Pneumatosis cystoides intestinalis after treatment with an alpha-glucosidase inhibitor

Pneumatosis intestinalis associated with α-glucosidase inhibitors: a pharmacovigilance study of the FDA adverse event reporting system from 2004 to 2022

BACKGROUND

A-glucosidase inhibitors (AGIs) are suitable for type 2 diabetes mellitus patients with carbohydrate-rich diets while were reported associated with the rare but potentially life-threatening pneumatosis intestinalis (PI).

RESEARCH DESIGN AND METHODS

Data from the US Food and Drug Administration Adverse Event Reporting System (FAERS) were examined for AGIs, acarbose, voglibose, miglitol, or other anti-hyperglycemic drug classes. The reporting odds ratio (ROR), proportional reporting ratio, gamma poisson shrinker, and bayesian confidence propagation neural network were applied to determine the safety signals, which were performed under two other models to control for bias from type 2 diabetes mellitus and other anti-hyperglycemic drugs.

RESULTS

We found a significantly higher reporting of PI in all AGIs group [ROR = 73.85 (61.56-88.58)]. When further subdivided, voglibose and miglitol had a larger ROR than acarbose whether models were adjusted or not. The safety signals of biguanides, sulfonylureas, thiazolidinediones, dipeptidyl peptidase 4 inhibitors inhibitors, glucagon-like peptide-1 receptor agonists, sodium-glucose co-transporter-2 inhibitors, and other drug classes were not detected in three models.

CONCLUSIONS

Our study identified the safety signals of the PI-AGIs pair, primarily based on disproportionality analysis while controlling for confounders such as the disease-associated risk of PI and concomitant drug exposure.

Novel quinazolin-sulfonamid derivatives: synthesis, characterization, biological evaluation, and molecular docking studies

In the design of novel drugs, the formation of hybrid molecules via the combination of several pharmacophores can give rise to compounds with interesting biochemical profiles. A series of novel quinazolin-sulfonamid derivatives (9a-m) were synthesized, characterized and evaluated for their in vitro antidiabetic, anticholinergics, and antiepileptic activity. These synthesized novel quinazolin-sulfonamid derivatives (9a-m) were found to be effective inhibitor molecules for the α-glycosidase, human carbonic anhydrase I and II (hCA I and hCA II), butyrylcholinesterase (BChE) and acetylcholinesterase (AChE) enzyme, with Ki values in the range of 100.62 ± 13.68-327.94 ± 58.21 nM for α-glycosidase, 1.03 ± 0.11-14.87 ± 2.63 nM for hCA I, 1.83 ± 0.24-15.86 ± 2.57 nM for hCA II, 30.12 ± 3.81-102.16 ± 13.87 nM for BChE, and 26.16 ± 3.63-88.52 ± 20.11 nM for AChE, respectively. In the last step, molecular docking calculations were made to compare biological activities of molecules against enzymes which are achethylcholinesterase, butyrylcholinesterase and α-glycosidase.Communicated by Ramaswamy H. Sarma.

Pneumatosis cystoides intestinalis induced by the alpha-glucosidase inhibitor complicated from sigmoid volvulus in a diabetic patient

INTRODUCTION

We present the case of a diabetic patient on treatment with acarbose who had presented a sigmoid volvulus with localized cystic pneumatosis of the sigmoid colon.

CASE REPORT

A 72-year-old patient with a medical history of atrial fibrillation, DNID in treatment since 10 years by acarbose. The patient was admitted to the emergency for abdominal pain and occlusive syndrome since 48 h without fever or nausea or vomiting. A CT scan was performed that showed a dolichocolon with a sigmoid volvulus. The colonic wall was thickening as well as submucosal and subserosal gas, without extra digestive air or collections. A rectosigmoidoscopy was achieving that showed a sigmoid volvulus with multiple small projections like a submucosa gas bubbles. A laparoscopic non-oncologic sigmoidectomy with primary termino terminal colorectal anastomosis was performed. During the surgical procedure, an aspect of PCI of the sigmoid colon was found. The sigmoid colon was long like a dolichocolon, dilated, and partially twisted.

