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Bezabih NA, Mehammed AH, Gebresilassie MY, Damtie MY, Midekso HD, Gidna EK. A rare case of extensive pneumatosis cystoides intestinalis with intestinal malrotation: Case report. Radiol Case Rep 2024; 19:5100-5104. [PMID: 39253045 PMCID: PMC11381972 DOI: 10.1016/j.radcr.2024.07.145] [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: 05/24/2024] [Revised: 07/24/2024] [Accepted: 07/25/2024] [Indexed: 09/11/2024] Open
Abstract
Intramural bowel gas (Pneumatosis intestinalis) refers to the radiological or clinical evidence of gas within the wall of the bowel lumen. While intramural gas could be secondary to life-threatening pathologies such as mesenteric ischemia in adults and necrotizing enterocolitis in neonates, it could also occur as a rare benign sub-type called Pneumatosis cystoides intestinalis, which is characterized by multiple gas-filled cysts in the submucosa and/or subserosal of the gastrointestinal tract. Distinguishing between life-threatening Pneumatosis intestinalis and its benign subtypes requires careful clinical and imaging evaluation. This involves identifying additional findings that could indicate potentially concerning causes of Pneumatosis intestinalis. Recognizing these signs is essential for effectively managing the patient because conservative management is preferred for Pneumatosis cystoides intestinalis. In this case study, we describe a patient presenting to our hospital with chronic intermittent abdominal pain persisting for about 2 years, accompanied by episodic vomiting. An abdominal CT scan revealed the presence of multiple air-filled cysts within the wall of the mal-rotated cecal bowel loop, which is abnormally located in the right upper quadrant. Associated with this pneumoperitoneum is seen in the peritoneal cavity. No other significant findings were observed on the scan. To our knowledge, this is the first case of pneumatosis cystoid interstinalis occurring in a mal-rotated gut. We also delve into the potential etiologies and management strategies for Pneumatosis cystoides intestinalis, as well as differentiating signs from the life-threatening intramural gas variant.
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Affiliation(s)
- Natnael Alemu Bezabih
- Addis Ababa University, College of Health Sciences, Department of Radiology, Addis Ababa, Ethiopia
| | - Abdudin Heru Mehammed
- Saint Paul's Hospital Millennium Medical College, Department of Radiology, Addis Ababa, Ethiopia
| | | | - Misganaw Yigletie Damtie
- Saint Paul's Hospital Millennium Medical College, Department of Radiology, Addis Ababa, Ethiopia
| | - Hawi Dida Midekso
- Addis Ababa University, College of Health Sciences, Department of Radiology, Addis Ababa, Ethiopia
| | - Eden Kasay Gidna
- Addis Ababa University, College of Health Sciences, Department of Radiology, Addis Ababa, Ethiopia
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Hizarcioglu-Gulsen H, Gumus E, Demir H, Saltik-Temizel IN, Varan A, Dincer HA, Dogrul AB, Ozen H. A Fatal Complication of Liver Transplant: Posttransplant Lymphoproliferative Disease. EXP CLIN TRANSPLANT 2022; 20:102-104. [PMID: 35570611 DOI: 10.6002/ect.pediatricsymp2022.o33] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Immunosuppressive therapy is a double-edged sword and causes a risk for some complications, such as opportunistic infections and posttransplant lymphoproliferative disease. The most likely risk factors for posttransplant lymphoproliferative disease are Epstein-Barr virus serology mismatch, prolonged and high viral load for Epstein-Barr virus, higher doses of immunosuppressive therapy, and cytomegalovirus infection. Transplant recipients who are seropositive for Epstein-Barr virus show a lower risk for posttransplant lymphoproliferative disease than seronegative recipients. Here, we present a 3.5-year-old boy who was seropositive for Epstein-Barr virus and developed posttransplant lymphoproliferative disease 18 months after liver transplant with a previous history of cytomegalovirus- related pneumatosis intestinalis.
