Potential Indicators of Intestinal Necrosis in Portal Venous Gas: A Case Report of an 82-Year-Old Woman on Long-Term Hemodialysis with Ascites and Pneumatosis Coli

BACKGROUND Several factors have been reported as possible predictors of intestinal necrosis in patients with portal venous gas (PVG). We describe potential indicators of intestinal necrosis in PVG identified by contrasting 3 episodes of PVG in a patient on hemodialysis against previously verified factors. CASE REPORT An 82-year-old woman undergoing hemodialysis was admitted to our hospital thrice for acute abdominal pain. On first admission, she was alert, with a body temperature of 36.3°C, blood pressure (BP) of 125/53 mmHg, pulse rate of 60/min, respiratory rate of 18/min, and 100% oxygen saturation on room air. Computed tomography (CT) revealed PVG, intestinal distension, poor bowel wall enhancement, bubble-like pneumatosis in the intestinal wall, and minimal ascites. PVG caused by intestinal ischemia was diagnosed, and she recovered after bowel rest and hydration. Three months later, she had a second episode of abdominal pain. BP was 115/56 mmHg. CT revealed PVG and a slight accumulation of ascites, without pneumatosis in the intestinal wall. She again recovered after conservative measures. Ten months later, the patient experienced a third episode of abdominal pain, with BP of 107/52 mmHg. CT imaging indicated PVG, considerable ascites, and linear pneumatosis of the intestinal walls. Despite receiving conservative treatment, the patient died. CONCLUSIONS A large accumulation of ascites and linear pneumatosis in the intestinal walls could be potential indicators of intestinal necrosis in patients with PVG caused by intestinal ischemia. As previously reported, hypotension was further confirmed to be a reliable predictor of intestinal necrosis.

[Pneumatosis cystoides intestinalis in lung transplant recipients: three cases report and literature review]

Objective: To report the clinical characteristics and treatment courses of pneumatosis cystoides intestinalis(PCI) after lung transplantation(LT). Methods: We included all cases of PCI after LT from March 2017 to June 2021 in China-Japan Friendship Hospital. In addition to our cases, we searched literatures published in Chinese and English languages using China National Knowledge Infrastructure (CNKI), Wanfang Data and PubMed/MEDLINE with the search terms"pneumatosis intestinalis"and"lung transplantation". The clinical characteristics and treatment courses of all cases were summarized and analyzed. Results: Three cases of PCI occurred after LT in this study, with an incidence of 0.804% (3/373). Thirteen related literatures were retrieved, with 51 cases enrolled. The median age of the 54 patients was 55.4 years (22-79 years), with 33 males and 21 females. 64.81% (35/54) of the 54 patients underwent LT for interstitial lung disease and 90.74% (49/54) underwent bilateral LT. Twenty-two cases(40.7%) were asymptomatic when PCI occurred. Thirty-eight cases (38/54,70.37%)had involvement of ascending colon, and 35 cases(35/54,64.81%)had involvement of transverse colon. Forty-three cases(43/54, 79.63%) were treated conservatively. The average interval between transplantation and PCI was 210 (5-2 495) days. Conclusion: PCI is a rare complication after lung transplantation, most often occurring in the colon. Most patients were asymptomatic and could improve by conservative treatments.

Pneumatosis intestinalis in the pediatric oncology population: An 11-year retrospective review at Memorial Sloan Kettering Cancer Center

BACKGROUND

Pneumatosis intestinalis (PI) is characterized by the presence of intramural gas in the gastrointestinal (GI) tract. The overall aim of this study was to review risk factors and outcome of pediatric oncology patients at our institution who developed PI.

PROCEDURE

Patients diagnosed with PI between 2007 and 2018 were identified from ICD-10 coding of radiology reports at Memorial Sloan Kettering Kids, a tertiary pediatric oncology center. Outcomes of interest were (a) resolution and time to resolution of PI, (b) surgical intervention within 2 weeks of diagnosis of PI, or (c) death secondary to PI. To capture the resolution of PI, we defined the "time to recovery (TTR)" as the time elapsed between date of PI diagnosis and the date of recovery.

