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Maina RM, Rader C, Kypa J, Asahngwa C, Jasmin HM, Zalamea NN, Nelson JS, Altomar JL, Owens MB, Muenyi CS, Foretia DA. Chemotherapy-associated pneumoperitoneum in cancer patients: a scoping review. Ann Med Surg (Lond) 2024; 86:2828-2835. [PMID: 38694333 PMCID: PMC11060304 DOI: 10.1097/ms9.0000000000001998] [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: 12/12/2023] [Accepted: 03/14/2024] [Indexed: 05/04/2024] Open
Abstract
Background The presence of air in the peritoneal cavity (pneumoperitoneum) is often secondary to perforated viscus. Emergent operative intervention is typically warranted in non-cancer patients. Cancer patients present a unique challenge as they have an increased risk of pneumoperitoneum due to local tumour invasion, radiation therapy, and frequent endoscopic procedures. There is a paucity of literature on the management of patients undergoing chemotherapy who present with pneumoperitoneum. The authors conducted a scoping review to identify and synthesize preliminary evidence on the presentation, management, and outcomes of this patient population. Materials and methods A scoping review of cases of pneumoperitoneum in cancer patients from 1990 to 2022 was conducted using the Arksey and O'Malley five-stage approach. Inclusion criteria were a known diagnosis of cancer, chemotherapy within 6 months of presentation, and imaging confirmation of pneumoperitoneum. The authors' exclusion criteria were cancer diagnosis at the time of presentation, perforation secondary to local cancer invasion, and last chemotherapy session greater than 6 months prior to presentation. Results Thirty-four cases (8 paediatric, 26 adults) were identified. The median time from the last chemotherapy treatment to presentation with pneumoperitoneum was 14 days. Twenty-one patients were managed operatively, and 13 were managed non-operatively. The most common source of perforation was multiple sites along the bowel. Thirty-day mortality was 33.3% for the operative cohort and 23.1% for the non-operative group. Conclusions Pneumoperitoneum in cancer patients remains a highly morbid condition with a mortality rate of approximately 30%, regardless of the treatment approach. Non-operative management should be pursued whenever possible.
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Affiliation(s)
| | | | | | - Constantine Asahngwa
- Division of Health Policy and Research, Nkafu Policy Institute, Yaoundé, Cameroon
| | | | - Nia N. Zalamea
- Department of Surgery
- General Surgery Research Group
- Global Surgery Institute, University of Tennessee Health Science Center, Memphis, TN
| | | | | | | | | | - Denis A. Foretia
- Department of Surgery
- General Surgery Research Group
- Global Surgery Institute, University of Tennessee Health Science Center, Memphis, TN
- Division of Health Policy and Research, Nkafu Policy Institute, Yaoundé, Cameroon
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2
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Yang L, Zhong X, Yang H, Wu Q, Gong Y, Wang B. Pneumatosis cystoides intestinalis associated with etoposide in hematological malignancies: a case report and a literature review. BMC Gastroenterol 2022; 22:150. [PMID: 35346061 PMCID: PMC8959780 DOI: 10.1186/s12876-022-02219-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Accepted: 03/16/2022] [Indexed: 12/17/2022] Open
Abstract
Pneumatosis cystoides intestinalis (PCI) is a rare condition characterized by the presence of air collection within the subserosa and/or submucosa of the gastrointestinal wall. Due to the lack of specific symptoms, PCI is likely to be misdiagnosed or missed without the use of imaging techniques or gastrointestinal endoscopy. Here, we report a patient who complained of abdominal distention and constipation after chemotherapy for hematological malignancies, and was diagnosed with secondary PCI via computed tomography (CT) and exploratory laparotomy. Pneumoperitoneum was no longer observed after two weeks of conservative treatments. Notably, the possibility of intra-abdominal pressure (IAP) as a predictor for surgical intervention was proposed. Furthermore, we conducted a literature review on PCI after chemotherapy in hematological malignancies to raise awareness of etoposide-related PCI, while whether PCI could be identified as an adverse event of etoposide requires more evidence.
