Benign Pneumatosis Intestinalis Research Articles

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.

MANAGEMENT OF PNEUMATOSIS INTESTINALIS IN LUNG TRANSPLANT RECIPIENTS: A SINGLE-CENTER EXPERIENCE

SESSION TITLE: Transplantation Posters SESSION TYPE: Original Investigation Posters PRESENTED ON: October 18-21, 2020 PURPOSE: Pneumatosis intestinalis (PI) is an uncommon, and often times incidental, clinical finding characterized by submucosal or subserosal gas-filled cysts within the bowel wall. PI may be encountered in a wide array of clinical settings, but it is scarcely reported after lung transplantation (LTx). METHODS: We constructed a retrospective review of LTx recipients with post-transplant, benign PI at our institution in 2019. RESULTS: Four LTx recipients developed post-transplant, benign PI at our institution during the study period. Two cases of benign PI were discovered incidentally on routine surveillance chest radiographs during clinic visits. Both patients had uneventful post-transplant recovery and were asymptomatic at presentation. A third case with otherwise uneventful post-transplant course presented to the emergency department with mild symptoms of vague abdominal discomfort, with chest radiograph revealing PI. A fourth case who underwent bilateral LTx with left atrial appendage clipping from cardiopulmonary bypass had a complicated post-transplant course, requiring tracheostomy and a gastric feeding tube; PI was identified in the ascending colon on ischemic stroke workup. All four patients were admitted for further observation, and contrast-enhanced abdominal CT scans confirmed the initial imaging findings. Clinical signs and imaging features in these situations may mimic true bowel perforation, so colorectal surgery was routinely consulted for discussion of appropriate management. A conservative approach consisting of bowel rest, intravenous hydration, nasogastric decompression, and gastric tube feedings was chosen for all four cases. All patients received empiric antibiotic treatment with Zosyn for bacterial decontamination. Antibiotic treatment and nasogastric decompression relieved symptoms, and surgical intervention remained unnecessary. Food was slowly reintroduced, as tolerated, when serial kidney, ureter, and bladder scans improved. There were no complications from PI. All patients were safely discharged when deemed stable after unremarkable abdominal scans. CONCLUSIONS: PI is a rare post-transplant condition that may be identified incidentally in an asymptomatic patient. Greater awareness of this entity, especially amongst transplant clinicians, may improve management of these patients. CLINICAL IMPLICATIONS: Herein, we detail the appropriate management in four patients with a post-transplant condition rarely reported after LTx. DISCLOSURES: No relevant relationships by ASHWINI ARJUNA, source=Web Response no disclosure on file for Bhuvin Buddhev; No relevant relationships by Hesham Mohamed, source=Web Response No relevant relationships by Michael Olson, source=Web Response Speaker/Speaker's Bureau relationship with Genentech Please note: $5001 - $20000 by Rajat Walia, source=Admin input, value=Honoraria Speaker/Speaker's Bureau relationship with Boehringer Ingelheim Please note: $5001 - $20000 by Rajat Walia, source=Admin input, value=Honoraria Speaker/Speaker's Bureau relationship with Grifols Please note: $5001 - $20000 by Rajat Walia, source=Admin input, value=Honoraria Speaker/Speaker's Bureau relationship with Shire Please note: $1001 - $5000 by Rajat Walia, source=Admin input, value=Honoraria Speaker/Speaker's Bureau relationship with Astellas Please note: $5001 - $20000 by Rajat Walia, source=Admin input, value=Honoraria

Intramural Gas: Would it be Life-threatening?

The CECT scan of the abdomen at axial and coronal views show gas bubbles tracking along the inner wall of the ascending colon and hepatic flexure, which is separated from the intraluminal gas within the bowel. These intramural gas bubbles appear to be outlining the bowel wall circumferentially. The bowel wall appears to be thickened however the inner mucosa is not enhanced. There are no ascites in the images provided. The colon of the hepatic flexure and transverse colon appears dilated. No significant atherosclerotic plaque in the visualised arteries. Based on the clinical presentations and CECT features in Figure 1 and Figure 2, the best diagnosis for him is benign pneumatosis intestinalis (PI) secondary to obstructed low rectal cancer. He was subjected for a trephine transverse colostomy to relieve the obstruction with simultaneous transanal rectal mass biopsy. Once the histology is available, he subsequently will be referred for concurrent chemo-radiotherapy as neoadjuvant treatment and later for a low anterior resection, provided that it is a localized disease.

