Pneumatosis intestinalis: a case report and approach to management. Case Rep Med. 2011;2011:571387. [PMID: 21331331 PMCID: PMC3038658 DOI: 10.1155/2011/571387]

Understanding the Nuances of Hepatic Portal Venous Gas in Pneumatosis Intestinalis: An Indication of Bowel Ischemia?

Pneumatosis intestinalis (PI) is a relatively rare gastrointestinal finding that has a wide variety of causes - ranging from benign to life-threatening. It is described as the pathological presence of gas within the bowel wall with multiple hypotheses emerging as to the likely mechanism. An important indicator of a life-threatening source of PI is the presence of gas within the hepatic portal vein, referred to as hepatic portal venous gas (HPVG). While non-specific for isolated PI, HPVG has been reported in PI patients to be associated with bowel ischemia and is thereby considered an indication for emergent management. Herein we report a case involving an atypical presentation of altered mental status in which the patient was found to have PI with contemporaneous HPVG. These findings have been reported to have a high mortality rate. Our patient rapidly deteriorated during their hospital course, expiring shortly after being deemed a poor surgical candidate due to their severe co-morbidity burden. Through this case, we review evidence supporting the management of patients with PI and concurrent HPVG from an extensive review of available literature. While PI is a non-specific finding and commonly a source of diagnostic confusion, a better understanding of its natural course and potentially unorthodox sequela may afford more directed and crucial care for critically ill patients, in which time is often a precious commodity.

Pneumatosis intestinalis after systemic chemotherapy for colorectal cancer: A case report

BACKGROUND

Pneumatosis intestinalis (PI), also known as intramural gas in the small intestine, is a rare condition encountered by patients with cancer after receiving chemotherapy.

CASE SUMMARY

A 78-year-old man with a history of colorectal cancer developed epigastric pain and diarrhea after receiving combination chemotherapy of fluorouracil, leucovorin, irinotecan, and cetuximab. Abdomen radiography revealed intramural air in the small intestinal wall. A computed tomography scan of the abdomen revealed the features of PI with air expanding into the mesentery. After surgery, the patient remained symptom-free throughout a 9 mo follow-up period during which he received chemotherapy of fluorouracil, leucovorin, and irinotecan.

CONCLUSION

Although chemotherapy-induced PI is rare among patients with cancer, the differential diagnosis of PI and fulminant complications (such as ischemia, infarction, and perforation of the gastrointestinal tract) should be conducted, in which case an urgent surgical intervention is required.

Pneumatosis intestinalis in abdominal CT: predictors of short-term mortality in patients with clinical suspicion of mesenteric ischemia

Purpose

Pneumatosis intestinalis (PI) in the bowel wall demonstrated in computed tomography (CT) of the abdomen is unspecific and its prognostic relevance remains poorly understood. The purpose of this study was to identify predictors of short-term mortality in patients with suspected mesenteric ischemia who were referred to abdominal CT and showed PI.

Methods

In this retrospective, IRB-approved, single-centre study, CT scans and electronic medical records of 540 patients who were referred to abdominal CT with clinical suspicion of mesenteric ischemia were analysed. 109/540 (20%) patients (median age 66 years, 39 females) showed PI. CT findings were correlated with surgical and pathology reports (if available), with clinical and laboratory findings, and with patient history. Short-term outcome was defined as survival within 30 days after CT.

Results

PI was found in the stomach (n = 6), small bowel (n = 65), and colon (n = 85). Further gas was found in mesenteric (n = 54), portal (n = 19) and intrahepatic veins (n = 36). Multivariate analysis revealed that PI in the colon [odds ratio (OR) 2.86], elevated blood AST levels (OR 3.00), and presence of perfusion inhomogeneities in other abdominal organs (OR 3.38) were independent predictors of short-term mortality. Surgery had a positive effect on mortality (88% lower likelihood of mortality), similar to the presence of abdominal pain (65% lower likelihood).

Conclusions

Our study suggests that in patients referred for abdominal CT with clinical suspicion of mesenteric ischemia, location of PI in the colon, elevation of blood AST, and presence of perfusion inhomogeneities in parenchymatous organs are predictors of short-term mortality.

Graphical abstract

Blinatumomab-related pneumatosis intestinalis in a pediatric patient with relapsed acute lymphoblastic leukemia: A case report

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.

Pneumatosis Intestinalis Presenting as Small Bowel Obstruction without Bowel Ischemia after Mechanical Ventilation

Pneumatosis intestinalis (PI) is a rare condition of the presence of gas within the bowel walls. PI is associated with numerous underlying diseases, ranging from life-threatening to innocuous conditions. PI is believed to be secondary to coexisting disorders in approximately 85% of all cases. This paper reviews the case of a patient who was diagnosed 7 years prior with pneumoperitoneum from unknown causes without any symptoms. The patient was admitted to the intensive care unit for the management of aspiration pneumonia and developed extensive PI after mechanical ventilation, presenting as small bowel obstruction with mesenteric torsion. Although the exact mechanism and etiology of PI are unclear, this case provides an update on the imaging features of and the clinical conditions associated with PI, as well as the management of this condition.

