Case of pneumatosis intestinalis and hepatic portal venous gas following a laparoscopic right hemicolectomy

Conservative versus Surgical Treatment of Pneumatosis Intestinalis: Experience from a Multidisciplinary Center

BACKGROUND Pneumatosis intestinalis (PI) is an uncommon condition that is not specific to any particular disease. Currently, there is no specific clinical guideline for treating and diagnosing PI. Furthermore, there are numerous causes of PI, which makes it difficult for clinicians - internal medicine physicians as well as surgeons - to take a clinical approach to diagnosis and treatment. CASE REPORT We present 3 clinical scenarios with PI. In the first patient there was a solitary image of PI, which was treated successfully with parenteral nutrition and intravenous antibiotics, and he was discharged after 5 days. The other 2 cases, which involve gas in the hepatic portal vein (HPVG), were handled in 2 distinct ways: surgically and conservatively. One needed diagnostic laparoscopy with necrotic segmentectomy and was discharged from the hospital on postoperative day 16. The last patient, received resuscitation treatment due to severe comorbidities and inability to tolerate surgery. After 3 days, abdominal CT scan revealed no signs of remaining PI. However, the patient was terminally discharged after 7 weeks of treatment due to septic shock caused by sacrococcygeal ulcer and urinary tract infection. By drawing comparisons among these 3 scenarios, we aim to highlight certain indicators for conservative treatment success. CONCLUSIONS PI with HPVG is a sign of severe prognosis, which often requires surgical intervention. However, the decision to manage conservatively or surgically depends on the patient's condition and other criteria such as peritonitis, free fluid in the abdominal cavity, and the presence of shock. Physicians should also weigh the benefits and risks of surgical intervention in critically ill patients.

The Challenge of Pneumatosis Intestinalis: A Contemporary Systematic Review

PURPOSE

Pneumatosis intestinalis is a radiological finding with incompletely understood pathogenesis. To date, there are no protocols to guide surgical intervention.

METHODS

A systematic review of literature, according to PRISMA criteria, was performed. Medline and PubMed were consulted to identify articles reporting on the items "emergency surgery, pneumatosis coli, and pneumatosis intestinalis" from January 2010 up to March 2022. This study has not been registered in relevant databases.

RESULTS

A total of 1673 patients were included. The average age was 67.1 ± 17.6 years. The etiology was unknown in 802 (47.9%) patients. Hemodynamic instability (246/1673-14.7% of the patients) was associated with bowel ischemia, necrosis, or perforation (p = 0.019). Conservative management was performed in 824 (49.2%) patients. Surgery was performed 619 (36.9%) times, especially in unstable patients with bowel ischemia signs, lactate levels greater than 2 mmol/L, and PVG (p = 0.0026). In 155 cases, surgery was performed without pathological findings.

CONCLUSIONS

Many variables should be considered in the approach to patients with pneumatosis intestinalis. The challenge facing the surgeons is in truly identifying those who really would benefit and need surgical intervention. The watch and wait policy as a first step seems reasonable, reserving surgery only for patients who are unstable or with high suspicion of bowel ischemia, necrosis, or perforation.

Ischemic Portal Venous Gas and Pneumatosis Intestinalis Managed Conservatively in a Patient with Rheumatic Heart Disease and Warfarin Induced Coagulopathy: A Case Report

Mesenteric ischemia is a surgical emergency. The presence of hepatic portal venous gas and pneumatosis intestinalis is a frequent finding in computed tomography. Not all hepatic portal venous gas and pneumatosis intestinalis are due to mesenteric ischemia. A 70-year-old female, with a known case of diabetes mellitus, rheumatic heart disease and atrial fibrillation under warfarin presented with diffuse abdominal pain, multiple episodes of vomiting and ecchymosis in bilateral flanks. Evaluation of the coagulation profile suggested warfarin-induced coagulopathy. Portal venous gas was detected during an ultrasound examination. Subsequent contrast-enhanced computed tomography abdomen showed hepatic portal venous gas, pneumatosis intestinalis, paucity of branches of the ileocolic artery, and reduced enhancement of caecum and ascending colon. Mild ascites were present in the pelvis. Arterial blood gas analysis revealed compensated metabolic acidosis. The patient was managed conservatively and discharged after nine days of hospital admission. Conservative approach can be considered for suspected mesenteric ischemia in surgically unfit candidates.

