in RCA: 97] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
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.
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Affiliation(s)
- Philipe N Khalil
- Department of Surgery, Downtown Medical Centre, Ludwig-Maximilians University, Munich, Germany.
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Pai HJ, Wang CS, Hsieh CC, Wang WK, Yang BY. Pneumatosis Intestinalis: A Rare Manifestation of Acute Appendicitis. J Emerg Med 2009; 37:127-30. [PMID: 17961964 DOI: 10.1016/j.jemermed.2007.02.058] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2006] [Accepted: 02/02/2007] [Indexed: 11/29/2022]
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35
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[Spontaneous pneumoperitoneum secondary to intestinal cystic pneumatosis]. Cir Esp 2009; 86:113-4. [PMID: 19439279 DOI: 10.1016/j.ciresp.2009.01.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2008] [Accepted: 01/09/2009] [Indexed: 11/24/2022]
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Saber A. Pneumatosis intestinalis with complete remission: a case report. CASES JOURNAL 2009; 2:7079. [PMID: 20184685 DOI: 10.1186/1757-1626-0002-0000007079] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 01/02/2009] [Accepted: 02/19/2009] [Indexed: 11/10/2022]
Abstract
INTRODUCTION Pneumatosis cystoides intestinalis is a rare disease characterized by presence of multilocular cysts in the gastrointestinal wall. Rarely, patients may experience symptoms secondary to the cysts. The pathogenesis of pneumatosis cystoides intestinalis is still unclear and many theories have been advocated to explain the exact origin. Complications occur in about 3% of cases and include obstruction, intussusception, volvulus, haemorrhage and intestinal perforation. CASE PRESENTATION The author reported a male patient aged 56 years presented to the emergency department with acute upper abdominal pain. Widespread variable sized serosal intestinal air cysts were seen at the first look involving long segment of jejunum and ileum. Perforated duodenal ulcer, as the cause of generalized peritonitis, was repaired with direct closure and omental patch. A second laparotomy, was done and exploration was systematically performed and denoted hugely distended stomach with cicatrisation at the site of previous closure of perforated duodenal ulcer and the whole length of small gut was completely free from the already described pneumatosis cystoides intestinalis. CONCLUSION The pneumatosis cystoides intestinalis is a rare disease and suspicion of this disease process should be based on imaging and clinical finding. The therapy can be conservative or surgical in restricted situations.
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Affiliation(s)
- Aly Saber
- Department of general surgery, Port-Fouad General Hospital, Al-obour street- Port-Fouad, 11361, Egypt.
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Bilici A, Karadag B, Doventas A, Seker M. Gastric pneumatosis intestinalis associated with malignancy: An unusual case report. World J Gastroenterol 2009; 15:758-60. [PMID: 19222105 PMCID: PMC2653449 DOI: 10.3748/wjg.15.758] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Pneumatosis intestinalis (PI) is an uncommon disease defined as gas-filled cysts that are found in the wall of the gastrointestinal (GI) tract. The exact causes of PI are still unclear, but it may associated with coexisting diseases, such as some GI disorders, connective tissue disease, some medication and drugs, and rarely malignancy. The most common localization is the small intestine. Gastric PI secondary to malignancy has been rarely documented. We report on a 94-year-old man with gastric PI associated with inoperable adenocarcinoma localized in the duodenum. Following the gastrojejunostomy and choledochojejunostomy bypass, his general condition improved and PI disappeared, but he died due to poor performance status and malignancy 6 mo later. We suggest that in patients presenting with PI, malignancy should be considered in the differential diagnosis.