RESULTS

Forty-two patients were identified. Within 30 days of diagnosis of PI, three patients had surgical intervention for PI (7%) and two patients died (5%) due to non-PI causes. Median TTR of PI was 4.5 days (95% CI: 3-7 days). In univariable and multivariable analyses, only steroid use in the prior 30 days was significantly associated with a faster TTR of PI (HR = 2.27 [95% CI: 1.17-4.41], p = .02).

CONCLUSIONS

This is the largest case series of patients with PI in the pediatric oncology population, which reveals significantly lower surgical and mortality rates than other published PI series. For the majority of patients, conservative medical management is indicated. A prospective study is warranted to define diagnosis and management guidelines for PI in the pediatric oncology population in a cooperative group setting.

A rare case of pneumatosis cystoides intestinalis with bowel perforation and secondary sepsis

MATERIALS AND METHODS

We present here the case of an 83 y.o. male with intestinal perforation from pneumatosis cystoides intestinalis and consequent sepsis.

RESULTS

The patient underwent urgency intestinal resection in our institute, with complete restitution ad integrum Discussion: Pneumatosis cystoides intestinalis is a rare affection, which can be categorized as primary (15%) or idiopathic( 85%). The clinical appearance can be very variable from patient to patient, since it can be completely asymptomatic or start with life-threatening clinical presentation of bowel perforation and sepsis. There are various theories about the formation of the gas bubbles trough the intestinal wall. The mechanical theory assumes that the gas, tearing trough the intestinal wall seeps trough it. The bacterial theory assumes that antibiotic treatment, such as with metronidazole, allows the creation of gas by microbiological elements like Clostridium Perfringens or Clostridium Difficile. The pulmonary theory, instead, assumes that air released from ruptured alveoli gets into the mediastinum and retro peritoneum, reaching the intestinal tract. The treatment is conservative most of the times, except for the cases of intestinal perforation and sepsis.

CONCLUSIONS

Despite of the long history of the disease, with the first description in 1783, little is known nowadays about PCI, due to the rarity of symptomatic disease. Further studies are needed to better evaluate the aetiology of the condition, and the prognostic criteria, which may be very important for clinical decisions about conservative or surgical treatment.

KEY WORDS

Diagnosis, Pneumatosis cystoides intestinalis, Peritonitis, Therapy.

Portal venous gas and pneumatosis intestinalis secondary to intestinal subocclusion: success of non-surgical management

The association of intestinal and portal pneumatosis in the same patient usually occurs in intestinal ischemic-necrotic processes, with ominous prognosis. However, there are forms of presentation outside this context, with a radically different management and evolution. We present the case of a patient with portal and gastric pneumatosis, managed conservatively successfully. The clinical presentation and a multidisciplinary management will be critical in the decision-making process to obtain favorable results.

Optimal treatment strategies for hepatic portal venous gas: A retrospective assessment

BACKGROUND

Hepatic portal venous gas (HPVG) generally indicates poor prognoses in patients with serious intestinal damage. Although surgical removal of the damaged portion is effective, some patients can recover with conservative treatments.

AIM

To establish an optimal treatment strategy for HPVG, we attempted to generate computed tomography (CT)-based criteria for determining surgical indication, and explored reliable prognostic factors in non-surgical cases.

METHODS

Thirty-four cases of HPVG (patients aged 34-99 years) were included. Necessity for surgery had been determined mainly by CT findings (i.e. free-air, embolism, lack of contrast enhancement of the intestinal wall, and intestinal pneumatosis). The clinical data, including treatment outcomes, were analyzed separately for the surgical cases and non-surgical cases.

RESULTS

Laparotomy was performed in eight cases (surgical cases). Seven patients (87.5%) survived but one (12.5%) died. In each case, severe intestinal damage was confirmed during surgery, and the necrotic portion, if present, was removed. Non-occlusive mesenteric ischemia was the most common cause (n = 4). Twenty-six cases were treated conservatively (non-surgical cases). Surgical treatments had been required for twelve but were abandoned because of the patients’ poor general conditions. Surprisingly, however, three (25%) of the twelve inoperable patients survived. The remaining 14 of the 26 cases were diagnosed originally as being sufficiently cured by conservative treatments, and only one patient (7%) died. Comparative analyses of the fatal (n = 10) and recovery (n = 16) cases revealed that ascites, peritoneal irritation signs, and shock were significantly more frequent in the fatal cases. The mortality was 90% if two or all of these three clinical findings were detected.