Intramural Gas: Would it be Life-threatening?

The CECT scan of the abdomen at axial and coronal views show gas bubbles tracking along the inner wall of the ascending colon and hepatic flexure, which is separated from the intraluminal gas within the bowel. These intramural gas bubbles appear to be outlining the bowel wall circumferentially. The bowel wall appears to be thickened however the inner mucosa is not enhanced. There are no ascites in the images provided. The colon of the hepatic flexure and transverse colon appears dilated. No significant atherosclerotic plaque in the visualised arteries. Based on the clinical presentations and CECT features in Figure 1 and Figure 2, the best diagnosis for him is benign pneumatosis intestinalis (PI) secondary to obstructed low rectal cancer. He was subjected for a trephine transverse colostomy to relieve the obstruction with simultaneous transanal rectal mass biopsy. Once the histology is available, he subsequently will be referred for concurrent chemo-radiotherapy as neoadjuvant treatment and later for a low anterior resection, provided that it is a localized disease.

Clinical characteristics and prediction of the asymptomatic phenotype of pneumatosis intestinalis in critically ill patients: a retrospective observational study.

AimThe differences in clinical characteristics between benign asymptomatic and symptomatic pneumatosis intestinalis (PI) remain unknown. This study aimed to reveal the clinical characteristics of PI in critically ill patients.MethodsThis was a retrospective observational study undertaken between 2013 and 2017 in a single facility. Patients with PI were enrolled. Pneumatosis intestinalis was diagnosed using computed tomography, and clinical data were collected. Pathologic PI refers to PI with bowel ischemia. Asymptomatic PI refers to PI with a benign etiology.ResultsThere were 17 patients with pathologic PI and 31 with asymptomatic PI. Pathologic PI was detected at day 4 of hospital stay, and asymptomatic PI was detected at day 30 of hospital stay (P < 0.01). The symptoms that were different between pathologic and asymptomatic PI were acute diarrhea (18% and 65%, P = 0.01), C‐reactive protein level elevation (9.9 and 2.1 mg/dL, P = 0.01), and systemic inflammatory reaction syndrome (100% and 13%, P < 0.01). Computed tomography findings showed a difference in the occurrence of ascites collection (94% versus 23%, P < 0.01) and PI of the ascending colon (47% versus 80%, P = 0.02). Hospital mortality of pathologic PI was 88%, whereas all patients with benign PI survived. The positive likelihood ratio of acute diarrhea with PI of the ascending colon to diagnose benign PI was 7.33 (1.11–48.5).ConclusionsPneumatosis intestinalis of the ascending colon that occurs in the post‐intensive care phase with a poor inflammatory reaction, acute diarrhea, and no ascites collection could be benign. In other cases, bowel ischemia should be promptly ruled out.

Pneumatosis cystoides intestinalis: case report and review of literature

Pneumatosis intestinalis is the presence of gas in the bowel wall and is divided into two categories: life-threatening pneumatosis intestinalis and benign pneumatosis intestinalis. Pneumatosis cystoides intestinalis is a rare condition characterized by gas-filled cysts in submucosa and subserosa. The pathogenesis is unclear, although some causes have been theorized. The presenting clinical findings may be very heterogeneous. Intestinal pneumatosis may lead to various complications. Distinguishing between pneumatosis cystoides intestinalis and life-threatening pneumatosis intestinalis may be challenging, although computed tomography scan allows the detection of additional findings that may suggest an underlying, potentially worrisome cause of pneumatosis intestinalis. To correctly manage the patients affected with this disease is important to differentiate the two types of pneumatosis. The patients with pneumatosis cystoides intestinalis are usually treated conservatively; the surgical treatment is reserved for complications. We described a case of a patient with pneumatosis cystoides intestinalis and gastric perforation. The medical history of the patient revealed a breast cancer treated with mastectomy and chemotherapy; the patient did not report a history of gastrointestinal disease. The abdomen CT showed abscess formation at the level of the antro-pylorus, linear pneumatosis in the gastric wall, and free abdominal air. Multiple small air bubbles was observed in intestinal wall. The intestinal wall was not thickened with normal contrast mucosal enhancement. CT examination showed neither mesenteric stranding nor portal venous gas embolism. The findings of the surgery were gastric perforated peptic ulcer and benign pneumatosis intestinalis.

