Current approaches to the management of pneumatosis intestinalis: an American Pediatric Surgical Association membership survey

PURPOSE

Pneumatosis intestinalis (PI) remains difficult to treat as it can lead to a broad range of clinical sequalae and there are little published data available to guide management. Our aim was to evaluate how pediatric surgeons currently manage children with PI, how treatment varies based on etiology, and to identify opportunities to optimize current PI management strategies.

METHODS

We administered a web-based survey of practicing pediatric surgeons in the United States and Canada. The survey was distributed to all members of the American Pediatric Surgical Association.

RESULTS

Of 1508 distributed surveys, 333 responses were received (22% response rate); 174 were complete and included in analysis (12% analyzed). For all scenarios, respondents recommended treatment for PI include a median 7 days of bowel rest and 7 days antibiotics. Only 41% reported their approach to PI management was optimal. Ways to optimize care include treatment based on etiology (83%), decreased number of repeat images (64%), shorter NPO course (49%), and shorter antibiotic course (47%).

CONCLUSION

Pediatric surgeons manage PI similarly regardless of etiology but most report this is suboptimal. Future work is needed to prospectively evaluate management protocols that consider etiology.

Pneumatosis intestinalis and pneumoretroperitoneum post steroid use in a patient with superior mesenteric artery syndrome

Pneumatosis intestinalis (PI) refers to the presence of gas within the wall of the small or large intestine. PI can be both asymptomatic and life-threatening. The patient was a 50-year-old man with previous cervical spine abscess and osteomyelitis post debridement 4 years ago, with a heroin abuse history. He presented with abdominal distension ongoing for 4 days and vomiting for 3 times with fluid content. Abdominal computed tomography revealed pneumatosis with pneumoretroperitoneum. A surgeon was contacted and antibiotic treatment was started. The patient was kept on nothing per os and intravenous fluid supply. A drainage tube was inserted into retroperitoneum space on the same day. Tracing back his history, our patient was discharged from the hospital recently with a diagnosis of superior mesenteric artery dyndrome (SMAS), hypersensitivity pneumonitis, and asbestosis with soft tissue pleural plaques and calcified pleural plaques. During the hospitalization period, hydrocortisone dexamethasone and methylprednisolone were prescribed for hypersensitivity pneumonitis. Steroid use and SMAS maybe the cause of PI. Finally, he was discharged 5 days later with a nasojejunal and drainage tubes and was arranged for OPD follow-up. PI can be asymptomatic or life-threatening, and patient management varies based on the clinical condition. Although in this case PI was found in the emergency department, a patient's past history of underlying disease and medication should be reviewed to find the most possible etiology.

Pneumatosis coli in a domestic ferret (Mustela putorius furo)

A 4-year-old spayed female ferret was presented with acute diarrhea and partial anorexia. Pneumatosis coli and segmental enteropathy were identified by ultrasonography and radiography. Fecal culture did not identify any pathogenic bacteria. Medical management of concurrent diseases and antibiotic therapy resulted in resolution of clinical signs and pneumatosis coli.

Four Cases of Pneumatosis Cystoides Intestinalis Complicated by Connective Tissue Diseases

Pneumatosis cystoides intestinalis (PCI) is a rare disease that involves the presence of gas in the intestinal wall. Connective tissue disease (CTD) is a major cause of secondary PCI. In addition to the nature of CTDs, the use of prednisolone and some immunosuppressants, and the presence of complicating diseases such as diabetes mellitus, constipation and pulmonary diseases are involved in the development of PCI. This report describes four cases of PCI with different CTDs (granulomatosis with polyangiitis, rheumatoid arthritis, dermatomyositis, and overlap syndrome) and discusses the background of each patient and common risk factors for the occurrence of PCI.

