Causes Of Pneumatosis Intestinalis Research Articles

Pneumatosis cystoides intestinalis: when the location of the air may be a pitfall

Pneumatosis cystoides intestinalis (PCI) is a rare and generally benign condition characterized by air within the walls of the small intestines or colon. Moreover, it may be a cause of free air in peritoneum. To correctly manage this entity when found at CT, it is of crucial importance for the radiologist to recognize and distinguish it from life-threatening causes of pneumatosis intestinalis or pneumoperitoneum. This differentiation may be challenging and the absence of additional findings (bowel wall thickening, altered contrast mucosal enhancement, fat stranding, dilated bowel, ascites, and the presence of portal venous gas) may be very helpful in suggesting the diagnosis. In this short communication we present a case of PCI in an asymptomatic 60-year old woman with a history of uterine carcinoma. The patient underwent a colonoscopy after a positive result of fecal occult blood test; the colonoscopy showed the presence of multiple grape-like nodules in the splenic flexure of the colon and biopsies were performed to exclude malignity of the findings. Then, a CT was conducted and it showed the presence of multiple, thin-walled, air-filled submucosal cysts in the splenic flexure of the colon. The endoscopic and CT findings, together with the absence of abdominal symptoms and altered laboratory test, allowed to establish the diagnosis of PCI. The patient was managed conservatively. Moreover, some free air bubbles were found in the pneumoperitoneum at one-year and two-year follow-up CTs, without abdominal symptoms.

Where is All This Air Coming from? A Rare Case of Pneumatosis Intestinalis with Extensive Pneumoperitoneum and Pneumomediastinum in Lung Transplant Patient Secondary to Mycophenolate Therapy

<h3>Introduction</h3> Pneumatosis intestinalis (PI) is rare phenomenon following lung transplantation. Most common causes identified are bowel perforation and bowel ischemia. Here we present a case of PI likely secondary to mycophenolate mofetil (MFM). <h3>Case Report</h3> 60-year-old man 4 months post bilateral lung transplant for idiopathic pulmonary fibrosis, course complicated by primary graft dysfunction grade, vocal cord paralysis, gastroparesis status post percutaneous endoscopic transgastric jejunostomy 10 weeks prior, admitted with nausea, vomiting, and abdominal pain. His immunosuppressive therapy consisted of tacrolimus, mycophenolate, and prednisone. On presentation patient was hemodynamically stable and afebrile, lactic acid was normal. Imaging with computed tomography (CT) of the abdomen and pelvis, which was significant for extensive pneumoperitoneum, pneumatosis intestinalis (PI) of the ascending and transverse colon. Patient underwent diagnostic laparoscopy and primary repair of umbilical hernia; surgical exploration revealed no perforated viscous or bowel ischemia. He was treated with antibiotics prophylactically. Initial lab work showed no systemic signs of infection, he was afebrile, blood cultures and stool studies were negative. Mycophenolate was discontinued initially, and he was started on Azathioprine few days later. Given the CT findings in conjunction with surgical findings, no systemic signs of infection, clinical improvement after cessation of MFM, and repeat CT 5 days later showing significant improvement in pneumoperitoneum and pneumatosis intestinalis. <h3>Summary</h3> PI has an incidence of 0.03% in the general population and can be caused by various conditions. Clinical symptoms can range from benign to life threatening. Incidence of PI post lung transplant 2.68% mostly secondary to perforated viscus requiring surgical resection. MFM is an unusual cause of PI. The pathogenesis remains unknown.

Pneumatosis Intestinalis Induced by Anticancer Treatment: A Systematic Review.

Simple SummaryAnticancer 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.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.

Pneumatosis Intestinalis After Living Donor Lung Transplantation Associated With Alpha-Glucosidase Inhibitor Treatment: A Case Report

Pneumatosis intestinalis (PI) is a rare but critical condition in which gas is found in the bowel wall. Although organ transplant recipients have an increased PI risk because of long-term immunosuppression, alpha-glucosidase inhibitors (α-GI), a standard diabetes therapy, often contribute to PI. However, little is known about the postorgan transplantation relationship between PI and α-GI. To the best of our knowledge, this is the first reported case of PI in a lung transplant recipient treated with α-GI. A 59-year-old man underwent hybrid (living-donor and cadaveric) lung transplantation (LTx). The patient was treated with prednisolone and tacrolimus as immunosuppressive therapy and α-GI for diabetes for 4 years. He developed asymptomatic PI 1031 days after transplantation without any acute abdominal finding. After excluding other possible causes of PI, his PI was attributed to α-GI. The suspected α-GI was immediately withdrawn. The patient was managed conservatively with bowel rest and oxygen therapy. After 11 days of α-GI discontinuation, PI improved, and the patient completely recovered. Physicians should keep this rare adverse drug reaction in mind when prescribing α-GI, particularly in patients with diabetes after organ transplantation and including LTx. The management strategy for asymptomatic PI caused by α-GI is the immediate discontinuation of α-GI therapy, followed by conservative management initiation.