DISCUSSION

PCI is a rare condition characterized by the presence of multiple pneumokystes at different layers of the colonic wall. In emergency setting, the presence of colonic pneumatosis precludes the differential diagnosis between the PCI and mesenteric ischemia or ischemic colitis. It can be the cause of unnecessary explorative laparotomy.

CONCLUSION

PCI is rare disease, in emergency setting, we had to consider in differential diagnosis with colonic vascular disorders.

Pneumatosis cystoides intestinalis: a case report and literature review

BACKGROUND

Pneumatosis cystoides intestinalis (PCI) is a low-incidence disease that confuses many doctors. A vast number of factors are suspected to contribute to its pathogenesis, such as Crohn's disease, intestinal stenosis, ulcerative colitis, drug use, extra-gastrointestinal diseases, and chronic obstructive pulmonary disease. Most consider its pathogenesis interrelated to an increase in intra-intestinal pressure and the accumulation of gas produced by aerogenic bacteria, and patients with atypical symptoms and imaging manifestations tend to be misdiagnosed.

CASE PRESENTATION

A 64-year-old man complained of a 3-month history of bloody stool without mucopurulent discharge, abdominal pain, or diarrhea. Colonoscopy revealed multiple nodular projections into the segmental mucosa of the sigmoid colon. Crohn's disease and malignant disease ware suspected first according to the patient's history, but laboratory examinations did not confirm either. Endoscopic ultrasound (EUS) revealed multiple cystic lesions in the submucosa. Moreover, computer tomography scan showed multiple bubble-like cysts. Combined with ultrasonography, computed tomography, and pathology findings, we ultimately made a diagnosis of PCI. Instead of surgery, we recommended conservative treatment consisting of endoscopy and oral drug administration. His symptoms improved with drug therapy after discharge, and no recurrence was noted on follow-up.

CONCLUSIONS

The incidence of PCI is low. Due to a lack of specificity in clinical manifestations and endoscopic findings, it often misdiagnosed as intestinal polyps, tumors, inflammatory bowel disease, or other conditions. Colonoscopy, computed tomography, and ultrasonography have demonstrated benefit in patients with multiple nodular projections in colon. Compared to the treatment of the above diseases, PCI treatment is effective and convenient, and the prognosis is optimistic. Therefore, clinicians should increase their awareness of PCI to avoid unnecessary misdiagnosis.

Pneumatosis cystoides intestinalis: a case report and literature review

Background

Pneumatosis cystoides intestinalis (PCI) is a low-incidence disease that confuses many doctors. A vast number of factors are suspected to contribute to its pathogenesis, such as Crohn’s disease, intestinal stenosis, ulcerative colitis, drug use, extra-gastrointestinal diseases, and chronic obstructive pulmonary disease. Most consider its pathogenesis interrelated to an increase in intra-intestinal pressure and the accumulation of gas produced by aerogenic bacteria, and patients with atypical symptoms and imaging manifestations tend to be misdiagnosed.

Case presentation

A 64-year-old man complained of a 3-month history of bloody stool without mucopurulent discharge, abdominal pain, or diarrhea. Colonoscopy revealed multiple nodular projections into the segmental mucosa of the sigmoid colon. Crohn’s disease and malignant disease ware suspected first according to the patient’s history, but laboratory examinations did not confirm either. Endoscopic ultrasound (EUS) revealed multiple cystic lesions in the submucosa. Moreover, computer tomography scan showed multiple bubble-like cysts. Combined with ultrasonography, computed tomography, and pathology findings, we ultimately made a diagnosis of PCI. Instead of surgery, we recommended conservative treatment consisting of endoscopy and oral drug administration. His symptoms improved with drug therapy after discharge, and no recurrence was noted on follow-up.

Conclusions

The incidence of PCI is low. Due to a lack of specificity in clinical manifestations and endoscopic findings, it often misdiagnosed as intestinal polyps, tumors, inflammatory bowel disease, or other conditions. Colonoscopy, computed tomography, and ultrasonography have demonstrated benefit in patients with multiple nodular projections in colon. Compared to the treatment of the above diseases, PCI treatment is effective and convenient, and the prognosis is optimistic. Therefore, clinicians should increase their awareness of PCI to avoid unnecessary misdiagnosis.