When the Benign Pneumatosis Intestinalis Becomes No Longer Benign: A Rare Case of Bowel Perforation in a Patient with Systemic Sclerosis

Systemic sclerosis is a multisystem disease featured with autoimmunity and organ fibrosis. Although gastrointestinal (GI) tract involvement is common in patients with systemic sclerosis, colonic perforation is extremely rare. Benign pneumatosis intestinalis, a phenomenon more frequently seen in rheumatologic conditions, makes the diagnosis of colonic perforation even more challenging. We report a unique case of colonic perforation in a patient with chronic systemic sclerosis. This patient initially presented with mild abdominal pain and hematemesis. Urgent upper endoscopy was unremarkable and radiology showed stable pneumatosis intestinalis. Due to worsening abdominal pain, laparotomy exploration was performed and colonic perforation with transmural ischemic necrosis was found.

An incidental finding of pneumatosis intestinalis: Conservative management without oxygen therapy

Pneumatosis intestinalis can be identified radiographically incidentally in an asymptomatic patient, or it may be present in its fulminant form with peritonitis. Although multiple mechanisms have been postulated, most believe it arises from mechanical or infectious factors. Respiratory factors have also been described as possible causes for this condition. Clinically, it is important to differentiate among patients whom require surgical intervention from those who would benefit from conservative management, such as hyperbaric oxygen, changes in diet, and/or antibiotic administration. Although supplemental oxygen has become the standard of care for the treatment of benign pneumatosis intestinalis, we question whether all patients require oxygen therapy as a treatment. Although oxygen may be beneficial, the literature suggests there may be detrimental effects from oxygen toxicity and the free radicals formed during hyper-oxygenation. Furthermore, given the rising epidemic of antibiotic resistance and the various toxicities associated with usage of antibiotics, do all patients really require antibiotics? We present a case of a patient with complaints of hematuria, but no other gross abdominal complaints and was incidentally found to have pneumatosis intestinalis and pneumoperitoneum without any evidence of vascular compromise or ischemia. This patient was managed successfully with conservative treatment without oxygen therapy or antibiotics.

Clinical and imaging features indicative of clinically worrisome pneumatosis: key components to identifying proper medical intervention.

The purpose of this retrospective study was to determine clinical and imaging factors on computed tomography (CT) associated with clinically worrisome pneumatosis intestinalis (PI) that may aid in the decision to provide conservative management or urgent surgical intervention. Informed consent was waived in this IRB approved study. Imaging features assessed included the presence, location, and pattern of PI, bowel dilatation, thickening, enhancement, stranding, portal venous (PV) and mesenteric venous gas, mesenteric edema, free air, and ascites. Two radiologists retrospectively evaluated 167 patients with CT reports containing the text "PI" between 1/1/11 and 12/31/13. Clinical data collected included serum lactate, malignancy, bowel disease, operative findings, and death during admission. Clinically, worrisome PI was tabulated by summation of surgical diagnosis of dead bowel and/or death during admission. Chi-square test or Fisher's exact test was used when appropriate to compare subjects with benign or worrisome PI for categorical variables and the Mann-Whitney test used to compare continuous measures. Clinically, worrisome PI was present in 44 cases. Benign PI was diagnosed in 97 cases, and these patients were followed conservatively. There was a statistically significant association between clinically worrisome PI and imaging features: location in small bowel (p<0.0001), bowel dilatation (p=0.0003), stranding (p=0.0002), bowel enhancement (p=0.0384), PV gas (p<0.0001), mesenteric venous gas (p=0.0141), and moderate mesenteric edema (p=0.0036). Location of PI in the small bowel exhibited a statistically significant association with benign PI (p<0.0002). Statistical significance was found between worrisome PI and the following clinical features: elevated serum lactate (p=0.0003), underlying bowel disease (p=0.0004), and mechanical cause of bowel obstruction (p=0.0497). CT imaging characteristics and clinical features can help predict clinically worrisome PI and guide crucial management decisions.