CONCLUSION

HPVG related to intestinal necrosis requires surgery, and our CT-based criteria are probably useful to determine the surgical indication. In non-surgical cases, ascites, peritoneal irritation signs and shock were closely associated with poor prognoses, and are applicable as predictors of patients’ prognoses.

"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.

[Pneumatosis Cystoides Intestinalis after Hematopoietic Stem Cell Transplantation for Malignant Lymphoma - A Case Report]

A 47-year-old man underwent hematopoietic stem cell transplantation for malignant lymphoma. He developed acute skin graft versus host disease(GVHD)and pneumomycosis which were treated with steroids. One hundred and fifteen days later, the patient had a diagnosis of free gas images in the abdominal cavity and streakly air collections in the bowel wall from the ascending colon to the sigmoid colon in the CT scan. He was asymptomatic and his physical examination was unrevealing. We diagnosed his condition as pneumatosis cystoides intestinalis(PCI). He was managed conservatively with the high concentration oxygen administration. The CT scan performed 3 days later revealed the marked improvement of intramural gas and disappearance of free gas. We considered image in the abdominal cavity that the occurrence of PCI was related to the damage of the bowel mucosa due to long term corticosteroid administration. In patients demonstrating PCI with free air in the abdominal cavity, it is important to evaluate not only the diagnostic date based on the physical, laboratory, and imaging findings, but also their medical history. Furthermore, it is important to make a correct diagnosis to avoid unnecessary surgery.

Pneumatosis cystoides intestinalis

A 54-year-old woman underwent colonoscopy for colon cancer screening. Colonoscopy showed multiple cysts in the sigmoid colon, with the largest being 4 cm in diameter. One of the cysts was biopsied. Cyst walls were observed; during biopsy, the gas was released and the cyst collapsed. Computed tomography of the abdomen confirmed a diagnosis of pneumatosis cystoides intestinalis. Pneumatosis cystoides intestinalis is a rare disease characterized by the presence in the intestinal submucosa or subserosa of multiple cysts filled with gas (nitrogen, oxygen, carbon dioxide and hydrogen). This condition occurs more often in males than in females, with cysts most frequently located in the colon. Causes may include elevated intraluminal pressure, pulmonary diseases, bacterial gas production, malnutrition, chemotherapy, connective tissue diseases, among others. Symptoms of pneumatosis cystoides intestinalis include abdominal pain, diarrhea, bloating and gastrointestinal bleeding. This condition is diagnosed by endoscopy or computed tomography of the abdomen. Conservative treatment is successful in 93% of patients. However, 3% of patients develop complications such as intestinal obstruction or perforation.

Does massive intraabdominal free gas require surgical intervention?

We describe a rare case of an 81-year-old man who presented with severe epigastralgia. A chest radiograph showed massive free gas bilaterally in the diaphragmatic spaces. Computed tomography (CT) scan also showed massive free gas in the peritoneal cavity with portal venous gas. We used a wait-and-see approach and carefully considered surgery again when the time was appropriate. The patient received conservative therapy with fasting, an intravenous infusion of antibiotics, and nasogastric intubation. The patient soon recovered and was able to start eating meals 4 d after treatment; thus, surgical intervention was avoided. Thereafter, colonoscopy examination showed pneumatosis cystoides intestinalis in the ascending colon. On retrospective review, CT scan demonstrated sporadic air-filled cysts in the ascending colon. The present case taught us a lesson: the presence of massive intraabdominal free gas with portal venous gas does not necessarily require surgical intervention. Pneumatosis cystoides intestinalis should be considered as a potential causative factor of free gas with portal venous gas when making the differential diagnosis.

