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Park DJ, Lee D, Park IK. Pneumatosis cystoides intestinalis induced by sunitinib therapy in a patient with metastatic renal cell carcinoma: A case report. Medicine (Baltimore) 2024; 103:e39075. [PMID: 39058831 PMCID: PMC11272240 DOI: 10.1097/md.0000000000039075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Accepted: 07/04/2024] [Indexed: 07/28/2024] Open
Abstract
INTRODUCTION Pneumatosis cystoides intestinalis (PCI) is a rare condition characterized by multiple gas-filled cysts in the gastrointestinal tract and is associated with numerous conditions. Benign PCI can occur secondary to certain medications, such as anticancer-targeted therapies. Here, we report a rare case of PCI that developed following sunitinib therapy for metastatic RCC and was successfully managed with conservative treatment without surgery. PATIENT CONCERNS A 57-year-old woman with a medical history of metastatic renal cell carcinoma (RCC) referred to the Department of General Surgery after completion of the 16th cycle of sunitinib because of abnormal findings on abdominopelvic computed tomography (CT), suggesting necrotizing enteritis with pneumoperitoneum involving the ileum. At the time of presentation to the Department of General Surgery, she was asymptomatic and had no abnormal findings on examination other than the imaging findings. DIAGNOSIS Sunitinib-induced PCI, metastatic RCC, liver cirrhosis, and diabetes mellitus. INTERVENTIONS She was admitted to the general ward for conservative treatment, and sunitinib was discontinued. Conservative treatments included nil per os, total parenteral nutrition, antibiotics, H2-blockers, and oxygen therapy. OUTCOMES On the fifth day of hospitalization, the PCI showed moderate resolution on plain radiography, and she was discharged on the seventh day. Follow-up CT imaging 3 months later demonstrated complete resolution of PCI. CONCLUSION This case emphasizes that the decision between conservative versus surgical treatment for PCI should be based not solely on radiological findings but rather on a comprehensive assessment, including the underlying condition, vital signs, physical examinations, and blood tests.
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Affiliation(s)
- Dong Jin Park
- Department of Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea
| | - Donghyoun Lee
- Department of Surgery, Jeju National University Hospital, Jeju National University College of Medicine, Jeju, Republic of Korea
| | - In Kyu Park
- Department of Surgery, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Republic of Korea
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Peixoto A, Pereira R, Leitão J. Idiopathic pneumatosis cystoides coli: An uncommon cause of pneumoperitoneum. Radiol Case Rep 2022; 17:4408-4412. [PMID: 36188071 PMCID: PMC9520510 DOI: 10.1016/j.radcr.2022.08.067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 08/18/2022] [Indexed: 02/07/2023] Open
Abstract
Pneumatosis cystoides intestinalis (PCI) is a rare entity characterized by the presence of gaseous cystic within the intestinal wall. The primary or idiopathic type represents 15% of cases and is a self-limited or chronic benign entity. The secondary type represents 85% of cases and is associated with various factors, such as surgery, pharmacotherapy, chemotherapy, autoimmune diseases, inflammatory diseases, and pulmonary illness. Pneumatosis cystoides intestinalis affects the colon (pneumatosis cystoides coli) in about half of the cases. The differential diagnosis of PCI includes potentially life-threatening diseases that cause pneumatosis intestinalis. The misdiagnosis of PCI is common and can lead to unnecessary treatments and surgical procedures. We describe an asymptomatic pneumoperitoneum incidentally seen on chest radiograph. The cause was pneumatosis cystoides coli, which did not require treatment.
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Moyon FX, Molina GA, Tufiño JF, Basantes VM, Espin DS, Moyon MA, Cevallos JM, Palacios NE, Parra RA, Eras KR. Pneumoperitoneum and Pneumatosis cystoides intestinalis, a dangerous mixture. A case report. Int J Surg Case Rep 2020; 74:222-225. [PMID: 32892124 PMCID: PMC7484497 DOI: 10.1016/j.ijscr.2020.07.086] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Revised: 07/31/2020] [Accepted: 07/31/2020] [Indexed: 11/13/2022] Open
Abstract
Pneumatosis cystoides intestinalis is a rare condition with a broad spectrum of clinical symptoms. Images are typically striking, which can confuse the medical team and lead to unnecessary procedures. Close follow up is needed as complications can lead to a troublesome outcome.
