Does massive intraabdominal free gas require surgical intervention?

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.

Case Report: An unusual case of small bowel volvulus associated with pneumatosis intestinalis

Pneumatosis cystoid intestinalis is a rare disease reported in the literature affecting 0.03% of the population. It has a variety of causes and its manifestation may change widely. It usually presents as a marginal finding resulting from various gastrointestinal pathologies. In the acute complicated form of pneumatosis intestinalis, management is challenging for physicians and surgeons. We present a case of a 60-year-old patient who was admitted to our surgical department with a symptomatology suggestive of small bowel occlusion. Computed tomography demonstrated ileal volvulus associated with parietal signs suffering and pneumoperitoneum. An emergent exploratory laparoscopy followed by conversion was performed demonstrating segmental ileal pneumatosis intestinalis secondary to a small bowel volvulus due to an inflammatory appendix wrapping around the distal ileum. Further, detorsion, retrograde draining, and appendectomy were performed because there were no signs of necrosis and the appendix was pathological. The postoperative course was uneventful. This case is exceedingly rare in the literature, because it was featured by the ileal volvulus due to appendicitis.This case report emphasizes the importance of surgical procedures in the management of symptomatic pneumatosis intestinalis.

Case Report: An unusual case of small bowel volvulus due to appendicitis associated with pneumatosis intestinalis: Review of the literature

Pneumatosis cystoid intestinalis is a rare disease reported in the literature affecting 0.03% of the population. It has a variety of causes and its manifestation may change widely. It usually presents as a marginal finding resulting from various gastrointestinal pathologies. In the acute complicated form of pneumatosis intestinalis, management is challenging for physicians and surgeons. We present a case of a 60-year-old patient who was admitted to our surgical department with a symptomatology suggestive of small bowel occlusion. Computed tomography demonstrated ileal volvulus associated with parietal signs suffering and pneumoperitoneum. An emergent exploratory laparoscopy followed by conversion was performed demonstrating segmental ileal pneumatosis intestinalis secondary to a small bowel volvulus due to an inflammatory appendix wrapping around the distal ileum. Further, detorsion, retrograde draining, and appendectomy were performed because there were no signs of necrosis and the appendix was pathological. The postoperative course was uneventful. This case is exceedingly rare in the literature, because it was featured by the ileal volvulus due to appendicitis.This case report emphasizes the importance of surgical procedures in the management of symptomatic pneumatosis intestinalis associated to an acute abdomen.

Clinical characteristics of pneumoperitoneum with pneumatosis intestinalis detected using computed tomography: A descriptive study

Pneumoperitoneum has always been considered a surgical emergency as it represents a perforation of the gastrointestinal tract. Although several cases of pneumoperitoneum with pneumatosis intestinalis (PI) have been reported, the characteristics of such cases remain unclear. The current study aimed to clarify the clinical characteristics of pneumoperitoneum cases with PI detected using computed tomography (CT).This descriptive study was conducted at a single center. In a total of 18,513 abdominal CT scans obtained between January 2010 and February 2017, extraluminal free air was detected in 254 examinations of 182 cases. The medical records and CT images of these 182 patients were retrospectively analyzed.Pneumoperitoneum with PI was detected through 23 examinations in 21 cases, and the average age of the patients was 80.1 years. The frequency was 0.12% in all abdominal CT examinations, but 24.7% in the 85 cases with extraluminal free air, excluding iatrogenic air. PI was classified as benign in 20 cases and as life-threatening in 1 case. The majority of cases with benign PI showed good general and local findings and little leukocytosis, while the case with life-threatening PI showed severe conditions. No evidence of bowel wall discontinuity, segmental bowel-wall thickening, perivisceral fat stranding, and abscesses were observed. Ascites were detected less frequently in the cases with PI than in the other pneumoperitoneum cases (P < .01). Pneumoperitoneum and PI occasionally recurred, and PI and/or extraluminal free air generally disappeared quickly.Pneumoperitoneum with PI is a relatively common condition in older patients, and the majority of cases are caused by benign PI. The characteristics of pneumoperitoneum cases with benign PI include well-maintained physical conditions, normal laboratory data, absence of CT findings indicative of peritonitis, and infrequent ascites. In pneumoperitoneum cases with PI, predicting whether the PI is benign or life-threatening is clinically very important, whereas the presence of extraluminal free air is considered to be insignificant.

