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Fleck M, Zein L, Doussot A, Turco C, Lakkis Z, Simon G, Busse-Coté A, Piton G, Delabrousse E, Calame P. CT evaluation of bowel wall enhancement in pneumatosis intestinalis: preventing non-therapeutic laparotomies. Abdom Radiol (NY) 2024:10.1007/s00261-024-04450-1. [PMID: 38954000 DOI: 10.1007/s00261-024-04450-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Revised: 06/07/2024] [Accepted: 06/09/2024] [Indexed: 07/04/2024]
Abstract
PURPOSE To evaluate the diagnostic performance of bowel wall enhancement for diagnosing concomitant bowel ischemia in patients with parietal pneumatosis (PI) diagnosed at abdominal CT. MATERIALS AND METHODS From January 1, 2012 to December 31, 2021, 226 consecutive patients who presented with PI on abdominal CT from any bowel segment were included. Variables at the time of the CT were retrospectively extracted from medical charts. CT examinations were blindly analyzed by two independent radiologists. The third reader classified all disagreement of bowel enhancement in three categories: (1) normal bowel enhancement; (2) doubtful bowel wall enhancement; (3) absent bowel wall enhancement. Multivariable logistic regression analysis was performed. Concomitant bowel ischemia was defined as requirement of bowel resection specifically due to ischemic lesion in operated patients and death from bowel ischemia in non-operated patients. RESULTS Overall, 78/226 (35%) patients had PI associated with concomitant bowel ischemia. At multivariate analysis, Only absence or doubtful bowel wall enhancement was associated with concomitant bowel ischemia (OR = 167.73 95%CI [23.39-4349.81], P < 0,001) and acute mesenteric ischemia associated with PP (OR = 67.94; 95%CI [5.18-3262.36], P < 0.009). Among the 82 patients who underwent a laparotomy for suspected bowel ischemia, rate of non-therapeutic laparotomy increased from 15/59 (25%), 2/6 (50%) and 16/17 (94%) when bowel wall enhancement was absent, doubtful and normal respectively. CONCLUSION Absence of enhancement of the bowel wall is the primary feature associated with concomitant bowel ischemia. It should be carefully assessed when PI is detected to avoid non-therapeutic laparotomy.
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Affiliation(s)
- Martin Fleck
- Department of Radiology, University of Bourgogne Franche-Comté and CHU Besançon, 25030, Besançon, France
| | - Lisa Zein
- Department of Radiology, University of Bourgogne Franche-Comté and CHU Besançon, 25030, Besançon, France
| | - Alexandre Doussot
- Department of Digestive Surgery, University of Bourgogne Franche-Comté and CHU Besançon, 25030, Besançon, France
| | - Celia Turco
- Department of Digestive Surgery, University of Bourgogne Franche-Comté and CHU Besançon, 25030, Besançon, France
| | - Zaher Lakkis
- Department of Digestive Surgery, University of Bourgogne Franche-Comté and CHU Besançon, 25030, Besançon, France
| | - Gabriel Simon
- Department of Radiology, University of Bourgogne Franche-Comté and CHU Besançon, 25030, Besançon, France
| | - Andreas Busse-Coté
- Department of Radiology, University of Bourgogne Franche-Comté and CHU Besançon, 25030, Besançon, France
| | - Gael Piton
- Medical Intensive Care Unit, University of Bourgogne Franche-Comté and CHU Besançon, 25030, Besançon, France
| | - Eric Delabrousse
- Department of Radiology, University of Bourgogne Franche-Comté and CHU Besançon, 25030, Besançon, France
- EA 4662 Nanomedicine Lab, Imagery and Therapeutics, University of Franche-Comté, Besançon, France
| | - Paul Calame
- Department of Radiology, University of Bourgogne Franche-Comté and CHU Besançon, 25030, Besançon, France.
- EA 4662 Nanomedicine Lab, Imagery and Therapeutics, University of Franche-Comté, Besançon, France.
- Service de Radiologie, CHRU Besançon, Hôpital Jean Minjoz, 3 Boulevard Fleming, 25030, Besançon, France.
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2
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Logue G, Chaudhry M. Pneumatosis cystoides intestinalis presenting as pneumoperitoneum in a patient with chronic obstructive pulmonary disease. BJR Case Rep 2023; 9:20230020. [PMID: 37576004 PMCID: PMC10412913 DOI: 10.1259/bjrcr.20230020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 05/17/2023] [Accepted: 05/20/2023] [Indexed: 08/15/2023] Open
Abstract
Pneumatosis is always an alarming sign that may result from life-threatening bowel ischaemia and infarction; however, benign intramural gas can also result from a variety of secondary conditions including chronic obstructive pulmonary disease (COPD). Pneumoperitoneum and pneumoretroperitoneum can be seen with both entities. Therefore, thorough discussions with the referring clinicians regarding the patient's medical history, clinical examination and laboratory results are mandatory. Benign causes can be managed conservatively, however, emergency exploratory laparotomy is often required in suspected life-threatening conditions. Misinterpretation of this finding can lead to incorrect diagnosis and unnecessary surgery.