Intestinal Pneumatosis Associated with Tuberculosis after Allogeneic Hematopoietic Stem Cell Transplantation

Pneumatosis intestinalis (PI), defined as intestinal intra- and extramural gas accumulation, is a rare radiographic finding in conditions of intestinal wall damage of varied etiology. Here, we report on a 56-year-old female with multiple myeloma who presented with undulating fever, fluctuating abdominal symptoms, and a distended abdomen 5 months after allogeneic hematopoietic stem cell transplantation (HSCT). Abdominal X-ray and CT scan documented PI with gas accumulation both in the intestinal and colonic bowel walls. Concurrently, thoracic CT revealed mediastinal and bihilar lymphadenopathy associated with bilateral pleural effusions. Microscopy of bronchoalveolar lavage fluid (BALF) revealed acid-fast bacilli, which were identified as Mycobacterium tuberculosis. Tuberculostatic treatment resulted in timely clinical improvement, a complete clearance of the radiological and clinical findings of PI, and the control of the tuberculosis (Tbc), determined by multiple negative BALF results. Taken together, PI occurred as the initial symptom of Tbc in an allogeneic stem cell recipient, achieving complete recovery by tuberculostatic treatment only.

[Pneumatosis cystoides intestinalis during palliative chemotherapy for colorectal cancer]

Pneumatosis cystoides intestinalis is a rare disease characterized by the presence of gas into the colonic wall. Symptoms are non specific and, most of the time, the diagnosis is done by an abdominal CT scan. We report a case of pneumatosis cystoides intestinalis which occurred in a patient with a colorectal cancer in palliative stage. This patient was treated by 5 fluorouracil (5FU), folinic acid and oxaliplatin chemotherapy, after a first lign of chemotherapy with 5FU, irinotecan and cetuximab. The association of chemotherapy is most likely probable.

Pneumatosis Cystoides Intestinalis with Systemic Sclerosis, Limited Type Resulting in a Poor Prognosis

Pneumatosis cystoides intestinalis (PCI) is a rare disease characterized by the presence of multilocular intramural clusters of gas in the alimentary tract and has been considered to have a favorable response to conservative treatment. We describe the first case of limited type of systemic sclerosis (SSc) with PCI. A 74-year-old Japanese woman presented with a 4-month history of an unhealed cutaneous ulcer on the right third finger, along with sclerodactyly of bilateral hands. Proximal skin sclerosis was absent. The patient reported acute abdominal pain, and a diagnosis of PCI was established on plain radiography. The patient died of multiple organ failure 5 months after the development of PCI. PCI is rarely complicated with SSc, and all cases previously reported were associated with diffuse SSc. Because PCI is one of the poor prognostic factors of SSc, we should recognize the presence of this condition even in patients with limited cutaneous involvement.

Pneumatosis intestinalis and AIDS: a case report and review of the literature

We report five AIDS patients who developed pneumatosis intestinalis and review the pertinent literature to clarify the contributory importance of underlying infections, to suggest a management plan, and to determine whether pneumatosis intestinalis alters prognosis. Of the five patients reported, three had concurrent infections including cryptosporidiosis (one patient), presumptive CMV (one patient), and toxoplasmosis of the central nervous system (one patient). One patient also had neutropenia. Another patient was immunosuppressed during treatment for lymphoma, and the fifth patient had been taking corticosteroids before the diagnosis of CNS lymphoma. In four of five patients pneumatosis involved the right colon. Pneumatosis was linear in all five patients and also was cystic in two of the five. All patients were followed conservatively without short term adverse events, despite the known association of linear pneumatosis with bowel necrosis. We advocate conservative management and an attempt to avoid surgery whenever possible.

[Scleroderma with an unusual complication]

A 30 year-old woman who had had progressive systemic sclerosis for seven years was admitted to our hospital with a history of one week of increasing abdominal girth and one month's history of increasing peripheral oedema, especially in the lower limbs, and a weight loss of 10 kilograms in the course of five months. On admission she had oedema of the lower limbs, lower back and abdomen, and had ascites but no signs of peritonitis. An abdominal X-ray examination revealed distended bowels with elevated air fluid levels and pneumoperitoneum. The combination of the clinical and radiological findings, as well as the history, strongly suggested a diagnosis of pneumocystosis cystoides intestinalis as a complication to progressive systemic sclerosis. The symptoms improved on treatment and no signs of recurrence were found at follow-up after four years. We discuss the underlying pathology and management of this condition.