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Kim SE, Lee SM, Kim JY. Blinatumomab-related pneumatosis intestinalis in a pediatric patient with relapsed acute lymphoblastic leukemia: A case report. J Oncol Pharm Pract 2021; 27:2045-2048. [PMID: 34053359 DOI: 10.1177/10781552211015776] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
INTRODUCTION Pneumatosis intestinalis is characterized by air in the subserosal or submucosal layer of the intestine, with the severity ranging from mild and asymptomatic to symptomatic with serious conditions such as intestinal ischemia and perforation requiring surgery. Although several etiologies, including those from conventional chemotherapy agents and molecular target agents, have been suggested, blinatumomab-related pneumatosis intestinalis is quite rare. CASE REPORT An 11-year-old girl with history of B-cell ALL presented with bone marrow relapse 3 years after completion of initial chemotherapy. Reinduction chemotherapy and blinatumomab as post-reinduction consolidation were initiated. On day 28 of blinatumomab therapy, pneumatosis intestinalis from the ascending colon to the hepatic flexure was found incidentally on abdominal computed tomography.Management and outcome: After withholding blinatumomab therapy for 1 month, pneumatosis intestinalis improved significantly without abnormal gastrointestinal symptoms. Blinatumomab was resumed and safely completed. The computed tomography performed 4 months later showed complete resolution of pneumatosis intestinalis. The patient has been in good condition for over 1 year to date. DISCUSSION To our knowledge, this is the first case report of pneumatosis intestinalis after blinatumomab therapy in a pediatric patient with relapsed precursor B-cell acute lymphoblastic leukemia. Herein, we highlight the importance of early detection of pneumatosis intestinalis through imaging follow-up during blinatumomab therapy.
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Affiliation(s)
- Sung Eun Kim
- Department of Pediatrics, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, South Korea
| | - So Mi Lee
- Department of Radiology, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, South Korea
| | - Ji Yoon Kim
- Department of Pediatrics, School of Medicine, Kyungpook National University, Kyungpook National University Hospital, Daegu, South Korea
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Ribolla M, Conti L, Baldini E, Palmieri G, Grassi C, Banchini F, Dacco' MD, Capelli P. Asymptomatic pneumoperitoneum in pneumatosis coli: A misleading operative indication. Int J Surg Case Rep 2020; 69:92-95. [PMID: 32305029 PMCID: PMC7163289 DOI: 10.1016/j.ijscr.2020.03.042] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 03/14/2020] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Pneumatosis cystoides intestinalis (PCI) is a rare clinical pathology characterized by sub-mucosal and/or sub-serous cysts of free gas, forming cystic lesions usually ranging from 0.5 to 2.0 cm in size within the gastrointestinal tract. About 3% of patients with PCI develop complications such as pneumoperitoneum, intestinal volvulus, obstruction, or hemorrhage, these cases need immediate surgical intervention. Cyst rupture can produce peritoneal irritation and pneumoperitoneum. PRESENTATION OF CASE A 65-years-old woman was admitted to the Emergency Department for epileptiform convulsions. Her medical hystory included epilepsy, diabetes, lichenoid dermatitis, hypothyroidism, severe cognitive impairment. Abdominal CT scan revealed a dilated large intestine with parietal pneumatosis from the appendix to the transverse colon associated to extensive pneumoperitoneum. The patient underwent emergency laparotomy which revealed the presence of gas within the wall of right and transverse colon and distension of great omentum. No resection was needed as normal blood supply to the bowel present. DISCUSSION Pneumatosis coli can be both asymptomatic or life-threatening condition associated to bowel infarction; this situation can mimic a bowel perforation causing pneumoperitoneum - that sometimes is a non-surgical pneumoperitoneum - and it could be a misleading indication to surgical exploration especially in the case of uncertain origin of a septic shock. CONCLUSIONS We report a case of pneuomoperitoneum due to PCI. Surgical intervention was required for patient's conditions and unclear origin of the sepsis.
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Affiliation(s)
- Marta Ribolla
- Department of Medicine and Surgery, AOU Parma, Via Gramsci 14, Parma, Italy
| | - Luigi Conti
- Department of Surgery, AUSL Piacenza, Via Taverna 49, 29121 Piacenza, Italy.
| | - Edoardo Baldini
- Department of Surgery, AUSL Piacenza, Via Taverna 49, 29121 Piacenza, Italy
| | - Gerardo Palmieri
- Department of Medicine and Surgery, AOU Parma, Via Gramsci 14, Parma, Italy
| | - Carmine Grassi
- Department of Surgery, AUSL Piacenza, Via Taverna 49, 29121 Piacenza, Italy
| | - Filippo Banchini
- Department of Surgery, AUSL Piacenza, Via Taverna 49, 29121 Piacenza, Italy
| | | | - Patrizio Capelli
- Department of Surgery, AUSL Piacenza, Via Taverna 49, 29121 Piacenza, Italy
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Khan T, Mujtaba M, Flores MS, Nahum K, Carson MP. A Case of Pneumatosis Intestinalis With Pneumoperitoneum as a Potential Delayed Adverse Effect of Capecitabine. World J Oncol 2019; 10:151-152. [PMID: 31312282 PMCID: PMC6615914 DOI: 10.14740/wjon1186] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 04/18/2019] [Indexed: 12/02/2022] Open
Abstract
Ileitis and colitis are known complications of capecitabine when used in patients with gastrointestinal cancers. However, to our knowledge, pneumatosis intestinalis (PI) has not previously been reported with this medication. We present a patient with breast cancer, without any metastases to the gastrointestinal tract, who presented with persistent diarrhea 4 weeks after discontinuing adjuvant capecitabine, which was found to be due to PI. As she had no other risk factors or identifiable causes, her PI was attributed to a delayed reaction to capecitabine. This case highlights the need to consider PI earlier in the differential diagnosis in patients with breast cancer who present with unexplained diarrhea after recent discontinuation of capecitabine.