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Lidia Vera-Lastra O. [Systemic sclerosis and the gastrointestinal tract. Diagnostic and therapeutic approach]. ACTA ACUST UNITED AC 2008; 2 Suppl 3:S24-30. [PMID: 21794384 DOI: 10.1016/s1699-258x(06)73104-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
In systemic sclerosis esophagus is affected in 90% followed by anal and rectal involvement (50-70%), stomach (40-70%), colon (10-50%) and small bowel (40%). The main clinical findings are esophagic: dysphagia and sign of gastroesophageal reflux and its complications. Gastric symptomatology is a consequence of gastroparesis (postprandial fullness, nausea). Intestinal affection produces hypomotility (abdominal distention, deficient intestinal absorption, bacterial overgrowth). In colon there are diverticula, intestinal constipation, and fecal incontinence. For the diagnosis of GIT involvement the following are useful: studies of digestive tract with contrast media, endoscopy of upper GIT; gastric emptying; pH metry; esophageal and rectal manometry, as well as test to investigate deficient intestinal absorption syndrome. The prokinetic are a cornerstone for the treatment of hypomotility of GIT, along with pump proton inhibitors for the esophageal alteration and antibiotics for bacterial overgrowth.
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Affiliation(s)
- Olga Lidia Vera-Lastra
- Departamento de Medicina Interna. Hospital de Especialidades Antonio Fraga Mouret. Centro Médico Nacional La Raza. IMSS. México DF. México
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Greenstein AJ, Watson J, Divino CM. Pneumoperitoneum and pneumatosis: a clinical conundrum. Int J Surg 2008; 6:e40-1. [PMID: 19059134 DOI: 10.1016/j.ijsu.2006.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2006] [Revised: 12/02/2006] [Accepted: 12/03/2006] [Indexed: 11/17/2022]
Affiliation(s)
- Alexander J Greenstein
- Department of Surgery, The Mount Sinai Medical Center, 5 East 98th Street, Box 1259, New York, NY 10029-6574, USA
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Ito M, Horiguchi A, Miyakawa S. Pneumatosis intestinalis and hepatic portal venous gas. ACTA ACUST UNITED AC 2008; 15:334-7. [PMID: 18535775 DOI: 10.1007/s00534-007-1246-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2006] [Accepted: 03/01/2007] [Indexed: 11/30/2022]
Abstract
We report two cases of pneumatosis intestinalis and hepatic portal venous gas. The first case was in a 67-year-old woman who complained of strong right lower abdominal pain and high fever on the twelfth day after pancreatoduodenectomy (PD) with portal vein (PV) resection. Abdominal X-ray and computed tomography showed hepatic portal venous gas and pneumatosis intestinalis. The emergency laparotomy performed disclosed extensive necrosis of the bowel from the jejunum to the ascending colon. All necrotic parts of the bowel were resected and a jejunostomy was performed. The residual intact small intestine was 30 cm in length. Her postoperative course was stable. This is a rare complication after PD and cannot be cured by any other treatment but surgery. The second case was in a 45-year-old woman with the chief complaint of abdominal pain and constipation. She had a past history of chronic toluene inhalation. Abdominal X-ray and computed tomography also showed hepatic portal venous gas and pneumatosis intestinalis, as well as free air, but no physical examination or laboratory test results supported a diagnosis of bowel necrosis. Hyperbaric oxygen (HBO) therapy effectively controlled the symptoms and signs.