Pneumatosis cystoides intestinalis in systemic lupus erythematosus with intestinal vasculitis: treatment with high dose prednisone

Pneumatosis cystoides intestinalis (PCI) is an uncommon disorder usually associated with intestinal and pulmonary obstructive diseases, recent abdominal procedures and systemic illnesses. PCI has been reported in patients with systemic lupus erythematosus associated with intestinal vasculitis. We describe herein a patient with a month history of intermittent abdominal pain, diarrhoea, hyporexia, and weight loss who underwent intestinal resection for acute abdomen. Post-operatively she gave a three-month history of arthritis of the right knee, ankles and feet, arthralgia of the wrists, MCPs and shoulders. She also described weakness, weight loss, Raynaud's phenomenon, and a skin rash. Laboratory examination revealed an increased ESR, low haemoglobin and haematocrit, positive rheumatoid factor, a positive ANA with a speckled pattern, as well antibodies to DNA, SS-A and cardiolipin. The abdominal symptomatology especially pain, cramps and bouts of diarrhoea persisted after the surgery and became worse two months later. Abdominal X-ray showed distention of bowel with cyst formation in the wall of the entire colon. A diagnosis of PCI was made radiologically. The intestinal pathology was reviewed and vasculitis was identified. The patient received treatment with high dose prednisone with an excellent response; prednisone was progressively tapered and she has been asymptomatic without abdominal complaints or other symptoms for over a year.

Response to octreotide of intestinal pseudoobstruction and pneumatosis cystoides intestinalis associated with progressive systemic sclerosis

Intestinal pseudoobstruction and pneumatosis cystoides intestinalis are uncommon complications of progressive systemic sclerosis. We report a 26-year-old woman with this disorder who responded poorly to conventional treatment. Subcutaneous administration of octreotide, a long-acting somatostatin analogue, at a dose of 50 micrograms/day for 3 weeks, relieved symptoms such as nausea and bloating. There was also a marked decrease of intestinal gas accumulation, as documented on X-ray films.

Pigmentation following long-term bismuth therapy for pneumatosis cystoides intestinalis

In the recent literature, only a few reports deal with generalized pigmentation caused by bismuth treatment. We report a patient developing generalized pigmentation of the skin and mucous membranes without further signs of chronic bismuth poisoning following long-term administration of bismuth for pneumatosis cystoides intestinalis. Bismuth deposits were documented in a skin biopsy.

Pneumatosis cystoides intestinalis in intestinal pseudoobstruction. Resolution after therapy with metronidazole

A 66-year-old man with chronic idiopathic intestinal pseudoobstruction was admitted for pneumatosis cystoides intestinalis, complicated by pneumoperitoneum. The latter conditions resolved after treatment with metronidazole. There was no favorable effect of the prokinetic agents cisapride and erythromycin. To the authors' knowledge, this is the first reported case of successful treatment of pneumatosis cystoides intestinalis with metronidazole in primary chronic intestinal pseudoobstruction.

Treatment of pneumatosis coli with metronidazole. Endoscopic follow-up of one case

A case of pneumatosis cystoides intestinalis in the large bowel with complete resolution after eight weeks of metronidazole treatment is reported. This symptomatic case, with an acute onset classified as the primary (idiopathic) type, became asymptomatic after a few days and was followed until complete endoscopic and radiologic resolution. No recurrence was noticed during 15-month follow-up. This lends support to the assumption that anaerobic bacteria contribute to the etiopathogenesis of this condition. The choice of metronidazole as an easy ambulatory therapy is encouraged.