Background Pneumatosis cystoides intestinalis (PCI) is a rare condition characterized by gas infiltration into the intestine wall. When gas is seen in the intestinal wall, it is usually a sign of bowel wall infarction and a surgical emergency; therefore, an adequate differentiation of benign and urgent conditions of pneumatosis intestinalis is necessary to prevent misdiagnosis and inadequate therapies. Case presentation We present the case of a 79-year-old male with past medical history of Alzheimer’s, cholecystectomy, and umbilical hernia. PCI was identified, and conservative therapy was started. Since the patient's pain persisted, a complication was suspected, and surgery was decided. After successful treatment, the patient completely recovered. Conclusion There are many benign and life-threatening causes of pneumatosis intestinalis, the imaging appearance of both may look very similar. Therefore, clinical history, physical examination, and laboratory test results are the best indicators of whether it is due to a benign or life-threatening cause. PCI must be managed with a multidisciplinary team of clinicians, radiologists, and surgeons to achieve better results for our patients.
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Affiliation(s)
- Fernando X Moyon
- Department of General Surgery, Hospital General San Francisco, IESS Quito-Ecuador, Ecuador.
| | - Gabriel A Molina
- Colegio de Ciencias de la Salud, Universidad San Francisco de Quito USFQ, Quito, Ecuador.
| | - Jorge F Tufiño
- Department of General Surgery, Hospital General San Francisco, IESS Quito-Ecuador, Ecuador.
| | | | - Darwin S Espin
- Department of General Surgery, Hospital General San Francisco, IESS Quito-Ecuador, Ecuador.
| | - Miguel A Moyon
- Department of General Surgery, Hospital General San Francisco, IESS Quito-Ecuador, Ecuador.
| | - Jaime M Cevallos
- Department of General Surgery, Hospital General San Francisco, IESS Quito-Ecuador, Ecuador.
| | - Néstor E Palacios
- PGY4, Radiology Resident, Universidad Central del Ecuador, Quito, Ecuador.
| | - Ruben A Parra
- Department of Internal Medicine, Division of Pathology, Hospital General San Francisco, IESS Quito-Ecuador, Ecuador.
| | - Karla R Eras
- Department of Internal Medicine, Hospital IESS Quito Sur, Quito, Ecuador.
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Yoshida M, Hoshioka Y, Makino Y, Kojima M, Horikoshi T, Mukai H, Hikosaka K, Norose K, Iwase H. Pseudo-‘Pneumatosis intestinalis’ sign: A case of parasite uniquely depicted on postmortem CT. FORENSIC IMAGING 2020. [DOI: 10.1016/j.fri.2020.200363] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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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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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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Goyal R, Lee HK, Akerman M, Mui LW. Clinical and imaging features indicative of clinically worrisome pneumatosis: key components to identifying proper medical intervention. Emerg Radiol 2017; 24:341-346. [DOI: 10.1007/s10140-017-1484-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Accepted: 01/27/2017] [Indexed: 01/20/2023]
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Lassandro F, Mangoni de Santo Stefano ML, Porto AM, Grassi R, Scaglione M, Rotondo A. Intestinal pneumatosis in adults: diagnostic and prognostic value. Emerg Radiol 2016; 17:361-5. [PMID: 20393776 DOI: 10.1007/s10140-010-0868-9] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Intestinal pneumatosis (IP) has been traditionally associated with intestinal infarction and poor outcome in adults; recent studies have questioned its clinical value. To assess its diagnostic and prognostic significance, we have retrospectively evaluated 102 patients correlating the CT finding of gastrointestinal parietal gas with clinical data and outcome. Fifty-three patients (52%) had surgical evidence of intestinal infarction. In the remaining patients, a variety of lesions were found including intestinal obstruction, cancer, volvulus, ulcer, hernia, trauma, Crohn's disease, diverticulitis, and iatrogenic causes. We observed the presence of portal vein gas (PVG) associated to IP in 25.5% of cases. In patients having both IP and PVG, intestinal infarction was observed in 69.2% of cases. In our series, overall mortality was 30.4% (31/102), and when PVG was present, it rose to 50% (13/26). In our study, IP has been observed in a broad range of lesions with very different prognosis, the most frequent of which was intestinal infarction. When associated to PVG, there was a much higher prevalence of intestinal infarct, and the prognosis was definitively worse.
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Primary pneumatosis intestinalis of small bowel: a case of a rare disease. Case Rep Surg 2014; 2014:350312. [PMID: 25478280 PMCID: PMC4248370 DOI: 10.1155/2014/350312] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Accepted: 10/25/2014] [Indexed: 12/16/2022] Open
Abstract
Pneumatosis intestinalis (PI) is a condition in which multiple gas-filled cysts are located in the bowel wall; it can represent a wide spectrum of diseases and a variety of underlying diagnoses. The present report describes the case of an 86-year-old man with symptomatic primary PI of small bowel treated with surgical approach after periodic episodes of cysts rupture and superimposed inflammation revealed on the basis of a clinical suspicion thanks to abdominal computed tomography. Moreover, after one year of followup, there has been no recurrence of digestive symptoms.