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Affiliation(s)
- Hayriye Hizarcioglu-Gulsen
- From the Department of Pediatric Gastroenterology, Hepatology and Nutrition, Hacettepe University Faculty of Medicine, Ankara, Turkey
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Raabe GG, Schelde-Olesen B, Bjørsum-Meyer T. OUP accepted manuscript. J Surg Case Rep 2022; 2022:rjac072. [PMID: 35308259 PMCID: PMC8929749 DOI: 10.1093/jscr/rjac072] [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: 12/21/2021] [Revised: 01/19/2022] [Accepted: 02/24/2022] [Indexed: 11/14/2022] Open
Abstract
A 46-year-old male referred to the Emergency Department with pain in the left flank. The patient suffered from Crohn’s disease. He had not experienced any fever, and a urine strip showed signs of blood. A ureteric calculus was suspected and a computed tomography scan was performed, which surprisingly showed free intraperitoneal air (FIA) located along the ascending colon. The patient had no signs indicative of peritonitis and the spontaneous pneumoperitoneum was suspected. Pneumoperitoneum is often associated with severe intraabdominal pathology, such as perforation of the gastrointestinal tract, requiring acute surgical intervention. In ~10% of all cases of FIA, the cause is related to conditions not requiring prompt surgical intervention. Doctors need to recognize the rare condition of spontaneous pneumoperitoneum and correlate these findings to patient complaints to be able to choose the correct conservative strategy and to avoid unnecessary surgical procedures and risks for the patient.
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Affiliation(s)
| | - Benedicte Schelde-Olesen
- Department of Surgery, Odense University Hospital and Svendborg Hospital, Odense and Svendborg, Denmark
| | - Thomas Bjørsum-Meyer
- Department of Surgery, Odense University Hospital and Svendborg Hospital, Odense and Svendborg, Denmark
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Van Den Bosch J, Broos P, Vijgen G. Is surgical exploration necessary in asymptomatic intestinal pneumatosis after lung transplantation? BMJ Case Rep 2021; 14:e243955. [PMID: 34772675 PMCID: PMC8593612 DOI: 10.1136/bcr-2021-243955] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/29/2021] [Indexed: 11/03/2022] Open
Abstract
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.
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Affiliation(s)
| | - Pieter Broos
- Surgery, Zuyderland Medical Centre Heerlen, Heerlen, Netherlands
| | - Guy Vijgen
- Surgery, Zuyderland Medical Centre Heerlen, Heerlen, Netherlands
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Ryan JL, Dandridge LM, Andrews WS, Daniel JF, Fischer RT, Rivard DC, Wieser AB, Kane BJ, Hendrickson RJ. Conservative Management of Pneumatosis Intestinalis and Portal Venous Gas After Pediatric Liver Transplantation. Transplant Proc 2020; 52:938-942. [PMID: 32122661 DOI: 10.1016/j.transproceed.2020.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 12/10/2019] [Accepted: 01/02/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Pneumatosis intestinalis (PI) is a rare pathologic finding in pediatric liver transplant (PLT) recipients. The presentation and course of PI can range from asymptomatic and clinically benign to life threatening, with no consensus regarding management of PI in children. We aim to review the clinical presentation and radiologic features of PLT recipients with PI and to report the results of conservative management. METHODS A retrospective medical chart review was conducted on PLT recipients between November 1995 and May 2016. Parameters evaluated at PI diagnosis included pneumatosis location, presence of free air or portal venous gas (PVG), symptoms, laboratory findings, and medication regimen. RESULTS PI developed in 10 of 130 PLT patients (7.7%) between 8 days and 7 years (median: 113 days) posttransplant. Five of the patients were male, and the median age was 2 years (range, 1-17 years). PI was located in 1 to 2 abdominal quadrants in 6 patients, and 3 patients had PVG. At diagnosis, all patients were on steroids and immunosuppressant medication and 6 patients had a concurrent infection. Laboratory findings were unremarkable. Symptoms were present in 7 patients. Nine patients were managed conservatively, and 1 patient received observation only. All patients had resolution of PI at a median of 7 days (range, 2-14 days). CONCLUSIONS PI can occur at any time after PLT and appears to be associated with steroid use and infectious agents. If PI/PVG is identified and the patient is clinically stable, initiation of a standard management algorithm may help treat these patients conservatively, thus avoiding surgical intervention.