Chronische benigne Pneumatosis intestinalis

History and clinical findings: We present the case of a 63-year-old male patient free of complaints with oncological follow up examination after renal cell carcinoma (RCC) who presented extent air in the intestinal wall. Investigations and diagnosis: The computed tomography showed a pronounced pneumatosis intestinalis with punctum maximum in the part of left and less right colon flexure. Free air as a sign of perforation was not found. Treatment and course: Retrospectively, the pneumatosis intestinalis was found in fluctuating extent in several preliminary CT and MRI investigations. Repeated colonoscopies with histologic sampling were unremarkable. Due to the long-term findings, the patient was treated conservatively. A cause for the pneumatosis was not finally identified. Conclusions: Our presented case demonstrates that pneumatosis intestinalis coli can persist over a long period of time and could be a chronic phenomenon. Nevertheless, exclusion of an acute cause of pneumatosis is mandatory in each case. If chronic benign pneumatosis intestinalis coli is considered, a continued interdisciplinary workup and patient support is necessary.

Pneumatosis intestinalis in oncologic patients: when should the radiologist not be afraid?

Pneumatosis intestinalis (PI) is a term used to describe the presence of submucosal and subserosal gas in the gastrointestinal tract. It can occur as a primary disease or, more commonly, secondary to various other causes ranging from benign conditions to fulminant diseases. We present four cases of benign PI in patients being treated for various types of cancer. They had no abdominal symptoms, the physical examination was normal and PI was an isolated incidental CT finding in the absence of other signs of bowel wall distress. A conservative non-surgical approach was advocated and follow-up imaging documented the resolution of PI. The radiologist should recognize this condition in order to help the oncologist to interpret its clinical significance and avoid unnecessary surgical procedures.

Pneumatosis intestinalis with pneumoperitoneum misdiagnosed as acute abdomen - a case report

Background: Pneumatosis intestinalis (PI), is defined as the presence of intramural gas within the bowel wall. Pneumatosis intestinalis is not a diagnosis. It is more a histological finding or a radiology sign, rather than a disease on itself. In most of the cases it is a benign finding, but it may be a reason for an unnecessary laparotomy, especially when associated with pneumoperitoneum. Case report: We present a case of pneumatosis intestinalis in a patient with a chronic obstructive pulmonary disease misdiagnosed as intestinal perforation due to bowel ischemia. The patient was admitted with increasing abdominal pain and nausea. On examination the abdomen was tender with diffuse pain. Plain X-rays and CT scans showed pneumoperitoneum with intramural gas in small intestine’s wall. With preoperative diagnosis of bowel ischemia the patient underwent exploratory laparotomy, on which a benign PI was found. Conclusion: Carefully taken medical history, prompt exam, laboratory and instrumental data all should be carefully analyzed before a decision for emergency operation is done. It is important to divide PI in two categories- benign and life-threating.

Benign pneumatosis intestinalis in a pediatric patient with multiple risk factors including granulomatosis with polyangiitis: A case report and review of the literature

ObjectiveTo describe the first reported case of pneumatosis intestinalis (PI) in a pediatric patient with granulomatosis with polyangiitis (GPA) and multiple other risk factors and review the literature for PI in adult and pediatric rheumatologic conditions. MethodsA PubMed search was completed using the search phrase “pneumatosis intestinalis.” Searches were limited to humans and the English language, and remaining articles involving patients with rheumatologic diagnoses were identified and included in our discussion. ResultsThis is the first reported of case of PI in a patient with underlying GPA or antineutrophil cytoplasmic antibody-associated vasculitides. Out of 90 previously reported cases of PI in patients with rheumatologic conditions, 79 cases were in adults and 11 in children. There were 30 patients with systemic sclerosis, 18 with MCTD/overlap syndrome, 18 with dermatomyositis or polymyositis, 16 with SLE, and 8 with other diagnoses. Overall, 81% of the patients were on corticosteroids or other immunosuppressants prior to development of PI. The most common presenting symptom was abdominal pain, and 51% of patients had associated pneumoperitoneum. ConclusionsPI can be associated with a broad spectrum of rheumatic diseases, including GPA, and should be included in the differential diagnosis of patients with rheumatologic conditions and nonspecific gastrointestinal symptoms.