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Distinguishing benign and life-threatening pneumatosis intestinalis in patients with cancer by CT imaging features. AJR Am J Roentgenol 2013; 200:1042-7. [PMID: 23617487 DOI: 10.2214/ajr.12.8942] [Citation(s) in RCA: 68] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE The purpose of this study is to determine the overall proportion of clinically worrisome and benign pneumatosis intestinalis (PI) occurring in patients with cancer and to evaluate associated risk factors and CT features. MATERIALS AND METHODS We retrospectively studied the CT examinations of 84 patients treated at our tertiary cancer center. Reviewers who were blinded to clinical data and classification analyzed PI in terms of location, pattern (linear, cystic, or both), and associated CT features, including pneumoperitoneum, portomesenteric venous air, bowel wall thickening, bowel dilatation, and ascites. On the basis of the review of clinical information and criteria derived from prior literature, the cases were classified as clinically worrisome PI (underlying bowel disease) or benign PI (diagnosis of exclusion that resolved on follow-up imaging without targeted therapy). Clinical factors reviewed included age, sex, cancer type, steroid use, and chemotherapy administration. RESULTS Forty-seven patients were classified as having benign PI (56%) and the remainder as having clinically worrisome PI (44%). The following imaging features correlated significantly with clinically worrisome PI: bowel wall thickening (p < 0.001), mesenteric stranding (p < 0.001), ascites (p < 0.001), bowel dilatation (p = 0.004), location confined to small bowel (p = 0.012), and portomesenteric venous gas (p = 0.02). Benign PI was significantly associated with PI confined to the colon (p = 0.004). CONCLUSION Benign PI was slightly more prevalent than clinically worrisome PI in our cohort of patients with cancer. The presence of certain CT features (mesenteric stranding, bowel wall thickening, and ascites) and the location of PI may be indicators of more significant bowel disease and, therefore, of clinically worrisome cases. There was no statistical significance achieved for nonimaging clinical factors.
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Pneumatosis intestinalis and pneumoperitoneum after bilateral lung transplantation in adults. AJR Am J Roentgenol 2011; 196:W273-9. [PMID: 21343474 DOI: 10.2214/ajr.10.4468] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE The purpose of this article is to determine the clinical features, imaging findings, and possible causes of pneumatosis intestinalis (PI) or pneumoperitoneum that developed in bilateral lung transplant recipients. MATERIALS AND METHODS From December 2004 to July 2009, seven (2%) of 321 bilateral lung transplant recipients (two women and five men; age range, 25-66 years) who developed PI or pneumoperitoneum, or both, were identified. Medical records were reviewed to determine the clinical presentation, laboratory findings, and medications at the time of presentation of PI or pneumoperitoneum. Hospital course and time to resolution of PI or pneumoperitoneum were recorded. Common factors that might explain the cause of the PI and pneumoperitoneum were evaluated. Two experienced abdominal radiologists reviewed all imaging studies and recorded the specific findings for each patient. RESULTS All patients had minimal or no symptoms, normal laboratory study results, and no systemic, intestinal, or proven respiratory infections. All patients but one were receiving triple immunosuppressive agents (i.e., prednisone, azathioprine, and tacrolimus). The imaging findings were similar in five of the patients with the PI dominated by a linear and cystic appearance and involving only the colon. Three of the six patients with PI had both PI and pneumoperitoneum. The mean time to resolution of PI was 24 days. No definite cause for the PI and pneumoperitoneum could be determined in the seven patients. CONCLUSION Bilateral lung transplant recipients may develop benign PI or pneumoperitoneum after surgery. Benign PI in bilateral lung transplant recipients has a similar and specific linear and cystic appearance and is not due to ischemic bowel. No specific cause for the PI and pneumoperitoneum could be determined.
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Olson DE, Kim YW, Ying J, Donnelly LF. CT Predictors for Differentiating Benign and Clinically Worrisome Pneumatosis Intestinalis in Children beyond the Neonatal Period. Radiology 2009; 253:513-9. [DOI: 10.1148/radiol.2532090168] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Abstract
This article presents the differential diagnosis for small bowel ischemia. Clinical presentation of small bowel ischemia is variable, presenting with a myriad of specific or nonspecific clinical and laboratory findings. The imaging findings associated with small bowel ischemia are variable and combinations of findings may be necessary for definitive diagnosis. More specific imaging findings in patients with acute small intestine ischemia include bowel wall gas, mesenteric vessel occlusion, mesenteric venous gas, portal venous gas, or absence of bowel wall enhancement. Less specific imaging findings include small bowel wall thickening, mesenteric stranding, and mesenteric fluid. Further complicating the issue, several small intestinal disease processes may mimic ischemia both clinically and radiographically. These alternate diagnoses include infectious, inflammatory, and infiltrative processes.