Management of Pneumatosis Intestinalis in a Pediatric Burn Patient

Pneumatosis intestinalis is gas in the wall of the gastrointestinal tract. It is not well described in pediatric burn patients. The authors present the case of a 23-month-old girl who sustained 40% total body surface area deep-partial and full-thickness burns as well as a grade two inhalational injury. On postburn day two, radiographic imaging showed extensive pneumatosis of the colon. She was managed with bowel rest, broad-spectrum antibiotics, and parenteral nutrition. Radiographic resolution of pneumatosis intestinalis occurred several days later and was followed by reinitiation of enteral feeds and bowel function. The patient later developed an abscess and a subsequent colocutaneous fistula that resolved with percutaneous drainage and conservative management. She healed and was able to avoid a laparotomy with possible bowel resection.

Improvements in Pneumatosis Cystoides Intestinalis and Hepatic Portal Venous Gas with Conservative Therapy in a Patient on Maintenance Dialysis

A 77-year-old man on maintenance dialysis developed hypotension, nausea and abdominal pain one hour after beginning to undergo hemodialysis. Abdominal computed tomography (CT) showed gas shadows in the intrahepatic portal vein and the small intestinal wall, but no signs indicating intestinal necrosis. Three days later, the gas shadows on abdominal CT disappeared by conservative therapy. In cases with both pneumatosis cystoides intestinalis and hepatic portal venous gas, intestinal necrosis should therefore be suspected and surgical therapy should also be considered, particularly in hemodialysis patients with a risk of intestinal ischemia. However, conservative therapy may be an option in cases with no intestinal necrosis.

[Pneumatosis Coli Treated with Metronidazole and Hyperbaric Oxygen Therapy: A Successful Case]

Pneumatosis intestinalis, characterized by the presence of gas within the bowel wall, is an uncommon condition with variable presentation. It may be idiopathic or secondary to other diseases. A computed tomography scan is the most sensitive method for diagnosis. In the absence of signs and symptoms of complications, such as perforation and peritonitis, pneumatosis intestinalis can be managed conservatively. We present the case of a 59-year-old woman with pneumatosis coli secondary to benign ovary teratoma. After surgery she remained symptomatic and was successfully treated with metronidazole and hyperbaric oxygen therapy.

[Case of portal venous gas and pneumatosis cystoides intestinalis occurring during chemotherapy for a castration-resistant prostate cancer]

Portal venous gas is a rare complication. We present a case of hepatic portal venous gas (HPVG) and pneumatosis cystoides intestinalis (PCI) in a patient treated with docetaxel for prostate cancer. An 80-year-old man with castration-resistant prostate cancer received 5 cycles of docetaxel. Diarrhea and vomiting appeared on the 4th day of the 5th cycle. An abdominal computed tomography (CT) scan revealed HPVG and PCI. Since there were neither peritoneal irritation signs nor intestinal necrosis, we performed conservative management. The HPVG and PCI were no longer detected in the abdominal CT scan on the 18th day. Mucosal injury of the bowel wall by docetaxel might have caused HPVG and PCI. This case report is the first description of HPVG and PCI in a patient with castration-resistant prostate cancer in Japan.

Pneumatosis intestinalis with a focus on hyperbaric oxygen therapy

Pneumatosis intestinalis is a rare condition of air in the bowel wall. Pneumatosis intestinalis is most often secondary to another medical condition. The diagnosis is most often made radiologically with a computed tomography scan. The disease severity ranges from benign to life-threatening. Predictors of poor outcomes include pH less than 7.3, bicarbonate level of less than 20 mEq/L, lactate level of more than 2 mmol/L, amylase level of more than 200 U/L, and portal venous gas on imaging. Early recognition of life-threatening signs and symptoms is critical. Treatment options include bowel rest, antibiotics, surgery, and, more recently, the use of hyperbaric oxygen therapy. Hyperbaric oxygen therapy is extremely safe, with no reported complications in the literature when used for pneumatosis intestinalis. When surgery is not emergently needed, symptomatic pneumatosis intestinalis can be safely treated with hyperbaric oxygen with a high likelihood of success without any considerable adverse effects.

A systematic analysis of pneumatosis cystoids intestinalis

AIM: To increase the understanding, diagnosis and treatment of pneumatosis cystoides intestinalis (PCI) and to find the characteristics and potential cause of the disease in China.