Benign Pneumatosis Intestinalis

A 28-year-old healthy woman presented to the hospital with abdominal discomfort. She complained of colic type abdominal pain and bloat of 3 days' duration, associated with a 1-day history of nausea and nonbilious vomiting. There was no change in frequency of her bowel habits and she was able to pass flatus. On physical examination, all her vital signs were within normal limits. The abdominal examination was essentially normal except for generalized mild abdominal tenderness with no signs of peritonitis. Laboratory investigations were unremarkable. A plain radiograph (Figure A) and computerized tomography scan (Figures B and C) showed extensive pneumatosis coli throughout the nondilated colon, from the cecum to the splenic flexure, with scattered free intraperitoneal and retroperitoneal gas pockets. No intra-abdominal collection or portal venous gas was seen. The patient was treated conservatively with intravenous antibiotics and was discharged from the hospital after 2 days with oral antibiotics. She remained well on outpatient follow-up evaluation. Pneumatosis intestinalis (PI) is a radiologic finding, defined by the presence of gas in the bowel wall. Various hypotheses have been proposed regarding the pathophysiology of PI, although the exact mechanism remains unknown.1Ho L.M. Paulson E.K. Thompson W.M. Pneumatosis intestinalis in the adult: benign to life- threatening causes.AJR Am J Roentgenol. 2007; 188: 1604-1613Crossref PubMed Scopus (248) Google Scholar PI can occur as a primary idiopathic condition or secondary to an underlying condition. The latter may be subdivided into benign and life-threatening causes.1Ho L.M. Paulson E.K. Thompson W.M. Pneumatosis intestinalis in the adult: benign to life- threatening causes.AJR Am J Roentgenol. 2007; 188: 1604-1613Crossref PubMed Scopus (248) Google Scholar, 2Wu L.L. Yang Y.S. Dou Y. et al.A systemic analysis of pneumatosis cystoids intestinalis.World J Gastroenterol. 2013; 19: 4973-4978Crossref PubMed Scopus (106) Google Scholar Benign conditions include pulmonary diseases such as asthma and chronic obstructive pulmonary disease, systemic lupus erythematosus, and the use of medications such as corticosteroids or chemotherapeutic agents. Life-threatening conditions that may cause PI include intestinal obstruction and intestinal ischemia. Patients with primary idiopathic and secondary benign PI are usually asymptomatic and are diagnosed incidentally through radiologic imaging. Patients with secondary life-threatening causes of PI are usually symptomatic and require surgical intervention.1Ho L.M. Paulson E.K. Thompson W.M. Pneumatosis intestinalis in the adult: benign to life- threatening causes.AJR Am J Roentgenol. 2007; 188: 1604-1613Crossref PubMed Scopus (248) Google Scholar, 2Wu L.L. Yang Y.S. Dou Y. et al.A systemic analysis of pneumatosis cystoids intestinalis.World J Gastroenterol. 2013; 19: 4973-4978Crossref PubMed Scopus (106) Google Scholar A computerized tomography scan is the most sensitive imaging test for the identification of PI and is also useful to identify the underlying cause.1Ho L.M. Paulson E.K. Thompson W.M. Pneumatosis intestinalis in the adult: benign to life- threatening causes.AJR Am J Roentgenol. 2007; 188: 1604-1613Crossref PubMed Scopus (248) Google Scholar The main challenge in the management of PI hinges on the identification of patients who require surgical intervention.1Ho L.M. Paulson E.K. Thompson W.M. Pneumatosis intestinalis in the adult: benign to life- threatening causes.AJR Am J Roentgenol. 2007; 188: 1604-1613Crossref PubMed Scopus (248) Google Scholar, 2Wu L.L. Yang Y.S. Dou Y. et al.A systemic analysis of pneumatosis cystoids intestinalis.World J Gastroenterol. 2013; 19: 4973-4978Crossref PubMed Scopus (106) Google Scholar Patients who present with clinical and laboratory features of an acute abdomen should undergo an immediate exploratory laparotomy. Clinical features found to be predictive of the need for surgical intervention include the following: history and physical examination findings suggestive of an acute abdomen, metabolic acidosis, increased serum lactate level, increased serum amylase level, or the presence of portal venous gas.3Knechtle S.J. Davidoff A.M. Rice R.P. et al.Pneumatosis intestinalis. Surgical management and clinical outcome.Ann Surg. 1990; 212: 160Crossref PubMed Scopus (179) Google Scholar Most cases of PI can be managed conservatively with treatment targeted at the underlying cause, especially in cases secondary to benign conditions.2Wu L.L. Yang Y.S. Dou Y. et al.A systemic analysis of pneumatosis cystoids intestinalis.World J Gastroenterol. 2013; 19: 4973-4978Crossref PubMed Scopus (106) Google Scholar Conservative management may entail antibiotic therapy, elemental diet, supplemental/hyperbaric oxygen therapy, or endoscopic therapy of cysts to relieve obstruction.2Wu L.L. Yang Y.S. Dou Y. et al.A systemic analysis of pneumatosis cystoids intestinalis.World J Gastroenterol. 2013; 19: 4973-4978Crossref PubMed Scopus (106) Google Scholar However, because of the rarity of the condition, there remains little evidence to date supporting any of the treatment modalities.

