A rare cause of acute abdomen in the ED: Chemotherapy-induced pneumatosis intestinalis

5-Fluorouracil-Related Pneumatosis Intestinalis: A Case Report and Review of the Literature

Pneumatosis intestinalis (PI) refers to the presence of air within the bowel wall. It can be associated with many causes including chemotherapy. We report a case of a 70-year-old male with metastatic tongue squamous cell carcinoma (SCC), whose hospital course was complicated by diarrhea and the development of PI, which was attributed to 5-fluorouracil (5-FU) chemotherapy after a comprehensive diagnostic workup and reassuring physical examination. The patient was treated conservatively with antibiotics and a bowel rest. A repeat imaging done before discharge showed stable findings. The patient was discharged afterward without complications. We highlight the importance of recognizing 5-FU as a cause for PI among patients with reassuring physical examination and diagnostic workup. Furthermore, we highlight that it may still be successfully managed with conservative measures.

Pneumatosis intestinalis post steroid use in a patient with immune-related adverse events: Case report, literature review and FAERS analysis

Introduction: The accurate diagnosis of pneumatosis intestinalis (PI) is increasing despite patients’ limited identification of etiologic factors. Recently a patient with lung squamous carcinoma who developed pneumatosis intestinalis following methylprednisolone administration for immune-related adverse events was treated at our hospital. Subsequent a literature review and an analysis of the FDA Adverse Event Reporting System (FAERS) database enabled the identification of additional cases of pneumatosis intestinalis.

Methods: A literature review of the MEDLINE/PubMed and Web of Science Core Collection databases using standard pneumatosis intestinalis search terms to identify published cases of immune checkpoint inhibitors (ICIs) or steroids causing pneumatosis intestinalis were performed. A separate retrospective pharmacovigilance study of FAERS enabled the extraction of unpublished cases of pneumatosis intestinalis between the first quarter of 2005 and the third quarter of 2022. Disproportionality and Bayesian analyses were performed to identify signal detection in reported odds ratios, proportional reporting ratios, information components, and empirical Bayesian geometric means.

Results: Ten case reports of steroid-related pneumatosis intestinalis were retrieved from six published studies. The implicated drug therapies included pre-treatment with steroids before chemotherapy, combination therapy with cytotoxic agents and steroids, and monotherapy with steroids. In the FAERS pharmacovigilance study, 1,272 cases of immune checkpoint inhibitors or steroid-related pneumatosis intestinalis were incidentally reported. The signal detected in five kinds of immune checkpoint inhibitors and six kinds of steroids implied a positive correlation between the drugs and adverse events.

Conclusion: Steroids might be the etiologic factors in the current case of pneumatosis intestinalis. Reports supporting the role of steroids in suspected cases of pneumatosis intestinalis can be found in literature databases and the FAERS database. Even so, as documented in FAERS, immune checkpoint inhibitors-induced pneumatosis intestinalis should not be excluded.

Pneumatosis Intestinalis Induced by Anticancer Treatment: A Systematic Review

Simple Summary

Anticancer treatments commonly cause adverse events (AE). Among others, pneumatosis intestinalis (PI) is reported to be infrequent, though it can lead to severe consequences. The aim of our systematic review was to investigate the concurrency of PI and oncological therapy exposure; moreover, we defined the characteristics of patients and the primarily involved tumor types. We analyzed 88 different episodes of PI. The median time of onset was 6 weeks and oncological patients with respiratory system cancers and those treated with targeted therapies appeared be at higher risk. Symptoms were frequently mild to absent; nevertheless, life-threatening complications were reported. Therefore, this AE, although uncommon, should be considered in the case of specific symptoms. Potential pharmacological mechanisms of anticancer drugs in inducing PI are also discussed.

Abstract

Pneumatosis intestinalis (PI) is a rare condition due to the presence of gas within the bowel wall; it is mainly caused by endoscopic procedures, infections and other gastrointestinal diseases. Oncological therapies have been reported to be a cause of PI as well, but their role is not clearly defined. This systematic review investigates the concurrency of PI and antitumor therapy in cancer patients, considering both solid tumors and onco-hematological ones. We performed a literature review of PubMed, Embase and the Web of Science up to September 2021 according to the PRISMA guidelines. A total of 62 papers reporting 88 different episodes were included. PI was mainly reported with targeted therapies (sunitinib and bevacizumab above all) within the first 12 weeks of treatment. This adverse event mostly occurred in the metastatic setting, but in 10 cases, it also occurred also in the neoadjuvant and adjuvant setting. PI was mostly localized in the large intestine, being fatal in 11 cases, while in the remaining cases, symptoms were usually mild, or even absent. A significant risk of PI reoccurrence after drug reintroduction was also reported (6/18 patients), with no fatal outcomes. Potential pharmacological mechanisms underlying PI pathogenesis are also discussed. In conclusion, although uncommonly, PI can occur during oncological therapies and may lead to life-threatening complications; therefore, consideration of its occurrence among other adverse events is warranted in the presence of clinical suspicion.