Segmental pneumatosis cystoides coli: computed tomography-facilitated diagnosis

Intestinal pneumatosis is a rare entity of unclear etiopathogenesis characterized by the presence of gaseous cystic or linear collections within the intestinal wall. Intestinal pneumatosis may be primary and idiopathic in origin or, more frequently, it accompanies various clinical conditions. Rarely, the development of intestinal pneumatosis is attributed to the pharmacotherapy with different drugs. This is a case report of cystic pneumatosis limited to the large intestine with predominant clinical presentation of chronic watery diarrhea in a 64-year-old man suffering from diabetes mellitus treated with metformin and acarbose. The patient had been referred to the outpatient gastroenterology clinic for further investigation of numerous polyp-like lesions found on colonoscopy. There was no history of cigarette smoking, drug abuse or extraintestinal complaints. The patient was in a good general condition and his laboratory tests were normal. No relevant abnormalities were found on chest X-ray, esophagogastroduodenoscopy or abdominal ultrasound, but computed tomography showed intramural gas-filled bubbles in the cecum and splenic flexure without signs of perforation or any other significant pathology in the abdominal cavity. The final diagnosis of pneumatosis cystoides coli (PCC), possibly related to treatment with acarbose, was established. On a follow-up visit after discontinuation of acarbose the patient reported no complaints and remained asymptomatic for the next 12 months. To conclude, drug-related PCC should be considered in a differential diagnosis of gastrointestinal symptoms and/or polyp-like lesions disclosed on colonoscopy in diabetic patients treated with acarbose.

Postoperative pneumatosis intestinalis (PI) and portal venous gas (PVG) may indicate bowel necrosis: a 52-case study

Background

The significance of pneumatosis intestinalis (PI) and portal venous gas (PVG) is controversial. This retrospective study evaluated the risk factors for bowel necrosis in patients with PI and/or PVG.

Methods

Between 2002 and 2015, 52 patients were diagnosed with PI and/or PVG and were included in this study. The patients were classified according to the presence or absence of bowel necrosis in surgical findings or at autopsy. Patient characteristics and clinical findings related to bowel necrosis were investigated.

Results

Bowel necrosis was diagnosed in 17 (32.7 %) patients. Amongst these 17, 10 patients received salvage surgical intervention, and seven of those diagnosed with bowel necrosis survived after the operation. The remaining 35 patients received conservative treatment with or without exploratory laparotomy. Between patients with and without bowel necrosis, laboratory data revealed significant differences in the levels of C-reactive protein (P = 0.0038), creatinine (P = 0.0054), and lactate (P = 0.045); clinical findings showed differences in abdominal pain (P = 0.019) and peritoneal irritation signs (P = 0.016); computed tomography detected ascites (P = 0.011) and changes of bowel wall enhancement (P = 0.03) that were significantly higher in patients with bowel necrosis. The rate of PI and/or PVG detected in patients postoperatively was significantly higher in patients with bowel necrosis (P < 0.0001). Multivariate analysis showed that bowel necrosis was significantly more likely when PI or PVG was detected in postoperative patients than in patients who had not had surgery (P = 0.003).

Conclusions

PI and/or PVG, alone, are not automatically indicative of bowel necrosis. However, when these conditions occur postoperatively, they indicate bowel necrosis requiring reoperation.

Pneumatosis intestinalis in a patient with recurrent Clostridium difficile infection

A 65-year-old man with long-standing diarrhoea, recurrent Clostridium difficile infection (CDI) in the previous 5 months presented to the gastroenterology clinic with recurrent diarrhoea and abdominal cramping. Physical examination was negative for signs of acute abdomen. Stool C difficile PCR was positive. Abdominal imaging demonstrated an extensive pneumatosis intestinalis involving the small bowel and a dilated small bowel loop. He was treated conservatively with oral vancomycin for recurrent CDI with resolution of diarrhoea and abdominal cramping on 1-month follow-up visit.

Pneumatosis cystoides intestinalis induced by the α-glucosidase inhibitor miglitol

Pneumatosis cystoides intestinalis (PCI) is a rare condition in which pneumocysts develop in the submucosa or subserosa of the colon. We report herein a case of PCI induced by the alpha-glucosidase inhibitor (alphaGI) miglitol. There have been 9 recorded cases of PCI induced by other alphaGIs, but this is the first report of miglitol causing PCI. The PCI lesions in our case were smaller than those induced by voglibose or acarbose. The possibility of PCI should be considered in diabetic patients on alphaGI therapy who complain of gastrointestinal symptoms, and the gastrointestinal tract should be thoroughly investigated in these patients.