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Affiliation(s)
- Jamie L Ryan
- Division of Pediatric Gastroenterology, Children's Mercy Kansas City, Kansas City, Missouri, USA; Division of Developmental and Behavioral Sciences, Children's Mercy Kansas City, Kansas City, Missouri, USA
| | - Laura M Dandridge
- Division of Pediatric Gastroenterology, Children's Mercy Kansas City, Kansas City, Missouri, USA; Division of Developmental and Behavioral Sciences, Children's Mercy Kansas City, Kansas City, Missouri, USA
| | - Walter S Andrews
- Department of Surgery, Children's Mercy Kansas City, Kansas City, Missouri, USA
| | - James F Daniel
- Division of Pediatric Gastroenterology, Children's Mercy Kansas City, Kansas City, Missouri, USA
| | - Ryan T Fischer
- Division of Pediatric Gastroenterology, Children's Mercy Kansas City, Kansas City, Missouri, USA
| | - Douglas C Rivard
- Department of Radiology, Children's Mercy Kansas City, Kansas City, Missouri, USA
| | - Andrea B Wieser
- Department of Surgery, Children's Mercy Kansas City, Kansas City, Missouri, USA
| | - Bartholomew J Kane
- Department of Transplantation, Lahey Hospital & Medical Center, Burlington, Massachusetts, USA
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Defining the Burden of Emergency General Surgery in Transplant Patients: A Nationwide Examination. J Surg Res 2019; 245:315-320. [PMID: 31421379 PMCID: PMC10182896 DOI: 10.1016/j.jss.2019.07.054] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 06/26/2019] [Accepted: 07/17/2019] [Indexed: 11/20/2022]
Abstract
BACKGROUND Transplant patients are at the risk of serious sequelae from medical and surgical intervention. The incidence and burden of emergency general surgery (EGS) in transplant patients are scarcely known. This study aims to identify predictors of outcomes in transplant patients with EGS needs. METHODS The Nationwide Inpatient Sample (2007-2011) was queried for adult patients (aged ≥16 y) who underwent abdominal visceral transplantation. These were further queried for a secondary diagnosis of an American Association for the Surgery of Trauma-defined EGS condition. Outcome measures included mortality, complications, length of stay, and cost of care. Propensity scores were used to match patients across baseline characteristics. Multivariate analysis was used to further adjust propensity score quintiles and hospital-level characteristics. RESULTS A total of 35,573 transplant patients were identified. Of these, 30% (n = 10,676) developed an EGS condition. Most common EGS conditions were resuscitation (7.7%), intestinal obstruction (7.3%), biliary conditions (3.9%), and hernias (3.2%). Patients with public insurance, those in the highest income quartile, and those treated at larger hospitals had a lower likelihood of developing an EGS condition (P < 0.05). Patients with an EGS condition had a ninefold higher likelihood of mortality and a threefold higher likelihood of developing complications (odds ratio [95% confidence interval (CI)]: 9.21 [1.80-10.89] and 3.17 [3.02-3.34], respectively). Transplant patients after EGS had a longer risk-adjusted length of stay and cost of index hospitalization (Absolute difference [95% CI]: 12.70 [12.14-13.26] and $57,797 [55,415-60,179], respectively]). CONCLUSIONS Transplant patients fare poorly after developing an EGS condition. The results of this study will help in identifying at-risk patients and determining outcomes.