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Affiliation(s)
- Masahiro Ito
- Second Department of Gastroenterological Surgery, Fujita-Health University, School of Medicine, 1-98 Dengakugakubo, Kutsukake-cho, Toyoake, Aichi 470-1192, Japan
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Altaf MA, Grunow JE. Atypical presentations of celiac disease: recurrent intussusception and pneumatosis intestinalis. Clin Pediatr (Phila) 2008; 47:289-92. [PMID: 18057156 DOI: 10.1177/0009922807307922] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Affiliation(s)
- Muhammad A Altaf
- Department of Pediatrics, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
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Lefrou L, Barbieux JP, Barbieux C, Metman EH. [Cystic pneumatosis of the colon and professional trichloroethylene exposure]. GASTROENTEROLOGIE CLINIQUE ET BIOLOGIQUE 2007; 31:1072-1073. [PMID: 18176359 DOI: 10.1016/s0399-8320(07)78337-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/25/2023]
Affiliation(s)
- Laurent Lefrou
- Service de gastroentérologie, Hôpital Trousseau, CHU de Tours, 37044 Tours Cedex 9
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Abstract
BACKGROUND Pneumatosis intestinalis is characterized by the accumulation of gas in the gastrointestinal wall. The histopathologic diagnosis is easily made on resection specimens in which the presence of submucosal or subserosal empty spaces lined by histiocytes and giant cells presents little diagnostic dilemma. In biopsy material, though, the diagnosis is more challenging, as giant cells and histiocytes can be interpreted as granulomatous inflammation indicative of other conditions such as infection or Crohn disease. DESIGN Nine gastrointestinal biopsies diagnosed as pneumatosis intestinalis from 7 patients were reviewed. Clinical history, radiologic features, and endoscopic findings were obtained from patient records. RESULTS Five patients presented with blood in the stool (one also with diarrhea) and 2 patients were diagnosed after screening colonoscopies. The endoscopist frequently described polyps or raised mucosal folds (6 cases). In all biopsies submucosal cystic spaces lined by giant cells could be observed. The cysts were intact (2 biopsies), partially intact (5 biopsies), or collapsed (5 biopsies), with 3 biopsies showing 2 cyst architectural conformations. The arrangement of the giant cells lining a rounded or cleft-like space was the most helpful feature in distinguishing pneumatosis intestinalis from granulomatous colitis. Additional useful features included the recognition of "pseudolipomatosis" (n=4) and the presence of round empty spaces in the submucosa resembling fat (n=3). Nonspecific findings included variable inflammation, eosinophilia, mild gland disarray, vascular ectasia and edema, and mild melanosis coli. Two cases were initially given a diagnosis of granulomatous inflammation. One patient with acquired immunodeficiency syndrome and positive cytomegalovirus antigenemia assay had ischemic colitis on the biopsy and another had a subsequent resection with ischemic colitis. A third patient was treated for cytomegalovirus colitis. None had a history of or developed Crohn disease. CONCLUSIONS Pneumatosis intestinalis remains a challenging diagnosis on biopsy material, particularly because endoscopy usually does not suggest that diagnosis. The presence of giant cells in the submucosa, variable inflammation, and crypt disarray can be easily confused with Crohn disease. Attention to the arrangement of the giant cells lining intact, partial, or collapsed cysts is crucial to making the correct diagnosis. Although nonspecific by itself, pseudolipomatosis may also indicate the presence of gas within the tissue and suggest the diagnosis.
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Affiliation(s)
- Aashiyana Koreishi
- James Homer Wright Pathology Laboratory at the Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
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Greenstein AJ, Nguyen SQ, Berlin A, Corona J, Lee J, Wong E, Factor SH, Divino CM. Pneumatosis intestinalis in adults: management, surgical indications, and risk factors for mortality. J Gastrointest Surg 2007; 11:1268-74. [PMID: 17687617 DOI: 10.1007/s11605-007-0241-9] [Citation(s) in RCA: 110] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2007] [Accepted: 07/04/2007] [Indexed: 01/31/2023]
Abstract
BACKGROUND Pneumatosis intestinalis (PI) is an unusual finding that can exist in a benign setting but can indicate ischemic bowel and the need for surgical intervention. We present a series of cases of PI in adults to illustrate factors associated with death and surgical intervention. METHODS We reviewed the radiology database of the Mount Sinai Medical Center for cases of PI between 1996-2006 in adult patients. Chi-square and multivariable logistic regression analyses were used to identify factors significant for surgery and death. RESULTS Forty patients developed PI over a 10-year span. The overall in-hospital mortality rate was 20%, and the surgical rate was 35%. Factors independently associated with surgical management on multivariable analysis were age >or= 60 years (p = 0.03), the presence of emesis (p = 0.01), and a WBC > 12 c/mm3 (p = 0.03). Pre-existing sepsis was independently associated with mortality (p = 0.03) while controlling for surgery. CONCLUSION Patients with the concomitant presence of PI, a WBC > 12 c/mm3, and/or emesis in the >60-year-old age group were most likely to have surgical intervention, whereas PI patients with sepsis had the highest risk for death. A management algorithm is proposed, but further research will be needed to determine which patients with PI may benefit most from surgery.