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Affiliation(s)
- Genna Logue
- Macclesfield District General Hospital, Macclesfield, United Kingdom
| | - Mubeen Chaudhry
- Macclesfield District General Hospital, Macclesfield, United Kingdom
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3
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Tropeano G, Di Grezia M, Puccioni C, Bianchi V, Pepe G, Fico V, Altieri G, Brisinda G. The spectrum of pneumatosis intestinalis in the adult. A surgical dilemma. World J Gastrointest Surg 2023; 15:553-565. [PMID: 37206077 PMCID: PMC10190725 DOI: 10.4240/wjgs.v15.i4.553] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 02/10/2023] [Accepted: 03/21/2023] [Indexed: 04/22/2023] Open
Abstract
Pneumatosis intestinalis (PI) is a striking radiological diagnosis. Formerly a rare diagnostic finding, it is becoming more frequently diagnosed due to the wider availability and improvement of computed tomography scan imaging. Once associated only with poor outcome, its clinical and prognostic significance nowadays has to be cross-referenced to the nature of the underlying condition. Multiple mechanisms of pathogenesis have been debated and multiple causes have been detected during the years. All this contributes to creating a broad range of clinical and radiological presentations. The management of patients presenting PI is related to the determining cause if it is identified. Otherwise, in particular if an association with portal venous gas and/or pneumoperitoneum is present, the eventual decision between surgery and non-operative management is challenging, even for stable patients, since this clinical condition is traditionally associated to intestinal ischemia and consequently to pending clinical collapse if not treated. Considering the wide variety of origin and outcomes, PI still remains for surgeons a demanding clinical entity. The manuscript is an updated narrative review and gives some suggestions that may help make the decisional process easier, identifying patients who can benefit from surgical intervention and those who can benefit from non-operative management avoiding unnecessary procedures.
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Affiliation(s)
- Giuseppe Tropeano
- Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome 00168, Italy
| | - Marta Di Grezia
- Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome 00168, Italy
| | - Caterina Puccioni
- Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome 00168, Italy
| | - Valentina Bianchi
- Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome 00168, Italy
| | - Gilda Pepe
- Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome 00168, Italy
| | - Valeria Fico
- Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome 00168, Italy
| | - Gaia Altieri
- Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome 00168, Italy
| | - Giuseppe Brisinda
- Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome 00168, Italy
- Department of Surgery, Università Cattolica del Sacro Cuore, Rome 00168, Italy
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4
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Wojack PR, Goldman IA. Emphysematous cystitis with extraperitoneal gas: new insights into pathogenesis via novel CT findings. Clin Imaging 2020; 65:1-4. [DOI: 10.1016/j.clinimag.2020.04.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 03/23/2020] [Accepted: 04/07/2020] [Indexed: 12/26/2022]
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5
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Lee NK, Kim S, Hong SB, Lee SJ, Kim TU, Ryu H, Lee JW, Kim JY, Suh HB. CT diagnosis of non-traumatic gastrointestinal perforation: an emphasis on the causes. Jpn J Radiol 2019; 38:101-111. [PMID: 31848888 DOI: 10.1007/s11604-019-00910-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 12/05/2019] [Indexed: 12/13/2022]
Abstract
Gastrointestinal tract (GI) perforations can occur due to various causes such as trauma, iatrogenic factor, infectious condition, peptic ulcer, inflammatory disease, or a neoplasm. Because GI perforations represent an emergency and life-threatening condition, prompt diagnosis and surgical treatment are required in most cases. However, according to the underlying causes of GI perforations, additional treatment strategies may be needed. Adjuvant chemotherapy or immunotherapy may be required in various GI neoplasms such as adenocarcinoma, lymphoma or gastrointestinal stromal tumor. Inflammatory bowel disease is a chronic disease repeating cycle of intermittent, thus appropriate medical treatment and periodic follow-up are also required. Moreover, vascular intervention may have a role in some cases of mesenteric ischemia associated with mesenteric artery occlusion. Recently, computed tomography (CT) has been the first choice for patients with suspected GI perforations, because CT plays an important role in the accurate assessment of the perforation site, the pathology causing the perforation and the ensuing complications. This review will illustrate characteristic CT findings that differentiate underlying pathologies causing GI perforations to help clinicians decision-making regarding an optimal treatment plan.
