Presentation and outcomes among inflammatory bowel disease patients with concurrent pneumatosis intestinalis: a case series and systematic review

Teasing out factors differentiating pathologic from benign pneumatosis intestinalis

BACKGROUND

Pneumatosis intestinalis (PI) is a rare radiographic finding that can range from being a benign process to needing emergency surgery. Sufficiently powered studies are lacking, and recommendations for management remain unclear. The purpose of this study was to identify key predictors of pathologic PI using physical examination, laboratory, and radiographic findings.

METHODS

A retrospective cohort study was conducted at two quaternary academic centers (2010-2020). A total of 334 consecutive patients 18 years or older with radiographic evidence of PI were identified. Patients were excluded if they pursued comfort care or if there was concurrent radiographic evidence of vaso-occlusive process. Pathologic PI was defined as presence of ischemic and/or perforated bowel on exploratory laparotomy or death prior to planned surgery.

RESULTS

Of the 334 patients included in our study, 91 (27%) underwent exploratory laparotomy, of which 59 (65%) had ischemic and/or perforated bowel. These latter patients and 10 other patients who died before exploratory laparotomy defined the pathologic PI cohort. A stepwise model was created for predicting pathologic disease. Significant predictors were the presence of portal venous gas, multisegment PI, vasopressor use, peritonitis, increasing leukocyte count, and end organ injury, which were used to construct a nomogram for clinical use.

CONCLUSION

A nomogram score based on presence of portal venous gas, multisegment PI, vasopressor use, peritonitis, leukocytosis, and end organ injury may help predict the probability of pathologic PI and therefore can inform surgical decision making.

LEVEL OF EVIDENCE

Therapeutic/Care Management; Level III.

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.

Pneumatosis Intestinalis Manifesting as an Atypical Presentation of Crohn's Disease

Crohn's disease is an inflammatory bowel disease that has a bimodal distribution, occurring most frequently between ages 15 to 30 years and 40 to 60 years. It presents with a relapsing and remitting course. The most common area involved is the terminal ileum and right colon and the inflammation oftentimes leads to non-caseating granulomas and ulcerations in both the superficial mucosa and deeper layers. Additionally, pneumatosis intestinalis is defined as the presence of gas and free air in the extraluminal space of the intestines which is an abnormal occurrence and correlates with underlying pathology. There are only a few cases reported in the literature that present pneumatosis intestinalis in the setting of, and possibly linked to, Crohn's disease. Our case presents an elderly male patient with jejunal ulcerations and strictures suggesting Crohn's disease and associated pneumatosis intestinalis as evidenced on outpatient computed tomography (CT) enterography. Upon presentation to the hospital, the patient was non-toxic and was not complaining of any pain. During his inpatient stay, there was a suspicion of Crohn's disease and therefore he was started on Infliximab therapy. We will review the possible pathogenesis of Crohn's disease and other cases presenting pneumatosis intestinalis in the setting of Crohn's disease.

MR Enterography in Ulcerative Colitis: Beyond Endoscopy

Ulcerative colitis (UC) is a chronic idiopathic inflammatory bowel disease (IBD) that progressively affects mucosa and submuccosa of the colon and rectum in a continual pattern. In comparison, Crohn disease (CD), the other type of IBD, is a chronic transmural inflammatory disorder that can involve any part of the gastrointestinal tract. MR enterography (MRE) has emerged as an important imaging modality for the diagnosis and detection of disease activity and complications in CD, with comparable results to those of endoscopy. But MRE has been underused for assessment of UC in recent years, and clinicians heavily rely on endoscopic findings for management of UC. Despite UC being considered an endoscopically assessable disease, MRE can provide useful information beyond that obtained with endoscopy about mural or extramural abnormalities, inaccessible parts of the colonic lumen, associated extraintestinal diseases, and superimposed pathologic conditions. Moreover, endoscopy might be contraindicated in some clinical settings due to the risk of colonic perforation. In addition to depicting the features of UC activity in different phases, MRE demonstrates findings of disease chronicity that cannot be achieved with endoscopy, particularly in a patient with colitis of unknown cause. The valuable diagnostic role of MRE to exclude undiagnosed CD in patients with UC who have refractory disease or those with postproctocolectomy complications is also emphasized. Radiologists can play a crucial role in the management of UC with MRE by addressing what is beyond endoscopy. ©RSNA, 2023 Test Your Knowledge questions are available in the supplemental material.

The spectrum of pneumatosis intestinalis in the adult. A surgical dilemma

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.

Pneumatosis Intestinalis Induced by Anticancer Treatment: A Systematic Review

Simple Summary

Anticancer treatments commonly cause adverse events (AE). Among others, pneumatosis intestinalis (PI) is reported to be infrequent, though it can lead to severe consequences. The aim of our systematic review was to investigate the concurrency of PI and oncological therapy exposure; moreover, we defined the characteristics of patients and the primarily involved tumor types. We analyzed 88 different episodes of PI. The median time of onset was 6 weeks and oncological patients with respiratory system cancers and those treated with targeted therapies appeared be at higher risk. Symptoms were frequently mild to absent; nevertheless, life-threatening complications were reported. Therefore, this AE, although uncommon, should be considered in the case of specific symptoms. Potential pharmacological mechanisms of anticancer drugs in inducing PI are also discussed.

Abstract

Pneumatosis intestinalis (PI) is a rare condition due to the presence of gas within the bowel wall; it is mainly caused by endoscopic procedures, infections and other gastrointestinal diseases. Oncological therapies have been reported to be a cause of PI as well, but their role is not clearly defined. This systematic review investigates the concurrency of PI and antitumor therapy in cancer patients, considering both solid tumors and onco-hematological ones. We performed a literature review of PubMed, Embase and the Web of Science up to September 2021 according to the PRISMA guidelines. A total of 62 papers reporting 88 different episodes were included. PI was mainly reported with targeted therapies (sunitinib and bevacizumab above all) within the first 12 weeks of treatment. This adverse event mostly occurred in the metastatic setting, but in 10 cases, it also occurred also in the neoadjuvant and adjuvant setting. PI was mostly localized in the large intestine, being fatal in 11 cases, while in the remaining cases, symptoms were usually mild, or even absent. A significant risk of PI reoccurrence after drug reintroduction was also reported (6/18 patients), with no fatal outcomes. Potential pharmacological mechanisms underlying PI pathogenesis are also discussed. In conclusion, although uncommonly, PI can occur during oncological therapies and may lead to life-threatening complications; therefore, consideration of its occurrence among other adverse events is warranted in the presence of clinical suspicion.

OUP accepted manuscript

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.