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Ho LM, Paulson EK, Thompson WM. Pneumatosis intestinalis in the adult: benign to life-threatening causes. AJR Am J Roentgenol 2007; 188:1604-13. [PMID: 17515383 DOI: 10.2214/ajr.06.1309] [Citation(s) in RCA: 225] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE The frequency of detection of pneumatosis intestinalis (PI) appears to be increasing. This increase may be the result of increased CT use. New medications and surgical procedures have been reported to be associated with an increase in the incidence of PI. The purpose of this review is to provide an update on the imaging features and clinical conditions associated with PI. CONCLUSION This article illustrates the imaging findings of PI due to benign and life-threatening causes, with emphasis placed on describing newly associated conditions and also the imaging appearance on CT.
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Affiliation(s)
- Lisa M Ho
- Department of Radiology, Duke University Medical Center, Box 3808 DUMC, Durham, NC 27710, USA.
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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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Cappell MS, Friedel D. The role of sigmoidoscopy and colonoscopy in the diagnosis and management of lower gastrointestinal disorders: endoscopic findings, therapy, and complications. Med Clin North Am 2002; 86:1253-88. [PMID: 12510454 DOI: 10.1016/s0025-7125(02)00077-9] [Citation(s) in RCA: 61] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Flexible sigmoidoscopy and colonoscopy have revolutionized the clinical management of colonic diseases. Colonoscopy is a highly sensitive and specific test. Colonic diseases often produce characteristic colonoscopic findings, as well as characteristic histologic findings, as identified in colonoscopic biopsy or polypectomy specimens. Colonoscopy is relatively safe, with a low incidence of serious complications, such as colonic perforation, hemorrhage, cardiopulmonary arrest, or sepsis. Colonoscopy is becoming more important clinically because of more widespread use of screening colonoscopy for colon cancer, application of therapeutic colonoscopy, and exciting new technical improvements.
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Affiliation(s)
- Mitchell S Cappell
- Division of Gastroenterology, Department of Medicine, Woodhull Medical Center, Department of Medicine, State University of New York, Downstate Medical School, Brooklyn, NY, USA
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Boerner RM, Fried DB, Warshauer DM, Isaacs K. Pneumatosis intestinalis. Two case reports and a retrospective review of the literature from 1985 to 1995. Dig Dis Sci 1996; 41:2272-85. [PMID: 8943984 DOI: 10.1007/bf02071412] [Citation(s) in RCA: 75] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Pneumatosis intestinalis (PI) is characterized by subserosal or submucosal gas-filled cysts of the gastrointestinal tract. The course may be benign or may lead to the need for urgent surgery. Knowledge of the differential diagnosis, course, and treatment modalities are key in providing optimal care to patients who present with this entity. In this article, two cases of "benign" pneumatosis seen at our institution over a one-month period are presented, along with a retrospective review of the English literature from January 1985 to March 1995. Incidence, symptoms, gross and microscopic appearance, radiographic appearance, etiology, differential diagnosis and therapy are reviewed.
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Affiliation(s)
- R M Boerner
- Department of Gastroenterology, University of North Carolina School of Medicine, Chapel Hill 27559, USA
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Hosomi N, Yoshioka H, Kuroda C, Sawai Y, Inoue E, Kadota T, Narumi Y, Kuriyama K, Fujita M, Iishi H. Pneumatosis cystoides intestinalis: CT findings. ABDOMINAL IMAGING 1994; 19:137-9. [PMID: 8199544 DOI: 10.1007/bf00203487] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Two patients with primary pneumatosis cystoides intestinalis are presented. In both cases, the sigmoid colon was involved and there were no major complications. On computed tomography (CT), at lung window settings, the gas cysts in the colonic wall were clearly delineated. CT was useful in confirming the intramural gas cysts in patients with primary pneumatosis cystoides intestinalis.
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Affiliation(s)
- N Hosomi
- Department of Diagnostic Radiology, Center for Adult Diseases, Osaka, Japan
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Smyrnios NA, Nitzberg MC, Irwin RS. A 37-Year-Old Woman with Altered Mental Status, Fever, and Renal Failure. J Intensive Care Med 1993. [DOI: 10.1177/088506669300800604] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Nicholas A. Smyrnios
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA
| | - Mark C. Nitzberg
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA
| | - Richard S. Irwin
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA
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