Distinguishing Benign and Life-Threatening Pneumatosis Intestinalis in Patients With Cancer by CT Imaging Features

The purpose of this study is to determine the overall proportion of clinically worrisome and benign pneumatosis intestinalis (PI) occurring in patients with cancer and to evaluate associated risk factors and CT features. We retrospectively studied the CT examinations of 84 patients treated at our tertiary cancer center. Reviewers who were blinded to clinical data and classification analyzed PI in terms of location, pattern (linear, cystic, or both), and associated CT features, including pneumoperitoneum, portomesenteric venous air, bowel wall thickening, bowel dilatation, and ascites. On the basis of the review of clinical information and criteria derived from prior literature, the cases were classified as clinically worrisome PI (underlying bowel disease) or benign PI (diagnosis of exclusion that resolved on follow-up imaging without targeted therapy). Clinical factors reviewed included age, sex, cancer type, steroid use, and chemotherapy administration. Forty-seven patients were classified as having benign PI (56%) and the remainder as having clinically worrisome PI (44%). The following imaging features correlated significantly with clinically worrisome PI: bowel wall thickening (p < 0.001), mesenteric stranding (p < 0.001), ascites (p < 0.001), bowel dilatation (p = 0.004), location confined to small bowel (p = 0.012), and portomesenteric venous gas (p = 0.02). Benign PI was significantly associated with PI confined to the colon (p = 0.004). Benign PI was slightly more prevalent than clinically worrisome PI in our cohort of patients with cancer. The presence of certain CT features (mesenteric stranding, bowel wall thickening, and ascites) and the location of PI may be indicators of more significant bowel disease and, therefore, of clinically worrisome cases. There was no statistical significance achieved for nonimaging clinical factors.

281 Protein C and Protein S in the Diagnosis, Management and Prognosis of Premature Infant with Necrotizing Enterocolitis

ObjectiveIn this prospective, observational study, we determined whether serum protein C and protein S (PC/PS) activity correlated with necrotizing enterocolitis (NEC) stages II and III in premature infant. We hypothesized...

Pneumatosis Intestinalis and Pneumoperitoneum After Bilateral Lung Transplantation in Adults

The purpose of this article is to determine the clinical features, imaging findings, and possible causes of pneumatosis intestinalis (PI) or pneumoperitoneum that developed in bilateral lung transplant recipients. From December 2004 to July 2009, seven (2%) of 321 bilateral lung transplant recipients (two women and five men; age range, 25-66 years) who developed PI or pneumoperitoneum, or both, were identified. Medical records were reviewed to determine the clinical presentation, laboratory findings, and medications at the time of presentation of PI or pneumoperitoneum. Hospital course and time to resolution of PI or pneumoperitoneum were recorded. Common factors that might explain the cause of the PI and pneumoperitoneum were evaluated. Two experienced abdominal radiologists reviewed all imaging studies and recorded the specific findings for each patient. All patients had minimal or no symptoms, normal laboratory study results, and no systemic, intestinal, or proven respiratory infections. All patients but one were receiving triple immunosuppressive agents (i.e., prednisone, azathioprine, and tacrolimus). The imaging findings were similar in five of the patients with the PI dominated by a linear and cystic appearance and involving only the colon. Three of the six patients with PI had both PI and pneumoperitoneum. The mean time to resolution of PI was 24 days. No definite cause for the PI and pneumoperitoneum could be determined in the seven patients. Bilateral lung transplant recipients may develop benign PI or pneumoperitoneum after surgery. Benign PI in bilateral lung transplant recipients has a similar and specific linear and cystic appearance and is not due to ischemic bowel. No specific cause for the PI and pneumoperitoneum could be determined.