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Affiliation(s)
- Alexander J Greenstein
- Department of Surgery, The Mount Sinai Medical Center, 5 E. 98th Street, 15th Floor, P.O. Box 1259, New York, NY 12029, USA
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Keam B, Lee JH, Oh MD, Kim I, Yoon SS, Kim BK, Park S. Pneumatosis intestinalis with pneumoperitoneum mimicking intestinal perforation in a patient with myelodysplastic syndrome after hematopoietic stem cell transplantation. Korean J Intern Med 2007; 22:40-4. [PMID: 17427646 PMCID: PMC2687608 DOI: 10.3904/kjim.2007.22.1.40] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Pneumatosis intestinalis (PI) is an uncommon disorder characterized by an accumulation of gas in the bowel wall, and has been associated with a variety of disorders and procedures. We describe a 35-year-old man who undertook hematopoietic stem cell transplantation due to myelodysplastic syndrome. An abdominal X-ray demonstrated extensive PI with pneumoperitoneum mimicking hollow organ perforation. However, the patient had no abdominal symptoms and there was no evidence of peritoneal inflammation. After two weeks of conservative management, including bowel rest and antibiotics, his pneumoperitoneum resolved spontaneously without any complications. Of the many factors that affect the gastrointestinal tract mucosal integrity, intramural pressure, and bacterial flora-produced intraluminal gas interact to produce PI. If the condition is accompanied by bowel ischemia, portomesenteric venous gas, metabolic acidosis, and abdominal sepsis, or if PI is severe in extent immediate surgical intervention is indicated. The described case supports that a mechanical rather than a bacterial etiology underlies the pathogenesis of PI.
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Affiliation(s)
- Bhumsuk Keam
- Department of Internal Medicine, Seoul National University Hospital, College of Medicine, Seoul National University, Seoul, Korea
| | - Jeong-Hoon Lee
- Department of Internal Medicine, Seoul National University Hospital, College of Medicine, Seoul National University, Seoul, Korea
| | - Myoung-Don Oh
- Department of Internal Medicine, Seoul National University Hospital, College of Medicine, Seoul National University, Seoul, Korea
| | - Inho Kim
- Department of Internal Medicine, Seoul National University Hospital, College of Medicine, Seoul National University, Seoul, Korea
| | - Sung-Soo Yoon
- Department of Internal Medicine, Seoul National University Hospital, College of Medicine, Seoul National University, Seoul, Korea
| | - Byoung Kook Kim
- Department of Internal Medicine, Seoul National University Hospital, College of Medicine, Seoul National University, Seoul, Korea
| | - Seonyang Park
- Department of Internal Medicine, Seoul National University Hospital, College of Medicine, Seoul National University, Seoul, Korea
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Stephant E, Rimbot A, Juglard R, Meusnier F, Talarmin B, Paoletti H, Arteaga C. Pneumatose du grand omentum révélé par une invagination sur métastase de mélanome. ACTA ACUST UNITED AC 2007; 88:285-8. [PMID: 17372559 DOI: 10.1016/s0221-0363(07)89818-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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Ryska A, Hornychová H, Tycová V, Cyrany J, Kopácová M. Pneumatosis cystoides intestinalis--is it possible to diagnose it by fine-needle aspiration cytology? Diagn Cytopathol 2006; 34:793-5. [PMID: 17041952 DOI: 10.1002/dc.20522] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Magrach LA, Martín E, Sancha A, García M, Cendoya I, Olabarria I, Gómez-Portilla A, Tejada I, Carrero C, López de Torre J, García-Urra JA, Echavarri J. [Hepatic portal venous gas. Clinical significance and review of the literature]. Cir Esp 2006; 79:78-82. [PMID: 16539944 DOI: 10.1016/s0009-739x(06)70824-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Hepatic portal venous gas in adults is a rare entity. The most frequent cause is intestinal ischemia. However, an increasing number of cases associated with benign conditions suitable for conservative treatment are being reported. We review the literature to define the clinical significance of portal venous gas, the role of computed tomography, and the need to perform emergency exploratory laparotomy.