METHODS: We report here one case of PCI in a 70-year-old male patient who received a variety of treatment methods. Then, we systematically searched the PCI eligible literature published from an available Chinese database from May 2002 to May 2012, including CBM, CBMDisc, CMCC, VIP, Wanfang, and CNKI. The key words were pneumatosis cystoides intestinalis, pneumatosis, pneumatosis intestinalis, pneumatosis coli and mucosal gas. The patients’ information, histories, therapies, courses, and outcomes were reviewed.

RESULTS: The study group consisted of 239 PCI cases (male:female = 2.4:1) from 77 reported incidents. The mean age was 45.3 ± 15.6 years, and the median illness course was 6 mo. One hundred and sixty patients (66.9%) were in high altitude areas. In addition, 43.5% (104/239) of the patients had potential PCI-related disease, and 16.3% had complications with intestinal obstruction and perforation. The most common symptom was abdominal pain (53.9%), followed by diarrhea (53.0%), distention (42.4%), nausea and vomiting (14.3%), bloody stool (12.9%), mucous stool (12.0%) and constipation (7.8%). Most multiple pneumocysts developed in the submucosa of the colon (69.9%). The efficacy of the treatments by combined modalities, surgery, endoscopic treatment, conservative approach, oxygen, and antibiotics were 100%, 100%, 100%, 93.3%, 68.3% and 26.3%, respectively.

CONCLUSION: PCI can be safely managed by conservative treatments, presents more frequently in males, in the large bowel and submucosa, than in females, in the small intestine and subserosa. High altitude residence maybe associated with the PCI etiology.

Gastrointestinal sarcoidosis associated with pneumatosis cystoides intestinalis

A 39-year-old male reported fevers, weight loss, watery loose stools, and decreased visual acuity in his right eye over the prior five years. He was pancytopenic, had an elevated American council on exercise level, total bilirubin, and alkaline phosphatase. Computed tomography revealed massive hepatosplenomegaly and emphysematous lung changes. Liver biopsy showed non caseating granulomas. The patient was diagnosed with extrapulmonary sarcoidosis and was treated with prednisone. The patient symptomatically improved but 5 mo later presented with abdominal pain caused by perforation of the cecum. He underwent a cecectomy and pathology revealed pneumatosis cystoides intestinalis. This represents the first reported association between pneumatosis cystoides intestinalis and sarcoidosis. The etiology of pneumatosis cystoides intestinalis in this case was likely multifactorial and involved both effects of the corticosteroids as well as the advanced nature of the gastrointestinal sarcoidosis. Furthermore this case has the unique features of emphysematous lung changes and pancytopenia which are uncommon with sarcoidosis.

[Conservative treatment of pneumatosis intestinalis and pneumoperitoneum after bone marrow transplantation]

OBJECTIVE

Pneumatosis intestinalis (PI) is a radiological sign that can be accompanied by pneumoperitoneum. It is not exclusive of neonatal necrotizing enterocolitis. It can also appear after bone marrow transplantation. We describe our experience with 6 patients diagnosed of PI after bone marrow transplantation (BMT) who were treated conservatively without surgery in any case and good outcome.

PATIENTS AND METHOD

We have reviewed the patients diagnosed of PI from 2000 to 2007 after BMT in our center.

RESULTS

Six patients have had 7 episodes of PI with pneumoperitoneum in 3. All cases previously developed intestinal graft-versus-host disease. PI was diagnosed from 1 to 4 months after transplantation. At diagnosis, any patient presented peritoneal signs. Computed tomography was used for PI diagnosis with colonic predominance (5), pneumomediastinum (1) and retropneumoperitoneum (2). The treatment was conservative with intestinal rest, antibiotics and total parenteral nutrition. Enteral feeding was initiated progressively between 1 and 2 months after diagnosis but in one case PI reappeared and it required to start again the conservative treatment. In the other cases, outcome was very satisfactory, improving the pneumatosis and with a correct oral feeding without needing of surgery in any case.