Is pneumatosis cystoides intestinalis a lymphatic pathology?: A case of small bowel lymphangioma and subsequent development of pneumatosis cystoides intestinalis in a 57-year-old female

The etiology of pneumatosis cystoides intestinalis (PCI) is multifactorial and its corresponding treatment is similarly complex. One causation of PCI, is lymphatic disruption. This association is discussed in this case report involving an incident of abdominal lymphangioma and subsequent development of PCI in a 57-year-old female. The purpose of this paper is to further understand the pathology of PCI, specifically as it relates to lymphatic disruption. Furthermore, the purpose of this article is to define a treatment protocol for this disease when it involves lymphatic pathology; i.e. when a surgical vs conservative approach is warranted.

Pneumatosis cystoides intestinalis associated with sunitinib and a literature review

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.

Pneumatosis intestinalis with obstructing intussusception: A case report and literature review

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.

A Rare Case of Hypermobile Mesentery With Segmental Small Bowel Pneumatosis Cystoides Intestinalis

Pneumatosis intestinalis is a rare condition that affects 0.03% of the population. Pneumatosis cystoides intestinalis (PCI) is characterized by the presence of multiple gas-filled cysts in the intestinal wall and the submucosa and/or intestinal subserosa. It is usually a secondary finding caused by a wide variety of underlying gastrointestinal or extragastrointestinal diseases. Here, we present the case of a 47-year-old man who was referred to our gastroenterology department with a history suggestive of intermittent small bowel obstruction associated with abdominal pain. Abdominal computed tomography demonstrated PCI of the small bowel. The mesentery and branches of the superior mesenteric artery and superior mesenteric vein were twisted with minimal pneumoperitoneum. Exploratory laparotomy was performed, and demonstrated segmental small bowel PCI secondary to hypermobile mesentery. The affected segment of the ileum was resected, and jejunoileal anastomosis was performed. Here, we report a rare case of segmental PCI probably due to repeated twisting of hypermobile mesentery. The clinical and imaging features of this disorder may mimic those of visceral perforation or bowel ischemia. PCI can be a cause of severe abdominal pain that may require surgical intervention.

Gastric emphysema a spectrum of pneumatosis intestinalis: a case report and literature review

The finding of gas within the gastric wall is not a disease by itself, rather than a sign of an underlying condition which could be systemic or gastric. We present the case of a woman identified with gastric emphysema secondary to the administration of high doses of steroids, with the purpose of differentiating emphysematous gastritis versus gastric emphysema due to the divergent prognostic implications. Gastric emphysema entails a more benign course, opposed to emphysematous gastritis which often presents as an acute abdomen and carries a worse prognosis. Owing to the lack of established diagnostic criteria, computed tomography is the assessment method of choice. Currently no guidelines are available for the management of this entity, since the evidence is limited to a few case series and a considerable number of single case reports.

The dilemma of pneumatosis intestinalis with pneumoperitoneum: nonoperative or surgical management-analysis of a case

Pneumatosis intestinalis (PI) is an uncommon condition and can be associated with a wide spectrum of diseases, ranging from life-threatening to innocuous conditions. We report the case of a 46-year-old women coming to our attention for an acute abdominal pain, nausea, vomiting, constipation, and increased inflammatory marks, with a CT showing pneumoperitoneum and pneumatosis intestinalis. The previous diagnosis was advanced neoplasia of unknown origin. Despite the surgical intervention, which excluded an ischemic colitis, the patient died in the early postoperative period. The postmortem diagnosis was carcinoma of thymus gland, and the presence of pneumatosis was put down to metastasis nodes in the pulmonary parenchima. This case demonstrates the wide spectrum of presentation of pneumatosis intestinalis, the importance of a careful radiologic evaluation beside the clinical history, since the identification of correct pathogenesis and treatment can be very difficult.

A rare case of segmental small bowel pneumatosis intestinalis: A case report

INTRODUCTION

Pneumatosis intestinalis is a rare condition affecting 0.03% of the population. It has a myriad of aetiological causes and hence presentation can vary immensely. The management of symptomatic pneumatosis intestinalis in an acute and outpatient setting remains a challenge to both physicians and surgeons.

CASE PRESENTATION

We present a case of a 79 year old who presented in a gastroenterology outpatients department with a history suggestive of intermittent small bowel obstruction associated with abdominal pain aggravated by eating and posture. He was found to have signs suggestive of Marfan's syndrome. Computed tomography demonstrated extensive pneumatosis intestinalis of the small bowel. Due to deterioration in symptoms, an exploratory laparotomy was performed demonstrating segmental small bowel pneumatosis intestinalis secondary to a hypermobile mesentery.

CONCLUSION

This case highlights the importance of both surgical and gastroenterology expertise in successfully managing symptomatic pneumatosis intestinalis.