Benign Pneumatosis Intestinalis in a Patient with Juvenile Dermatomyositis

To the Editor: Juvenile dermatomyositis (JDM) is an autoimmune vasculopathy involving primarily the proximal muscles and skin but can involve other organ systems, particularly the gastrointestinal (GI) tract1. In the presence of cutaneous vasculitic ulcerations, one needs to monitor for signs and symptoms suggestive of GI vasculopathy2, which can lead to bowel ischemia, necrosis, ulceration, and perforation1,2,3,4,5. The presence of gas in the bowel wall, also referred to as pneumatosis intestinalis (PI), is an ominous finding when it is due to a GI vasculopathy3. PI is a radiographic finding that is associated with both benign and life-threatening causes. The benign variant of PI has been described in relation to immunosuppressive therapy6 and to JDM itself7. We describe a child with JDM complicated by cutaneous ulcerations and benign PI. An 8-year-old girl, following a 1-month history of rash and fatigue, was diagnosed with JDM based on the presence of Gottron sign, heliotrope rash, symmetric proximal muscle weakness, elevated serum muscle enzymes [creatine kinase (CK) 533 U/l (normal 44–189); lactate dehydrogenase 442 U/l (normal 142–261); aldolase 9.3 U/l (normal 0–7.6)] and findings consistent with myositis on magnetic resonance imaging of the proximal hip and shoulder girdle muscles. Antinuclear and anti-Jo1 antibodies were … Address correspondence to Dr. Scuccimarri; E-mail: rosie.scuccimarri{at}muhc.mcgill.ca

Benign pneumatosis intestinalis in a child with cavopulmonary shunt and immune thrombocytopenic purpura

We present the case of a nine-year-old boy with hypoplastic left heart syndrome and immune thrombocytopenic purpura who subsequently developed pneumatosis intestinails with a benign clinical examination. While benign pneumatosis intestinails is a well-known clinical entity, the alarming radiographic findings set off a cascade of clinical angst among many providers. This case reminds physicians to correlate the ancillary study results with the patient's clinical presentation and stability.

CT Predictors for Differentiating Benign and Clinically Worrisome Pneumatosis Intestinalis in Children beyond the Neonatal Period

To determine whether computed tomographic (CT) findings can help differentiate between benign and clinically worrisome causes of pneumatosis intestinalis (PI) in children. This retrospective study was approved by the institutional review board, and requirement for informed consent was waived. Data were stored in a secured and HIPAA-compliant fashion. CT reports from an 8-year period (July 2000-July 2008) were reviewed to determine all cases with a diagnosis of PI. In these cases, demographic information, clinical presentation, underlying medical condition, and CT findings were reviewed. The cases were grouped into one of two final diagnostic groups: clinically worrisome versus benign PI (diagnosis of exclusion, resolution documented at serial imaging without therapeutic intervention). In each case, the CT findings reviewed included distribution (small bowel, large bowel), extent (mild, moderate, extensive), and morphologic characteristics (linear, cystic, both) of the PI and associated findings such as soft-tissue bowel wall thickening, periintestinal soft-tissue stranding, free air, free fluid, portal venous gas, small-bowel obstruction, and bowel dilatation. Associations between CT findings and benign or clinically worrisome PI were assessed with logistic regression models. There were 44 cases identified. Final diagnostic categories for PI included benign (n = 15) and associated underlying bowel disease (n = 29; definitive in 26 and suspected but not defined in three). The following findings were significant (expressed as percentage of clinically worrisome PI vs percentage of benign): soft-tissue bowel wall thickening (51.2% vs 13.3%, P = .0167), free peritoneal fluid (82.8% vs 33.3%, P = .002), extent of PI (extensive 17.2% vs 69%, P < .001), and periintestinal soft-tissue stranding (55.2% vs 20.0%, P = .0228). Distribution, free peritoneal air, and characteristic morphology (linear vs cystic) were not associated with clinically worrisome PI (all P > .05). The cystic or linear pattern of pneumatosis in children is not a useful CT sign to differentiate benign from clinically worrisome PI. CT findings that include soft-tissue thickening of the bowel wall, free fluid, periintestinal soft-tissue stranding, and the extent of PI can be useful in differentiating these entities.