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Affiliation(s)
- Nam Kyung Lee
- Department of Radiology, Biomedical Research Institute, Pusan National University Hospital, and Pusan National University School of Medicine, 179, Gudeok-ro, Seo-gu, Busan, 49241, Korea.
| | - Suk Kim
- Department of Radiology, Biomedical Research Institute, Pusan National University Hospital, and Pusan National University School of Medicine, 179, Gudeok-ro, Seo-gu, Busan, 49241, Korea
| | - Seung Baek Hong
- Department of Radiology, Biomedical Research Institute, Pusan National University Hospital, and Pusan National University School of Medicine, 179, Gudeok-ro, Seo-gu, Busan, 49241, Korea
| | - So Jeong Lee
- Department of Pathology, Pusan National University Hospital, and Pusan National University School of Medicine, Busan, Korea
| | - Tae Un Kim
- Department of Radiology, Pusan National University Yangsan Hospital, and Pusan National University School of Medicine, Gyeongsangnam-do, Korea
| | - Hwaseong Ryu
- Department of Radiology, Pusan National University Yangsan Hospital, and Pusan National University School of Medicine, Gyeongsangnam-do, Korea
| | - Ji Won Lee
- Department of Radiology, Biomedical Research Institute, Pusan National University Hospital, and Pusan National University School of Medicine, 179, Gudeok-ro, Seo-gu, Busan, 49241, Korea
| | - Jin You Kim
- Department of Radiology, Biomedical Research Institute, Pusan National University Hospital, and Pusan National University School of Medicine, 179, Gudeok-ro, Seo-gu, Busan, 49241, Korea
| | - Hie Bum Suh
- Department of Radiology, Biomedical Research Institute, Pusan National University Hospital, and Pusan National University School of Medicine, 179, Gudeok-ro, Seo-gu, Busan, 49241, Korea
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6
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Cavalea AC, Heidel RE, Daley BJ, Lawson CM, Benton DA, Mcloughlin JM. Pneumatosis Intestinalis in Patients Receiving Tube Feeds. Am Surg 2017. [DOI: 10.1177/000313481708300830] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Pneumatosis intestinalis (PI) identified on computed tomography (CT) suggests an underlying pathology including bowel ischemia. Patients receiving tube feeds can develop PI, potentially requiring surgical intervention. We identify clinical factors in PI to predict those that may be safe to observe versus those that need immediate intervention. We retrospectively reviewed patients from a single institution from 2008 to 2016 with CT findings of PI and an enteric feeding tube. Patients who had not received tube feeds within one week of the CT were excluded. We analyzed clinical, operative, and outcome data to differentiate benign from pathologic outcomes. P values < 0.05 were set as significant. Forty patients were identified. We classified 24 as benign (no intervention) and 16 as pathologic (requiring intervention). A pathologic outcome was demonstrated for free fluid on CT [odds ratio (OR) = 5.00, confidence interval (CI) 1.23-20.30, P = 0.03)], blood urea nitrogen (BUN) elevation (OR = 8.27, CI 1.53-44.62, P = 0.01), creatinine (Cr) elevation (OR = 5.00, CI 1.27-19.62, P = 0.02), BUN/Cr ratio >30 (OR = 8.57, CI 1.79-40.98, P = 0.006), and vomiting/ feeding intolerance (OR = 9.38, CI 1.64-53.62, P = 0.01). Bowel function within 24 hours of the CT, bowel dilatation (small ≥ 3 cm; large ≥6 cm), and lactic acidemia were not significant. Peritonitis was only seen in pathologic states, but this did not reach statistical significance (P = 0.06). This represents the largest single-center retrospective analysis of tube feeding-induced PI to date. The presence of free fluid on CT, BUN and Cr elevation, BUN/Cr >30, vomiting/feeding intolerance and peritonitis were predictive of a pathologic etiology of PI.