Pneumatosis cystoides intestinalis of the ascending colon related to acarbose treatment: a case report

Introduction

Pneumatosis cystoides intestinalis is characterized by the presence of multiple gas-filled cysts in the intestinal wall, the submucosa and/or subserosa of the intestine. The term pneumatosis cystoides coli is synonymous with pneumatosis cystoides intestinalis when the disorder is limited to the colon. It is a secondary finding caused by a wide variety of underlying gastrointestinal or extragastrointestinal diseases but rarely occurs in the course of treatment with an α-glucosidase inhibitor. This is the first report of pneumatosis cystoides intestinalis after 12 years of treatment with the α-glucosidase inhibitor acarbose.

Case presentation

A 65-year-old Caucasian German woman was referred to our hospital for hemicolectomy. She had been treated for type 2 diabetes mellitus with an α-glucosidase inhibitor (acarbose, 150 mg daily) for 12 years. Three months before referral, she had complained of left abdominal pain. 'Polyposis coli' in the ascending colon and diverticulosis were diagnosed. Colonoscopy and computed tomography scans of the abdomen were repeated and revealed pneumatosis cystoides coli located in the ascending colon, whereas diverticulosis of the sigmoid colon was confirmed. Histological examination of a biopsy specimen only showed colon mucosa. After discontinuing administration of the α-glucosidase inhibitor for 3 months and on repeated colonoscopy, the polypoid lesions had completely disappeared.

Conclusion

This case illustrates that pneumatosis cystoides coli can be a source of diagnostic confusion. Pneumatosis cystoides coli must be considered in the initial differential diagnosis of patients especially in the presence of multiple colonic polypoid lesions. It is important to take pneumatosis cystoides intestinalis into consideration when prescribing α-glucosidase inhibitors to patients with diabetes who have diabetic autonomic neuropathy with decreased intestinal motility, or to patients taking steroids.

Natural history, clinical pattern, and surgical considerations of pneumatosis intestinalis

Objective

Pneumatosis intestinalis has been increasingly detected in recent years with the more frequent use of computed tomography for abdominal imaging of the intestine. The underlying causes of the gas found during radiographic studies of the bowel wall can vary widely and different hypotheses regarding its pathophysiology have been postulated. Pneumatosis intestinalis often represents a benign condition and should not be considered an argument for surgery. However, it can also require life-threatening surgery in some cases, and this can be a difficult decision in some patients.

Methods

The spectrum of pneumatosis intestinalis is discussed here based on various computed tomographic and surgical findings in patients who presented at our University Medical Centre in 2003-2008. We have also systematically reviewed the literature to establish the current understanding of its aetiology and pathophysiology, and the possible clinical conditions associated with pneumatosis intestinalis and their management.

Results

Pneumatosis intestinalis is a primary radiographic finding. After its diagnosis, its specific pathogenesis should be ascertained because the appropriate therapy is related to the underlying cause of pneumatosis intestinalis, and this is sometimes difficult to define. Surgical treatment should be considered urgent in symptomatic patients presenting with an acute abdomen, signs of ischemia, or bowel obstruction. In asymptomatic patients with otherwise inconspicuous findings, the underlying disease should be treated first, rather than urgent exploratory surgery considered. Extensive and comprehensive information on the pathophysiology and clinical findings of pneumatosis intestinalis is provided here and is incorporated into a treatment algorithm.

Conclusions

The information presented here allows a better understanding of the radiographic diagnosis and underlying aetiology of pneumatosis intestinalis, and may facilitate the decision-making process in this context, thus providing fast and adequate therapy to particular patients.