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Telegrafo M, Stabile Ianora AA, Angelelli G, Moschetta M. Reversible pneumatosis cystoides intestinalis after liver transplantation. G Chir 2019; 38:239-242. [PMID: 29280704 DOI: 10.11138/gchir/2017.38.5.239] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Pneumatosis cystoides intestinalis (PCI) is a rare disease characterized by the presence of multiple gas-filled cysts within the submucosa or subserosa of the intestinal wall. We report a case of PCI in a 54-yearold man 4 weeks after liver transplantation due to hepatitis B virus (HBV)-associated liver cirrhosis presenting with illness, diarrhea and abdominal pain. CT scans revealed normal shape of the abdominal parenchymal organs and no intra-hepatic complication due to liver transplantation. Main abdominal venous and arterial vessels resulted patent. Colic loops appeared diffusely thickened for the presence of variable diameter air-filled cysts located within the bowel wall. The patient underwent conservative treatment and the CT control after 4 weeks showed a complete PCI resolution. PCI after adult liver transplantation is probably due to the pre-transplantation chemotherapy, immunosuppressive therapy and opportunistic enteric infections. Abdominal CT represents the gold standard technique for diagnosing PCI and for evaluating its extension and complications providing data on other abdominal pathologies. It appears as variable diameter gas-filled cysts located within the bowel wall and it is often associated with pneumo-peritoneum probably due to the rupture of subserosal cysts. PCI has a favorable outcome and requires conservative treatment. Major differential diagnosis includes intestinal pneumatosis due to bowel ischemia. PCI after liver transplantation represents an uncommon bowel disease with a favorable prognosis. CT represents the reference imaging technique for diagnosing the disease and evaluating the response to therapy which is usually conservative rather than surgical.
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Treyaud MO, Duran R, Zins M, Knebel JF, Meuli RA, Schmidt S. Clinical significance of pneumatosis intestinalis - correlation of MDCT-findings with treatment and outcome. Eur Radiol 2016; 27:70-79. [PMID: 27106233 PMCID: PMC5127863 DOI: 10.1007/s00330-016-4348-9] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Revised: 03/14/2016] [Accepted: 03/29/2016] [Indexed: 12/18/2022]
Abstract
Objectives To evaluate the clinical significance of pneumatosis intestinalis (PI) including the influence on treatment and outcome. Method and Materials Two radiologists jointly reviewed MDCT-examinations of 149 consecutive emergency patients (53 women, mean age 64, range 21-95) with PI of the stomach (n = 4), small (n = 68) and/or large bowel (n = 96). PI extension, distribution and possibly associated porto-mesenteric venous gas (PMVG) were correlated with other MDCT-findings, risk factors, clinical management, laboratory, histopathology, final diagnosis and outcome. Results The most frequent cause of PI was intestinal ischemia (n = 80,53.7 %), followed by infection (n = 18,12.1 %), obstructive (n = 12,8.1 %) and non-obstructive (n = 10,6.7 %) bowel dilatation, unknown aetiologies (n = 8,5.4 %), drugs (n = 8,5.4 %), inflammation (n = 7,4.7 %), and others (n = 6,4 %). Neither PI distribution nor extension significantly correlated with underlying ischemia. Overall mortality was 41.6 % (n = 62), mostly related to intestinal ischemia (p = 0.003). Associated PMVG significantly correlated with underlying ischemia (p = 0.009), as did the anatomical distribution of PMVG (p = 0.015). Decreased mural contrast-enhancement was the only other MDCT-feature significantly associated with ischemia (p p < 0.001). Elevated white blood count significantly correlated with ischemia (p = 0.03). Conclusion In emergency patients, ischemia remains the most common aetiology of PI, showing the highest mortality. PI with associated PMVG is an alerting sign. PI together with decreased mural contrast-enhancement indicates underlying ischemia. Key Points • In emergency patients, PI may be caused by various disorders. • Intestinal ischemia remains the most common cause of PI in acute situations. • PI associated with decreased mural contrast-enhancement indicates acute intestinal ischemia. • PI associated with PMVG should alert the radiologist to possible underlying ischemia.
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Affiliation(s)
- Marc-Olivier Treyaud
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Rafael Duran
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Marc Zins
- Department of Radiology, Fondation Hôpital St Joseph, 185 Rue Raymond Losserand, 75014, Paris, France
| | - Jean-Francois Knebel
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Reto A Meuli
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Sabine Schmidt
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital, Rue du Bugnon 46, 1011, Lausanne, Switzerland.
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