Pneumatosis Intestinalis in Patients on Chemotherapy or Molecular Targeted Therapy: Report of 3 Cases

Pneumatosis intestinalis (PI) is a radiological term to describe the presence of gas in the bowel wall. It can occur as a primary disease or secondary to various other causes ranging from benign conditions to life-threatening diseases. We present three cases of PI in patients being treated for different types of gastrointestinal cancer. The diagnosis was made incidentally on follow-up CT scanning for two patients, who had only mild gastrointestinal symptoms. For the last patient, it was diagnosed in the setting of fever and clostridium difficile infection. A conservative treatment was advocated and follow-up imaging showed resolution of the PI in two out of three cases. It is important to distinguish between chemotherapy induced PI and other life-threatening causes of PI, which often require urgent surgery. After resolution, risks and possible benefits of restarting of the culprit agent should be outweighed.

3234 Unique Case of Gastroenteritis Presenting as Pneumatosis Intestinalis With Emphysematous Gastritis and Portal Vein Gas: Do Not Take Gastroenteritis Lightly

INTRODUCTION: Pneumatosis intestinalis (PI) refers to presence of multiple thin gas filled cysts in the wall of gastrointestinal tract. It is a uncommon entity and can involve any site from stomach to the rectum. Isolated stomach involvement is very rare. PI can represent a wide spectrum of diseases with variable prognosis. CASE DESCRIPTION/METHODS: An 87-year-old male presented with multiple episodes of non-bloody watery diarrhea associated with nausea and epigastric pain for 2 days. He has past medical history of hypertension, hyperlipidemia and coronary artery disease with bypass surgery. Denied any fever, vomiting, sick contact, recent travel or chest pain. On physical exam, blood pressure was 146/90 mmgh, pulse rate 90/min, respiratory rate 20/min with temperature of 100.5 F. The abdomen was diffusely tender with hypoactive bowel sounds without rebound tenderness or guarding. The laboratory findings showed normal blood counts except leukocytosis of 14000/ml, elevated urea levels of 30 mmol/L, creatinine levels of 1.4 mg/dl and potassium of 3.5. A CT abdomen/pelvis with contrast showed air in gastric wall and air in portal vein which was concerning for emphysematous gastroenteritis. Further work up came back negative including blood cultures, stool studies, clostridium difficile and lactic acid levels. He was admitted to ICU and evaluated by surgeon, Gastroenterology and Infectious disease specialist. Patient was made nothing per oral, received intravenous fluids and IV antibiotics including Ciprofloxacin and Metronidazole. With no other exact cause of PI, the patient's presentation was ultimately thought to represent a mild bacterial infection yielding minimal clues to the definitive diagnosis aside from radiographic data. The patient actually did very well with conservative management and was discharged on antibiotics after a few days with plan to follow up with an outpatient CT scan. DISCUSSION: Emphysematous gastritis with air in portal vein is very rare with underlying gastroenteritis, a worldwide very common disease. It can be easy to miss especially if presentation is benign. This is extremely rare and can easily mimic viral gastroenteritis. High index of suspicion with low threshold of scan can be lifesaving.