Pneumatosis cystoides intestinalis following alpha-glucosidase inhibitor treatment: A case report and review of the literature

A 69-year-old man was diagnosed as having myasthenia gravis (MG) in September 2004, and treated with thymectomy and prednisolone. He was then diagnosed as having steroid-induced diabetes mellitus, and received sulfonylurea (SU) therapy in May 2005. An alpha- glucosidase inhibitor (αGI) was added in March 2006, resulting in good glycemic control. He experienced symptoms of abdominal distention, increased flatus, and constipation in October 2007, and was admitted into our hospital in late November with hematochezia. Plain abdominal radiography revealed small linear radiolucent clusters in the wall of the colon. Computed tomography (CT) showed intramural air in the sigmoid colon. Colonoscopy revealed multiple smooth surfaced hemispherical protrusions in the sigmoid colon. The diagnosis of pneumatosis cystoides intestinalis (PCI) was made on the basis of these findings. As the αGI voglibose was suspected as the cause of this patient’s PCI, treatment was conservative, ceasing voglibose, with fasting and fluid supplementation. The patient progressed well, and was discharged 2 wk later. Recently, several reports of PCI associated with αGI therapy have been published, predominantly in Japan where αGIs are commonly used. If the use of αGIs becomes more widespread, we can expect more reports of this condition on a global scale. The possibility of PCI should be considered in diabetic patients complaining of gastrointestinal symptoms, and the gastrointestinal tract should be thoroughly investigated in these patients.

Fulminant pneumatosis intestinalis in a patient with diabetes mellitus and minimal change nephrotic syndrome

We report a case of pneumatosis intestinalis in a diabetic patient with minimal change nephrotic syndrome, receiving immunosuppressive drugs and an alpha-glucosidase inhibitor. The patient was a 72-year-old female, who suffered from right lower abdominal pain. Abdominal CT showed massive air in the intestinal wall, compatible with pneumatosis intestinalis. Her general condition rapidly deteriorated with systemic inflammatory response syndrome. The patient had received respiratory support for a week, along with antimicrobial therapy and continuous hemofiltration, and then recovered. Even though pneumatosis intestinalis is generally recognized as a mild disease, careful attention is necessary when it follows a serious condition.

Pneumatosis cystoides intestinalis after alpha-glucosidase inhibitor treatment in a patient with interstitial pneumonitis

A 56-year-old woman was admitted to our hospital for treatment of non-specific interstitial pneumonitis (NSIP). The patient started prednisone treatment, but one month later treatment with voglibose, an alpha-glucosidase inhibitor (alpha-GI), was started because of prednisone-induced diabetes mellitus. One week later, a massive volume of free air below the diaphragm was detected by a chest X-ray examination. An abdominal CT examination demonstrated pneumatosis coli and the patient was diagnosed with pneumatosis cystoides intestinalis (PCI). Voglibose was discontinued and parenteral nutrition and oxygen inhalation were initiated. Radiographic findings of PCI disappeared within 7 days. We encountered a rare case of PCI, that was associated with alpha-GI treatment.

Inhibitory effect of voglibose and gymnemic acid on maltose absorption in vivo

AIM: To determine whether diabetic care can be improved by combination of voglibose and gymnemic acid (GA), we compared the combinative and individual effects of voglibose and GA on maltose absorption in small intestine.

METHODS: The small intestine 30 cm long from 2 cm caudal ward Treitz’s ligament of Wistar rat was used as an in situ loop, which was randomly perfused in recircular mode with maltose (10 mmol/L) with or without different dosages of voglibose and/or GA for 1 h. To compare the time course, perfusion of 10 mmol/L maltose was repeated four times. Each time continued for 1 h and separated by 30 min rinse. In the first time, lower dosages of GA (0.5 g/L) and/or voglibose (2 μmol/L) were contained except control.

RESULTS: Absorptive rate of maltose was the lowest in combinative group (P < 0.05, ANOVA), for example, the inhibition rate was about 37% during the first hour when0.5 g/L-GA and 2 μmol/L voglibose with 10 mmol/L maltose were perfused in the loop. The onset time was shortened to 30 min and the effective duration was prolonged to 4 h with the combination; therefore the total amount of maltose absorption during the effective duration was inhibited more significantly than that in the individual administration (P < 0.05, U test of Mann Whitney). The effect of GA on absorptive barriers of the intestine played an important role in the combinative effects.

CONCLUSION: There are augmented effects of voglibose and GA. The management of diabetes mellitus can be improved by employing the combination.