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Affiliation(s)
- Taimoor Khan
- Department of Medicine, Jersey Shore University Medical Center, Hackensack Meridian Health, Neptune, NJ 07753, USA
| | - Mohamed Mujtaba
- Department of Medicine, Jersey Shore University Medical Center, Hackensack Meridian Health, Neptune, NJ 07753, USA
| | - Marcus S Flores
- Department of Medicine, Jersey Shore University Medical Center, Hackensack Meridian Health, Neptune, NJ 07753, USA
| | - Kenneth Nahum
- Department of Medicine, Jersey Shore University Medical Center, Hackensack Meridian Health, Neptune, NJ 07753, USA
| | - Michael P Carson
- Department of Medicine, Jersey Shore University Medical Center, Hackensack Meridian Health, Neptune, NJ 07753, USA
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Lee YS, Han JJ, Kim SY, Maeng CH. Pneumatosis cystoides intestinalis associated with sunitinib and a literature review. BMC Cancer 2017; 17:732. [PMID: 29121860 PMCID: PMC5679335 DOI: 10.1186/s12885-017-3744-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Accepted: 10/31/2017] [Indexed: 12/11/2022] Open
Abstract
Background Pneumatosis cystoides intestinalis (PCI) is a rare self-limiting condition characterized by air-filled cysts within intestinal walls. Diagnosis should be prudent because it can mimic pneumoperitoneum leading to unnecessary treatment such as surgical exploration. Although various drugs including anti-neoplastic agents have been suggested as etiologies, cases related to sunitinib are sparse. Because of the rarity of this unusual side effect by sunitinib, we report the case report. Case presentation A 68-year-old female with pancreatic neuroendocrine tumor who was treated with sunitinb for 4 months visited to our hospital complaining of severe diarrhea and mild abdominal discomfort. The abdominal X-ray showed subdiaphragmatic air mimicking intestinal perforation. After the meticulous evaluation including abdomino-pelvic computed tomography, the patient was diagnosed of PCI induced by sunitinib and fully recovered with conservative management. Conclusions It is important to note that PCI can develop after treatment with sunitinib because PCI has not been widely known as an adverse event caused by the agent. Furthemore, emergent surgery while sunitinib was administrated without adequate washout period can result in substantial surgical complications which could be avoided with the precise diagnosis.
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Affiliation(s)
- Yong Suk Lee
- Division of Medical Oncology-Hematology, Department of Internal Medicine, Kyung Hee University Hospital, College of Medicine, Kyung Hee University, (02447) 23 Kyungheedae-ro, Dongdaemun-gu, Seoul, South Korea
| | - Jae Joon Han
- Division of Medical Oncology-Hematology, Department of Internal Medicine, Kyung Hee University Hospital, College of Medicine, Kyung Hee University, (02447) 23 Kyungheedae-ro, Dongdaemun-gu, Seoul, South Korea
| | - Si-Young Kim
- Division of Medical Oncology-Hematology, Department of Internal Medicine, Kyung Hee University Hospital, College of Medicine, Kyung Hee University, (02447) 23 Kyungheedae-ro, Dongdaemun-gu, Seoul, South Korea
| | - Chi Hoon Maeng
- Division of Medical Oncology-Hematology, Department of Internal Medicine, Kyung Hee University Hospital, College of Medicine, Kyung Hee University, (02447) 23 Kyungheedae-ro, Dongdaemun-gu, Seoul, South Korea.
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Furihata T, Furihata M, Ishikawa K, Kosaka M, Satoh N, Kubota K. Does massive intraabdominal free gas require surgical intervention? World J Gastroenterol 2016; 22:7383-7388. [PMID: 27621584 PMCID: PMC4997647 DOI: 10.3748/wjg.v22.i32.7383] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2016] [Revised: 05/24/2016] [Accepted: 06/15/2016] [Indexed: 02/06/2023] Open
Abstract
We describe a rare case of an 81-year-old man who presented with severe epigastralgia. A chest radiograph showed massive free gas bilaterally in the diaphragmatic spaces. Computed tomography (CT) scan also showed massive free gas in the peritoneal cavity with portal venous gas. We used a wait-and-see approach and carefully considered surgery again when the time was appropriate. The patient received conservative therapy with fasting, an intravenous infusion of antibiotics, and nasogastric intubation. The patient soon recovered and was able to start eating meals 4 d after treatment; thus, surgical intervention was avoided. Thereafter, colonoscopy examination showed pneumatosis cystoides intestinalis in the ascending colon. On retrospective review, CT scan demonstrated sporadic air-filled cysts in the ascending colon. The present case taught us a lesson: the presence of massive intraabdominal free gas with portal venous gas does not necessarily require surgical intervention. Pneumatosis cystoides intestinalis should be considered as a potential causative factor of free gas with portal venous gas when making the differential diagnosis.