Non-surgical treatment of gastric emphysema with intraabdominal free gas and hepatic portal venous gas: Lessons from a rare case

We herein describe a case of an 83-year-old man who presented with epigastralgia, vomiting, and abdominal distention. The physical abdominal examination revealed mild tenderness. Computed tomography revealed intramural gastric gas spread throughout the stomach, intraabdominal free gas, and hepatic portal venous gas. We diagnosed gastric emphysema with intraabdominal free gas and hepatic portal venous gas. We selected a wait-and-watch approach because physical examination did not show any peritoneal signs, although the radiological examinations showed remarkable findings. As a result, he received conservative therapy with fasting, intravenous infusion of antibiotics, and gastric decompression by nasogastric intubation. The patient was relieved of the symptoms, and follow-up computed tomography showed that all the abnormal gas disappeared soon after the treatment. In conclusion, the intramural gastric gas even with both intraabdominal free gas and hepatic portal venous gas does not always require surgical intervention. In case clinicians including general surgeons and physicians encounter intraabdominal free gas with hepatic portal venous gas, gastric emphysema should be considered in the different diagnosis. Lack of knowledge may lead to misdiagnosis, which may result in unnecessary surgical intervention.

"Cystamatic" Review: Is Surgery Mandatory for Pneumatosis Cystoides Intestinalis?

INTRODUCTION

Pneumatosis cystoides intestinalis (PCI) is a rare condition characterized by the presence of intramural gas cysts within the small and large intestines. We describe a case of a 70-year-old man admitted to the Emergency Surgery Department for PCI who was treated conservatively.

AREAS COVERED

We reviewed 60 cases of PCI described in the international literature over the last 5 years. From our analysis, it appears that the etiology of the gas production within the submucosa or the subserosa of the gastrointestinal tract is still unknown. The rupture of the cysts can lead to pneumoperitoneum that can simulate a surgical emergency.

EXPERT COMMENTARY

For patients with PCI, a conservative approach is the treatment of choice, with surgery mandatory only for complicated disease.

"Cystamatic" Review: Is Surgery Mandatory for Pneumatosis Cystoides Intestinalis?

INTRODUCTION

Pneumatosis cystoides intestinalis (PCI) is a rare condition characterized by the presence of intramural gas cysts within the small and large intestines. We describe a case of a 70-year-old man admitted to the Emergency Surgery Department for PCI who was treated conservatively.

AREAS COVERED

We reviewed 60 cases of PCI described in the international literature over the last 5 years. From our analysis, it appears that the etiology of the gas production within the submucosa or the subserosa of the gastrointestinal tract is still unknown. The rupture of the cysts can lead to pneumoperitoneum that can simulate a surgical emergency.

EXPERT COMMENTARY

For patients with PCI, a conservative approach is the treatment of choice, with surgery mandatory only for complicated disease.

Intestinal Involvement in Systemic Sclerosis: A Clinical Review

Systemic sclerosis (SSc) is a chronic systemic disease characterized by microvasculopathy, autoantibodies, and extensive fibrosis. Intestinal involvement is frequent in SSc and represents a significant cause of morbidity. The pathogenesis of intestinal involvement includes vascular damage, nerve dysfunction, smooth muscle atrophy, and fibrosis, causing hypomotility, which leads to small intestinal bacterial overgrowth (SIBO), malabsorption, malnutrition, diarrhea, pseudo-obstruction, constipation, pneumatosis intestinalis, and fecal incontinence. Manifestations are often troublesome and reduce quality of life and life expectancy. Assessment of intestinal involvement includes screening for small intestine hypomotility, malnutrition, SIBO, and anorectal dysfunction. Current management of intestinal manifestations is largely inadequate. Patients with diarrhea are managed with low-fat diet, medium-chain triglycerides, avoidance of lactulose and fructose, and control of bacterial overgrowth with antibiotics for SIBO. In diarrhea/malabsorption, bile acid sequestrant and pancreatic enzyme supplementation may help, and nutritional support is needed. General measures are applied for constipation, and intestine rest plus antibiotics for pseudo-obstruction. Fecal incontinence is managed with measures for associated SIBO, or constipation, and with behavioral therapies. Pneumatosis intestinalis is usually an incidental finding that does not require any specific treatment. Immunomoduation should be considered early in intestinal involvement. Multidisciplinary approach of intestinal manifestations in SSc by gastroenterologists and rheumatologists is required for optimum management.