Is raised breath hydrogen related to the pathogenesis of pneumatosis coli?

Clinical and physiological studies were carried out in five patients with pneumatosis coli in order to investigate the origin of the high fasting breath hydrogen concentration in this condition and to determine its possible significance in the pathogenesis of the disease. All five patients excreted abnormally high fasting concentrations of hydrogen in their breath (69 +/- 9 ppm, mean +/- SEM). Moreover, analysis of the contents of the gas filled cysts revealed between 2% and 8% of hydrogen gas. Colonic washout significantly reduced breath hydrogen concentrations to 9 +/- 6 ppm, but did not abolish the cysts. Conversely, deflation of the cysts was achieved with oxygen or antibiotics, though this only reduced breath hydrogen concentrations to about 66% of their original value. After feeding a radiolabelled meal, breath hydrogen concentrations rose before the meal appeared to reach the colon, suggesting overgrowth of anaerobic bacteria in the small intestine. Despite this, 14C glycocholate breath tests were within normal limits. An alternative possibility is that the high levels of hydrogen excreted in the breath may be produced in the intestinal lumen possibly from the fermentation of copious amounts of colonic mucus. Finally, measurement of whole gut transit time and stool weight suggested that patients were constipated despite passing mucus and blood. The relevance of our observations to the pathogenesis of submucosal cysts is unclear, but the data favour the hypothesis that these are produced by invasion of the colonic submucosa with anaerobic bacteria.

Pneumatosis intestinalis in children with leukaemia; report of three cases

Three children with leukaemia (one with acute myeloid, two with acute lymphoblastic leukaemia) developed pneumatosis intestinalis during cytostatic treatment. The aetiology of pneumatosis intestinalis in these children could not be elucidated. Pneumatosis intestinalis may be caused by entry of gas into a bowel wall which is altered by steroid or cytostatic treatment. Otherwise, anaerobic bacteria may produce gas in the intestinal walls, therefore we treated all children with metronidazole.

Pneumatosis cystoides intestinalis: Report of 3 cases with special reference to its non-surgical treatment

Three patients with pneumatosis cystoides intestinalis had been reported. All patients are females with lesions in the left and sigmoid colon, grouped as idiopathic etiology. Two patients are in middle age, workers in the manufacturing plant for electric apparatus. One patient received surgical resection of the affected segment. After oral antibiotics treatment, one patient was resected only the intensely affected segment, so that many cysts were still remained, but they disappeared after 3 weeks. One patient was treated with lactobacillus preparations and lactulose. Her subjective symptoms and fecal occult blood disappeared, and X-ray studies and endoscopic examination revealed an almost complete recovery.

[Intestinal pneumatosis. Analysis of 30 cured cases]

The study included 30 patients with gastroenteritis and pneumatosis intestinalis, seen at the pediatric hospital of the IMSS, who followed a satisfactory course. Complications and associated diseases were found in these patients to be less severe than in other patients who died. Lethality in this type of patients (33%) is analyzed together with the clinical records in 33 cases of death from gastroenteritis and pneumatosis intestinalis during the period from January 1974 to April 1975. It was found that the period of hospital stay was shorter than in the group that recovered; that complications leading to death were severe and of acute evolution among which, bronchopneumonia, septic shock, intestinal infarct and others, predominated. Decrease in lethality may be considered to lie in an earlier diagnosis together with prevention and treatment of pneumatosis intestinalis and its complications.

Pneumatosis cystoides coli recurs after oxygen treatment. A clue to the pathogenesis?

Two patients with pneumatosis cystoides coli associated with chronic pulmonary disease are described. In both patients, cysts and symptoms recurred after successful treatment with O2. Both patients had exceptionally high expiratory H2 fasting values. On the basis of these and other observations a new hypothesis is proposed for the pathogenesis of the cysts and for their frequent association with chronic pulmonary disease. It is suggested that the cysts result from excessive colonic gas production in a patient unable to excrete this excess gas via the lungs.