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8
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Pneumatosis coli mimicking colorectal cancer. Case Rep Surg 2014; 2014:428989. [PMID: 25400972 PMCID: PMC4220578 DOI: 10.1155/2014/428989] [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: 03/22/2014] [Accepted: 09/24/2014] [Indexed: 11/17/2022] Open
Abstract
Pneumatosis coli (PC) is a rare condition of the gastrointestinal tract involving extraluminal gas confined within the bowel wall. We report the case of a 40-year-old gentleman presenting clinically and endoscopically with suspected colorectal cancer. In light of the patient's red flag symptoms, and carpet of polyps seen endoscopically, surgical management by an anterior resection was performed with the patient making a successful recovery. Histological analysis of the resected specimen confirmed pneumatosis coli with no evidence of colonic neoplasia. Although PC can be an incidental finding in asymptomatic patients and considered a benign condition, it can also present as a life-threatening emergency with bowel necrosis and obstruction requiring emergency surgical intervention. Also, when PC mimics malignancy, surgical management is the most appropriate step to ensure that the diagnosis of cancer is not missed.
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9
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Patel RV, Sutton PA, Colliver D, Stewart R. Pneumoperitoneum and pneumatosis cystoides intestinalis (PCI) following chemotherapy in an adolescent with Hodgkin's lymphoma. BMJ Case Rep 2014; 2014:bcr-2013-203433. [PMID: 24567185 PMCID: PMC3939415 DOI: 10.1136/bcr-2013-203433] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Affiliation(s)
- Ramnik V Patel
- Department of Paediatric Urology, University College London Hospitals NHS Foundation Trust, London, UK
- Department of Paediatric Urology, Great Ormond Street Children Hospital NHS Trust, London, UK
| | - Paul Anthony Sutton
- Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, UK
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10
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Wu LL, Yang YS, Dou Y, Liu QS. A systematic analysis of pneumatosis cystoids intestinalis. World J Gastroenterol 2013; 19:4973-4978. [PMID: 23946603 PMCID: PMC3740428 DOI: 10.3748/wjg.v19.i30.4973] [Citation(s) in RCA: 123] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2012] [Revised: 04/02/2013] [Accepted: 07/01/2013] [Indexed: 02/06/2023] Open
Abstract
AIM: To increase the understanding, diagnosis and treatment of pneumatosis cystoides intestinalis (PCI) and to find the characteristics and potential cause of the disease in China.
METHODS: We report here one case of PCI in a 70-year-old male patient who received a variety of treatment methods. Then, we systematically searched the PCI eligible literature published from an available Chinese database from May 2002 to May 2012, including CBM, CBMDisc, CMCC, VIP, Wanfang, and CNKI. The key words were pneumatosis cystoides intestinalis, pneumatosis, pneumatosis intestinalis, pneumatosis coli and mucosal gas. The patients’ information, histories, therapies, courses, and outcomes were reviewed.
RESULTS: The study group consisted of 239 PCI cases (male:female = 2.4:1) from 77 reported incidents. The mean age was 45.3 ± 15.6 years, and the median illness course was 6 mo. One hundred and sixty patients (66.9%) were in high altitude areas. In addition, 43.5% (104/239) of the patients had potential PCI-related disease, and 16.3% had complications with intestinal obstruction and perforation. The most common symptom was abdominal pain (53.9%), followed by diarrhea (53.0%), distention (42.4%), nausea and vomiting (14.3%), bloody stool (12.9%), mucous stool (12.0%) and constipation (7.8%). Most multiple pneumocysts developed in the submucosa of the colon (69.9%). The efficacy of the treatments by combined modalities, surgery, endoscopic treatment, conservative approach, oxygen, and antibiotics were 100%, 100%, 100%, 93.3%, 68.3% and 26.3%, respectively.
CONCLUSION: PCI can be safely managed by conservative treatments, presents more frequently in males, in the large bowel and submucosa, than in females, in the small intestine and subserosa. High altitude residence maybe associated with the PCI etiology.
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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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Li S, Traubici J, Ethier MC, Gillmeister B, Alexander S, Gassas A, Sung L. Pneumatosis intestinalis in children with acute lymphoblastic leukemia and acute myeloid leukemia. Support Care Cancer 2011; 20:343-7. [DOI: 10.1007/s00520-011-1088-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2010] [Accepted: 01/03/2011] [Indexed: 11/30/2022]
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