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Affiliation(s)
- Alexander C. Cavalea
- Department of Surgery, University of Tennessee Graduate School of Medicine, Knoxville, Tennesssee
| | - Robert E. Heidel
- Department of Surgery, University of Tennessee Graduate School of Medicine, Knoxville, Tennesssee
| | - Brian J. Daley
- Department of Surgery, University of Tennessee Graduate School of Medicine, Knoxville, Tennesssee
| | - Christy M. Lawson
- Department of Surgery, University of Tennessee Graduate School of Medicine, Knoxville, Tennesssee
| | - Darrell A. Benton
- Department of Surgery, University of Tennessee Graduate School of Medicine, Knoxville, Tennesssee
| | - James M. Mcloughlin
- Department of Surgery, University of Tennessee Graduate School of Medicine, Knoxville, Tennesssee
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7
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Diffuse pneumatosis intestinalis and pneumoperitoneum. Dig Liver Dis 2017; 49:938. [PMID: 28473301 DOI: 10.1016/j.dld.2017.03.016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2017] [Revised: 03/17/2017] [Accepted: 03/22/2017] [Indexed: 12/11/2022]
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8
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Blair HA, Baker R, Albazaz R. Pneumatosis intestinalis an increasingly common radiological finding, benign or life-threatening? A case series. BMJ Case Rep 2015; 2015:bcr-2014-207234. [PMID: 25694632 DOI: 10.1136/bcr-2014-207234] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
This case series reviews two cases where elderly patients were found to have pneumatosis intestinalis on imaging. The two clinical presentations differed from one another, however, both were managed conservatively to good effect. In case one the patient presented with abdominal pain, a change in bowel habit and weight loss. In case two the patient presented with problematic diarrhoea, reduced oral intake, lethargy and weight loss. Both patients were haemodynamically stable and neither had an abnormal abdominal examination. Case 2 was started on oral metronidazole and by day 11 of treatment there was resolution of the pneumatosis on her abdominal X-ray and her diarrhoea had settled. These two cases illustrate the benefit of conservative management and avoidance of unnecessary surgical intervention in primary pneumatosis intestinalis. However, it is important to distinguish between these benign causes of pneumatosis intestinalis and those which are life-threatening in which surgery may be necessary.
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Affiliation(s)
| | - Richard Baker
- John Goligher Colorectal Unit, St James University Hospital, Leeds, UK
| | - Raneem Albazaz
- Department of Radiology, St James University hospital, Leeds, UK
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9
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Rottenstreich A, Agmon Y, Elazary R. A Rare Case of Benign Pneumatosis Intestinalis with Portal Venous Gas and Pneumoperitoneum Induced by Acarbose. Intern Med 2015; 54:1733-6. [PMID: 26179526 DOI: 10.2169/internalmedicine.54.4255] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Alpha glucosidase inhibitors have been shown to be associated with pneumatosis intestinalis (PI) in recent reports. We herein report the case of a 73-year old man who received treatment with an alpha glucosidase inhibitor (acarbose) and presented with acute abdomen. A computed tomography scan demonstrated PI in addition to intrahepatic portal air and pneumoperitoneum. During exploratory laparotomy, we found no evidence of hollow organ perforation or bowel necrosis. The patient recovered after conservative treatment with cessation of the alpha glucosidase inhibitor. This is the first report to describe the combination of PI with portal venous gas and pneumoperitoneum caused by an alpha-glucosidase inhibitor.
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Affiliation(s)
- Amihai Rottenstreich
- Department of General Surgery, Hadassah-Hebrew University Medical Center, Israel
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10
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Zorgdrager M, Pol R. Pneumatosis intestinalis associated with enteral tube feeding. BMJ Case Rep 2013; 2013:bcr-2013-009378. [PMID: 24302661 DOI: 10.1136/bcr-2013-009378] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A 49-year-old man presented with a Hinchey II perforated diverticulitis and underwent laparoscopic peritoneal lavage. During the postoperative course the patient received enteral tube feeding which was followed by a bowel obstruction accompanied with pneumatosis intestinalis (PI). Explorative laparotomy showed an omental band adhesion without signs of ischaemia. After a short period of total parenteral nutrition PI resolved almost completely and enteral tube feeding could be continued once again. In the weeks that followed the patient developed atypical bowel symptoms and recurrent PI which resolved each time the drip feeding was discontinued. Despite the mild clinical course, a CT scan showed massive PI on day 21 after the laparotomy. After excluding life-threatening conditions conservative management was instituted and the patient recovered completely after discontinuing the drip feeding. We present one of the few cases of subclinical PI associated with enteral tube feeding that could be managed conservatively.
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Hong KD, Lee SI, Moon HY. Pneumatosis intestinalis and laparoscopic exploration: beware of gas explosion. J Laparoendosc Adv Surg Tech A 2012; 22:273-5. [PMID: 22288881 DOI: 10.1089/lap.2011.0465] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Colonic gas explosion, although rare, is sometimes a fatal iatrogenic complication in endoscopic procedures or laparotomic surgery, but it has not been reported during port incision of laparoscopy. We report a case of gas detonation in a patient with pneumatosis intestinalis and pneumoperitoneum, on opening the peritoneum with a diathermy for umbilical trocar insertion. Based on our experience, in cases of pneumoperitoneum, surgeons need to avoid using a diathermy in opening the peritoneum.
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Affiliation(s)
- Kwang Dae Hong
- Department of Surgery, Korea University College of Medicine, Seoul, Korea
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