COMMENTS

PI with or without pneumoperitoneum is an condition to have in mind in bone marrow transplantation patients. Pneumoperitoneum with good general condition and no sign of peritonitis is not indicative of surgery in these patients. Conservative treatment with antibiotics and parenteral nutrition allows resolution spontaneously

[Pneumatosis cystoides intestinalis: a rare illness in adults]

Pneumatosis cystoides intestinalis (PCI) is a rare illness in adults with gas filled blebs found in the submucosa or subserosa of the bowel wall. The main localization is the terminal ileum although all parts of the intestine can be affected. Clinical symptoms can vary from aqueous-slimy, bloody diarrhea to constipation and/or vague abdominal pain. Patients can also be completely asymptomatic. In symptomatic patients the therapy of PI is based on the assumed pathogenesis, so that a combined treatment of metronidazole 1500 mg daily during a period of 6-8 weeks additionally and oxygen application (PaO2 of 200-350 mmHg) for 7 days is suggested. In addition, elemental diets are recommended. Complications are indicated in the literature with 3%. In particular mechanical ileus, invagination and perforation as well as substantial intestinal bleeding up to the volvolus lead to further diagnostic and therapeutic steps. A surgical intervention is reserved for rare cases.

Conservative management of nongangrenous esophageal and gastric pneumatosis

Pneumatosis intestinalis, or air within the wall of the gastrointestinal tract, has been documented from the esophagus to the rectum. Its presence can suggest gangrenous changes of the stomach or colon and represents a surgical emergency. However, pneumatosis intestinalis can also occur as a result of a benign, nongangrenous condition. We report the conservative management of a patient with nongangrenous gastric and esophageal pneumatosis.

Pneumatosis intestinalis with pneumoperitoneum mimicking intestinal perforation in a patient with myelodysplastic syndrome after hematopoietic stem cell transplantation

Pneumatosis intestinalis (PI) is an uncommon disorder characterized by an accumulation of gas in the bowel wall, and has been associated with a variety of disorders and procedures. We describe a 35-year-old man who undertook hematopoietic stem cell transplantation due to myelodysplastic syndrome. An abdominal X-ray demonstrated extensive PI with pneumoperitoneum mimicking hollow organ perforation. However, the patient had no abdominal symptoms and there was no evidence of peritoneal inflammation. After two weeks of conservative management, including bowel rest and antibiotics, his pneumoperitoneum resolved spontaneously without any complications. Of the many factors that affect the gastrointestinal tract mucosal integrity, intramural pressure, and bacterial flora-produced intraluminal gas interact to produce PI. If the condition is accompanied by bowel ischemia, portomesenteric venous gas, metabolic acidosis, and abdominal sepsis, or if PI is severe in extent immediate surgical intervention is indicated. The described case supports that a mechanical rather than a bacterial etiology underlies the pathogenesis of PI.

Pneumatosis Intestinalis in a Burn Patient: Case Report and Literature Review

Pneumatosis Intestinalis (PI) is a rare condition characterized by gas in the intestinal wall. PI is not a disease in itself but a sign of an underlying problem. It is associated with a wide variety of underlying disorders, ranging from benign to life-threatening. When found, it should prompt a search for the underlying cause. Diagnostic efforts should be aimed at ruling out catastrophic problems such as intestinal ischemia and necrosis. The presence of peritonitis, rectal bleeding, portomesenteric venous gas, and lactic acidosis are important factors to determine the best course of action. Burn patients have multiple risk factors for developing this condition. Despite this, PI is not well-described in the burn literature. We present here a case report, a brief review of the literature, and clinical considerations.

Additive contribution of multiple factors in the development of pneumatosis intestinalis: a case report and review of the literature

We describe a 53-year-old patient with dermatomyositis, who developed pneumatosis intestinalis (PI) accompanied by pneumoperitoneum, pneumoretroperitoneum, pneumomediastinum, and subcutaneous emphysema of the neck. The development of PI in our patient was possibly attributed to the effect of factors such as dermatomyositis, corticosteroids, methotrexate, and alpha-glucosidase inhibitor (AGI). The coexistence of multiple factors associated with PI might enhance the risk of developing PI, even though each of them alone is not sufficient to induce it. In particular, the use of AGIs for patients treated with immunosuppressive agents such as corticosteroids requires evaluation.

Conservative management of pneumatosis intestinalis

BACKGROUND

Pneumatosis intestinalis is a rare condition characterized by subserosal and submucosal gas-filled cysts in the gastrointestinal tract; it may be associated with bowel ischemia, perforation, and a high mortality rate. As a result, many authorities advocate an aggressive surgical approach in patients with pneumatosis intestinalis.