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Affiliation(s)
- Luis Alberto Magrach
- Servicio de Cirugía General y Aparato Digestivo, Hospital Santiago Apóstol, Vitoria, Alava, Spain.
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Hawn MT, Canon CL, Lockhart ME, Gonzalez QH, Shore G, Bondora A, Vickers SM. Serum Lactic Acid Determines the Outcomes of CT Diagnosis of Pneumatosis of the Gastrointestinal Tract. Am Surg 2004. [DOI: 10.1177/000313480407000104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Computed tomography (CT) diagnosis of pneumatosis involving the gastrointestinal tract can represent a broad range of clinical entities from a benign process to ischemic bowel. The purpose of this study is to define the significance and outcome of pneumatosis intestinalis (PI). All CT scans from 5/93 to 12/01 with the finding of PI were reviewed. Eighty-six CT scans had the finding of PI, with the colon being the most frequent location (51%), followed by small bowel (36%) and gastric (9%). Forty per cent of patients underwent surgery, with an overall mortality rate of 42 per cent and a surgical mortality rate of 47 per cent. Univariate analysis demonstrated significant correlation between serum lactic acid (LA) >2.0 mmol/L [odds ratio (OR) = 23.4; 95% confidence interval (C.I.), 7.21–75.92] and serum creatinine >1.5 mg/dL (OR = 3.05; 95% C.I., 1.25–7.42) with mortality. Age was suggestive but not a significant risk factor for mortality ( P = 0.09). Multivariate analysis found serum LA >2.0 (OR = 30.37; 95% CI., 7.31–126.2) to be the only significant predictor of mortality. CT diagnosis of PI is associated with significant in-hospital mortality, especially in the elderly. Serum LA level >2.0 mmol/L at time of diagnosis is associated with a greater than 80 per cent mortality. Surgical consultation is necessary to determine which patients need urgent surgical intervention.
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Affiliation(s)
- Mary T. Hawn
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Cheri L. Canon
- Department of Radiology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Mark E. Lockhart
- Department of Radiology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Quintin H. Gonzalez
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Gregg Shore
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Anthony Bondora
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Selwyn M. Vickers
- Department of Surgery, University of Alabama at Birmingham, Birmingham, Alabama
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Chelimsky G, Blanchard S, Sivit C, Davis I, Czinn S. Pneumatosis intestinalis and diarrhea in a child following renal transplantation. Pediatr Transplant 2003; 7:236-9. [PMID: 12756050 DOI: 10.1034/j.1399-3046.2003.00061.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Pneumatosis intestinalis is an uncommon finding beyond the neonatal period, but it has been reported in immunocompromized pediatric patients. The association of pneumatosis intestinalis in children following renal transplantation has to the best of our knowledge been only reported once in children. We describe a 4-year-old female who developed intermittent emesis, weight loss, and intermittently loose bloody stools after cadaveric renal transplantation at age 3.5 years. An abdominal x-ray demonstrated extensive pneumatosis in the colon. The infectious work-up was negative. Histologically, she had increased eosinophils throughout the lamina propria in the rectum. A glucose breath test was suggestive of small bowel bacterial overgrowth. She was treated with 10 days of metronidazole with resolution of the diarrhea and occult blood in stools. One month after the treatment she had radiologic resolution of her pneumatosis. Based on this report, pneumatosis intestinalis should be considered in the differential diagnosis of children after organ transplant suffering from diarrhea, abdominal pain, or blood in the stool.
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Affiliation(s)
- G Chelimsky
- Division of Pediatric Gastroenterology & Nutrition, Department of Pediatrics, Rainbow Babies & Children's Hospital, University Hospital of Cleveland & CWRU, Cleveland, OH, USA.
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