Keywords

case reports; mesenteric ischemia; portal vein; rheumatic heart disease; warfarin.

Bezoar as a cause of portal vein pneumatosis: a case report

Pneumatosis of the portal vein is considered a rare imaging sign rather than a disease. It usually occurs in patients with digestive tract diseases such as intestinal obstructive diseases, mesenteric vascular diseases, closed abdominal trauma, and liver transplantation. Because of its high mortality rate, it is also termed the "sign of death." Hawthorn contains tannic acid, and seafood is rich in calcium, iron, carbon, iodine, and other minerals and proteins. Thus, consuming both hawthorn and seafood together can result in the formation of an indigestible complex in the body, acting as the main pathogenic factor in patients with intestinal obstruction. We herein describe a patient with duodenal obstruction caused by hawthorn who developed the hepatic portal venous gas sign and was cured by nonsurgical treatment.

Is surgical exploration necessary in asymptomatic intestinal pneumatosis after lung transplantation?

Pneumatosis intestinalis is described as gas within the bowel wall and can be a sign of bowel ischaemia with a pending perforation. The described patient presented with the incidental diagnosis of pneumatosis intestinalis with free intraperitoneal gas on CT scan. His medical history included a successful lung transplantation. We here describe the clinical decision-making and evaluate our case with previous cases in the literature.

Conservative treatment of hepatic portal venous gas resulting from non-occlusive mesenteric ischemia: a case report

A 73-year-old man with severe intellectual disability, malnutrition, and hypoalbuminemia presented to our hospital after experiencing vomiting following dinner. Electrocardiography revealed a sinus rhythm. Plain abdominal radiography showed branching radiolucency in the liver. Abdominal computed tomography (CT) revealed branching gaseous foci of low density in the portal vein and its tributaries, suggesting the presence of hepatic portal venous gas (HPVG). Abdominal contrast-enhanced CT showed a segmental lack of contrast enhancement in the intestinal wall despite the absence of vascular occlusion in the main trunk and branches of the mesenteric artery. The patient was diagnosed with non-occlusive mesenteric ischemia (NOMI) accompanied by HPVG. Peripheral parenteral nutrition, antibiotic treatment, and human serum albumin were administered. The HPVG disappeared approximately 20 h after hospitalization. Intravascular dehydration associated with hypoalbuminemia was considered to be the cause of NOMI; the latter improved through the early correction of dehydration and hypoalbuminemia. The presence of HPVG is usually considered a diagnostic clue in patients with abdominal catastrophe and is associated with high mortality. However, the current case demonstrates the pitfalls of assessing the severity of the underlying condition based solely on the presence of HPVG.

The Role of Hyperbaric Oxygen Therapy in Pneumatosis Cystoides Intestinalis-A Scoping Review

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.

Hepatic portal venous gas after colonoscopy: A case report and review

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Here we reported a rare case of hepatic portal venous gas with a relevant review of literature.

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Actually the mechanism of HPVG is still unknown.

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The case present in literature are few and the mortality, generally caused by complications like necrotizing enterocolitis, is still high.

Introduction

Hepatic portal venous gas (HPVG) is a rare radiological finding in which gas enters the portal venous system and it is associated in case of necrotizing colitis with a mortality of 75%. We report a case of iatrogenic HPVG with a review of literature.

Presentation of case

A 41 years old patient underwent total colectomy and ileal pouch- anal anastomosis with derivative ileostomy for a familiar adenomatous polyposis coli in June 2008. A stenosis of the pouch-anal anastomosis developed. The patient underwent several endoscopic dilations. A recurrence of the stenosis was observed. The patient underwent to several endoscopic procedure. After the last colonoscopy the patient showed a fever with abdominal pain. A CT scan showed little peri-anastomotic collections and massive hepatic portal venous gas.

Discussion

The management of HPVG varied from surgical intervention to non-operative procedure. The surgical approach it's reserved to clinically unstable patients or those with evidence of peritonitis or bowel perforation. Stable patients, like those with an HPVG consequence of an endoscopic procedure, can be treated with non- operative management.

Conclusion

Our experience confirm that hepatic portal venous gas can be related to endoscopic procedure; thus, it can be managed on the basis of patient's general clinical conditions, and in selected cases it will disappear without therapeutic interventions with a good outcome.

Successful treatment of pneumatosis intestinalis with associated pneumoperitoneum and ileus with hyperbaric oxygen therapy

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.