CASE

A 53-year-old female with recurrent, metastatic uterine leiomyosarcoma underwent resection of the pelvic recurrence, low anterior rectal resection with primary anastomosis, and partial hepatectomy for liver metastasis. Her postoperative course was notable for a small bowel obstruction and the finding of pneumatosis intestinalis on radiologic studies. The patient developed mild abdominal pain. She did not develop tenderness or fevers. She was managed with bowel rest, nasogastric tube decompression, total parenteral nutrition, and broad-spectrum antibiotics. The finding of pneumatosis intestinalis resolved over the ensuing 6 days. Her diet was slowly advanced, and she was discharged home in stable condition without further surgical intervention or recurrence of the obstruction or pneumatosis. Currently, her only evidence of disease is pulmonary metastases.

CONCLUSIONS

In select patients, the outcome of a conservative approach to the management of pneumatosis intestinalis is not much different than surgical re-exploration for highly selected patients. The clinical condition of the patient, not solely the finding of pneumatosis intestinalis, should drive management in these cases.

Pneumatosis cystoides intestinalis associated with perforated chronic duodenal ulcer and Meckel's diverticulum

A case of pneumatosis cystoides intestinalis (PCI) associated with perforated duodenal ulcer and Meckel's diverticulum is presented. The patient was managed with direct suturing of the perforation and reinforcement with an omental patch. Meckel's diverticulum was excised. PCI was followed up and disappeared postoperatively in the 4th week.

Systemic arterial pneumatosis in a neonate with necrotizing enterocolitis

Ultrasound is exquisitely sensitive for the identification of portal vein pneumatosis, which in neonates is commonly caused by necrotizing enterocolitis. We describe the ultrasound finding of systemic arterial pneumatosis in a case of necrotizing enterocolitis associated with congenital heart disease. A combination of a patent ductus venosus and an extracardiac right-to-left shunt via the great vessels through a patent ductus arteriosus provided a pathway for the pneumatosis from the portal vein to the abdominal aorta.

Evaluation of HBO2 therapy in pneumatosis cystoides intestinalis

Pneumatosis cystoides intestinalis (PCI) is a disease characterized by retention of gas in the intestinal wall. Retention of gas can be caused by three mechanisms; gas entry through the intestinal mucosa, gas dissection from the pulmonary alveoli and bronchi, and gas generation in the mucous membrane. Since gas in cysts is composed almost entirely of nitrogen, hyperbaric oxygen therapy (HBO2) is effective for treating PCI due to the oxygen windows effect. However, PCI, caused by a mechanism involving pulmonary alveoli or branches, can become aggravated by HBO2. Therefore, we propose modifying HBO2 protocols for cases that do not require an invasive treatment. This study describes favorable results obtained in 2 PCI cases after HBO2 therapy according to our protocol.

The spectrum of pneumatosis intestinalis

HYPOTHESIS

A review of the spectrum of illness associated with pneumatosis intestinalis enables us to identify the probable causes of, the best diagnostic approaches to, and the most appropriate treatments for this condition.

DATA SOURCES

A review of all published material in the English language regarding pneumatosis intestinalis was conducted using the PubMed and MEDLINE databases. Any relevant work referenced in those articles and not previously found or published before the limit of the search engine was also retrieved and reviewed.

STUDY SELECTION

There were no exclusion criteria for published information relevant to the topic. All of the studies cited in the present review make a point that contributes to the portrayal of this condition. In circumstances in which the same point was made in several different studies, not all were cited herein.

DATA EXTRACTION

All published material on pneumatosis intestinalis was considered. Information was extracted for preferentially selected ideas and theories supported in multiple studies.

DATA SYNTHESIS

The collected information was organized by theory.

CONCLUSIONS

Mucosal integrity, intraluminal pressure, bacterial flora, and intraluminal gas all interact in the formation of pneumatosis intestinalis. Radiography and computed tomography are the best diagnostic tests. Nonoperative management should be pursued in most patients, and underlying illnesses should be treated. When acute complications appear, such as perforation, peritonitis, and necrotic bowel, surgery is indicated.