1620 Pneumatosis Intestinalis Associated With Clostridium difficile Colitis in Crohn’s Disease

INTRODUCTION: Pneumatosis intestinalis (PI) or pneumatosis cystoides intestinalis is defined as the presence of extraluminal bowel gas that is confined within the bowel wall. Characterized by intramural gas in the gastrointestinal tract, PI represents an alarming radiographic sign rather than a specific diagnosis. PI is associated with a wide spectrum of underlying pathological processes such as bowel ischemia, mechanical trauma, inflammatory/autoimmune bowel disease, intestinal neoplasms, bacterial infections like C. Diff, drug-induced including immunosuppression therapy. Differentiating these causes is critical in directing an appropriate care plan and specific treatment is best directed at the underlying disease process. Described here is a case of pneumatosis intestinalis associated with Clostridium Difficile infection in the setting of Inflammatory Bowel Disease (IBD). CASE DESCRIPTION/METHODS: 11-year-old white male with Crohn's Disease on remission on Remicade and Methotrexate, presented with severe periumbilical pain radiating to right lower quadrant associated with fever, multiple episodes of loose stools and vomiting. Denied recent travel, sick contacts or recent exposure to antibiotics. On exam he had significant right lower quadrant abdominal tenderness with no guarding or rebound. Lab data only revealed mild elevation of CRP. US abdomen showed poorly visualized appendix. Subsequent CT abdomen revealed pneumatosis of ascending colon without wall thickening. Following, he was admitted and considering his stable clinical conditions and lab assays, he was treated conservatively with IV antibiotics and bowel rest. A day later, stool studies returned positive for C. Diff toxins. He was started on oral Vancomycin. Serial abdominal X-rays revealed disappearance of PI. Patient began to show clinical improvement, tolerating feeding advances gradually over the next four days. DISCUSSION: IBD is a rare cause of PI. Concurrently, patients with IBD are at increased risk of developing C. Difficile infection. C. Diff infections have a different and often more severe clinical course in patients with IBD. PI patients should be carefully evaluated for possible surgery due to the risk of severe complications. However, management decisions should be made on combined clinical, lab findings and underlying etiology. As in the above case, supportive care and appropriate antibacterial agents sufficed to alleviate symptoms and resolve the pneumatosis.

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.

Benign versus life-threatening causes of pneumatosis intestinalis: differentiating CT features.

To assess the diagnostic performance of CT findings in differentiating causes of pneumatosis intestinalis (PI), including benign and life-threatening causes. All CT reports containing the word "pneumatosis" were queried from June 1st, 2006 to May 31st, 2015. A total of 42 patients with PI were enrolled (mean age, 63.4 years; 23 males and 19 females) and divided into two groups on based on electronic medical records: a benign group (n=24) and a life-threatening group (n=18). Two radiologists reviewed CT images and evaluated CT findings including bowel distension, the pattern of bowel wall enhancement, bowel wall defect, portal venous gas (PVG), mesenteric venous gas (MVG), extraluminal free air, and ascites. CT findings including bowel distension, decreased bowel wall enhancement, PVG, and ascites were more commonly identified in the life-threatening group (all p<0.05). All cases with PVG were included in the life-threatening group (8/18 patients, 44.4%). Bowel wall defect, extraluminal free air, and mesenteric venous gas showed no statistical significance between both groups. PI and concurrent PVG, bowel distension, decreased bowel wall enhancement, or ascites were significantly associated with life-threatening causes and unfavorable prognosis. Thus, evaluating ancillary CT features when we encountered PI would help us characterize the causes of PI and determine the appropriate treatment option.

A Case of Pneumatosis Intestinalis Caused by Systemic Lupus Erythematous

Introduction: Pneumatosis intestinalis (PI) is a radiographic finding with wide spectrum of presentation, ranging from asymptomatic to perforation and death. There are more than 60 known causes of PI, but systemic lupus erythematous is a rare cause, and infrequently described. Case 42 year old woman was admitted with non-bloody diarrhea and left upper quadrant abdominal cramps for one week. She has a history of GERD (status post fundoplication x3), chronic constipation due to pelvic floor dysfunction, SLE with autonomic instability, resulting in hypotension, syncope, and bradycardia requiring pacemaker placement. Her symptoms occurred in the setting of discontinuing her lupus medications (belimumab and leflunomide), tapering her prednisone, and holding IVIG to repeat testing for autonomic dysfunction, as she had worsening episodes of hypotension and bradycardia in Fall 2016, requiring pacemaker placement. She had a similar presentation in 2015, when she was found to have PI in the splenic flexure. Infectious work up was negative at that time, and symptoms did not improve with a week of IV antibiotics. It then resolved with prednisone taper for presumed SLE exacerbation, resulting in PI. CT abdomen this time showed increased prominence of PI at the splenic flexure, a watershed area. She was placed on bowel rest, given high flow oxygen, and started on metronidazole, but remained symptomatic with nausea, bloating and diarrhea. Colonoscopy showed melanosis coli without evidence of colitis or bowel perforation. Patient then improved with a higher dose of prednisone. Discussion SLE is a rare cause of PI, but could contribute to it through several different mechanisms. A mechanism that was proposed by previous case report was SLE causing enteric vasculitis. Antiphospholipid antibodies and/or lupus anticoagulant may affect the gut mucosa resulting in ischemia, although this patient did not have these antibodies. The patient's autonomic dysfunction may have resulted in hypotensive episodes that could damage the watershed area.

Clinical significance of pneumatosis intestinalis \u2013 correlation of MDCT-findings with treatment and outcome

ObjectivesTo evaluate the clinical significance of pneumatosis intestinalis (PI) including the influence on treatment and outcome.Method and MaterialsTwo radiologists jointly reviewed MDCT-examinations of 149 consecutive emergency patients (53 women, mean age 64, range 21-95) with PI of the stomach (n = 4), small (n = 68) and/or large bowel (n = 96). PI extension, distribution and possibly associated porto-mesenteric venous gas (PMVG) were correlated with other MDCT-findings, risk factors, clinical management, laboratory, histopathology, final diagnosis and outcome.ResultsThe most frequent cause of PI was intestinal ischemia (n = 80,53.7 %), followed by infection (n = 18,12.1 %), obstructive (n = 12,8.1 %) and non-obstructive (n = 10,6.7 %) bowel dilatation, unknown aetiologies (n = 8,5.4 %), drugs (n = 8,5.4 %), inflammation (n = 7,4.7 %), and others (n = 6,4 %). Neither PI distribution nor extension significantly correlated with underlying ischemia. Overall mortality was 41.6 % (n = 62), mostly related to intestinal ischemia (p = 0.003). Associated PMVG significantly correlated with underlying ischemia (p = 0.009), as did the anatomical distribution of PMVG (p = 0.015). Decreased mural contrast-enhancement was the only other MDCT-feature significantly associated with ischemia (p p < 0.001). Elevated white blood count significantly correlated with ischemia (p = 0.03).ConclusionIn emergency patients, ischemia remains the most common aetiology of PI, showing the highest mortality. PI with associated PMVG is an alerting sign. PI together with decreased mural contrast-enhancement indicates underlying ischemia.Key Points• In emergency patients, PI may be caused by various disorders.• Intestinal ischemia remains the most common cause of PI in acute situations.• PI associated with decreased mural contrast-enhancement indicates acute intestinal ischemia.• PI associated with PMVG should alert the radiologist to possible underlying ischemia.

A simple score for predicting mortality in patients with pneumatosis intestinalis

Background and aimThis study was conducted to identify simple computerized tomography (CT) and clinical predictors of mortality in patients with pneumatosis intestinalis (PI). Thus, the clinical characteristics and outcomes of PI were assessed and the predictors of mortality were identified. MethodsThe medical records of 123 patients with PI were reviewed retrospectively. Multivariate logistic regression models were constructed to determine independent predictors of mortality. These data were used to develop a simple score that would predict mortality on the first and seventh day after diagnosis. ResultsThe median age at diagnosis was 62 (range, 20–91) years. The most common cause of PI was mesenteric vascular ischemia (n=43, 35.0%). Twenty-nine (23.6%) disease-related deaths occurred during the index admission. Both signs of peritoneal irritation on physical examination and decreased or absent enhancement of the bowel wall were associated with increased mortality. If both factors were absent, the in-hospital mortalities on both the first and seventh days after the diagnosis of PI were less than 5%. However, if both factors were present, the in-hospital mortality was 57% on the first day and 59% on the seventh day. ConclusionsA simple and novel risk score that predicts mortality in patients with PI was proposed. Patients with both peritoneal irritation and decreased or absent enhancement of bowel wall on CT should be observed vigilantly and early intervention should be instituted.

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.

Three Cases of Preterm Infants Showing Pneumatosis Intestinalis without Progression to Typical Necrotizing Enterocolitis

Necrotizing enterocolitis (NEC) is a major gastrointestinal disorder in premature infants associated with high morbidity and mortality rates. When NEC is clinically suspected, radiological and laboratory studies should be performed to confirm the diagnosis and to aid in the management of patients. As the clinical manifestations of NEC are usually nonspecific, diagnoses are often made using abdominal radiographic findings, such as pneumatosis intestinalis. Clinicians typically consider the presence of pneumatosis intestinalis on radiographs as the definite evidence of stage II NEC. Here, we report 3 cases of preterm infants who had radiographic findings of pneumatosis intestinalis but did not have any other associated laboratory and clinical evidence of NEC, except bloody stools. The infants’ systemic manifestations were mild or absent, and all of them completely recovered within 2–3 days, as demonstrated by the resolution of pneumatosis intestinalis on abdominal radiographs. The combination of hematochezia and intestinal pneumatosis in preterm infants strongly suggests the diagnosis of NEC. In our cases, there was no laboratory evidence of inflammation or platelet consumption, and the clinical course was benign without any sings of surgical abdomen. Additionally, our patients had barium-induced colitis or milk protein allergy, which are other possible causes of pneumatosis intestinalis. Because pneumatosis intestinalis can result from causes other than NEC, it is important to consider clinical, laboratory, and radiological findings to confirm the diagnosis of NEC.

A Case of Acute Gastric Pneumatosis Associated with Advanced Pancreatic Cancer

Pneumatosis intestinalis (PI) is a rare condition that is characterized by multiple subserosal and submucosal gas-filled areas in the bowel wall. Gastric pneumatosis describes the presence of gas within the stomach wall. This is caused by a disruption in gastric mucosa leading to the dissection of air into the wall. The extract cause of PI is still unknown; however, it may be associated with coexisting disease. Gastric PI has been rarely documented. So, we report on a 75-year-old man with acute gastric pneumatosis following his palliative chemotherapy. He underwent 3rd cycle of gemcitabine and erlotinib 3 weeks prior to admission. The treatment was started with nasogastric tube insertion and parenteral nutrition. Then, gastric pneumatosis was improved. However, the patient was died because of worsening underline disease and general condition. We suggest that chemotherapy should be considered the case of pneumatosis and careful X-ray interpretation will be necessary for detecting the pneumatosis earlier. Key words: Chemotherapy; Drug therapya

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.

Pneumatosis intestinalis and mesenteric venous gas - A manifestation of bacterascites in a patient with cirrhosis

We herein report a patient with decompensated cirrhosis secondary to autoimmune hepatitis, who presented with pneumatosis intestinalis (PI) and portal venous gas. Mesenteric ischemia has been recognized as a common and life-threatening cause of PI which portends a grave prognosis. The patient was found to have bacterascites and recovered after appropriate antibiotic therapy. Spontaneous bacterial peritonitis/bacterascites with gas-forming organisms manifesting as PI has not been previously reported.

Pneumatosis intestinalis versus pseudo-pneumatosis: review of CT findings and differentiation

Pneumatosis intestinalis is defined as the presence of gas within the wall of the gastrointestinal tract. Originally described on plain abdominal radiographs, it is an imaging sign rather than a specific diagnosis and it is associated with both benign and life-threatening clinical conditions. The most common life-threatening cause of pneumatosis intestinalis is bowel ischaemia. Computed tomography (CT) is usually requested to detect underlying disease. The presence of pneumatosis intestinalis often leads physicians to make a diagnosis of serious disease. However, an erroneous diagnosis of pneumatosis intestinalis may be made (i.e. pseudo-pneumatosis) when intraluminal beads of gas are trapped within or between faeces and adjacent mucosal folds. The purpose of this pictorial essay is to review and describe the CT imaging findings of pneumatosis and pseudo-pneumatosis intestinalis and to discuss key discriminatory imaging features.

Three cases of conservatively treated pneumatosis intestinalis associated with jejunal feeding after pancreaticoduodenectomy

Summary Background & aims Pneumatosis intestinalis (PI), characterised by the presence of intramural air in the bowel wall, is seen in various diseases, in some cases leading to explorative laparotomy and resection of the involved bowel. Here, we describe three cases of PI after pancreaticoduodenectomy (PD) associated with post-operative feeding through a needle catheter jejunostomy (NCJ). Method Retrospective analysis of three cases of PI after PD with clinical and radiological findings. Results All patients underwent a PD for periampullary cancer and an NCJ was performed for post-operative feeding. PI was observed 8–32 days after surgery. None of the patients had an acute abdomen or hemodynamical instability necessitating acute surgery. After excluding associated causes of PI, immediate discontinuation of enteral feeding and initiation of parenteral nutrition resulted in a rapid recovery. None of the patients required surgery. Conclusion In patients with an NCJ for post-operative nutritional support who develop PI, we advise to take these measures as a first step, while excluding associated complications and other causes for PI.

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.