Extensive Pneumatosis Intestinalis Research Articles

Conservative Management of a Case with Extensive Pneumatosis Intestinalis Esophageal Involvement

Conservative Management of a Case with Extensive Pneumatosis Intestinalis Esophageal Involvement

S3042 Celiacomesenteric Trunk Variant Occlusion: A Culprit of Mesenteric Ischemia

Introduction: Superior mesenteric artery (SMA) usually arises from the abdominal aorta just below the celiac trunk. Celiacomesenteric trunk (CMT) is a rare anatomical variant where the SMA shares the same origin as the celiac trunk. We present a case of mesenteric ischemia due to CMT occlusion. Case Description/Methods: A 78-year-old female with history of CAD, hypertension, diabetes, CVA, and GERD presented with 5 days of abdominal pain, associated with nausea, vomiting, and nonbloody diarrhea. She was prescribed levofloxacin 7 days prior to presentation after COVID-19 diagnosis. Vital signs were normal. Physical exam revealed epigastric tenderness without rebound or guarding. Labs showed WBC 15.5 x 103/uL, lactic acid 2.6 mmol/L, AST 1275 units/L, ALT 1403 units/L, ALP 105 units/L, total bilirubin 1.4 mg/dL, and INR 1.7. Acute hepatitis and autoimmune serologies were negative, as were acetaminophen, salicylate, and ethanol levels. Liver ultrasound with doppler showed patent liver vasculature and chronic parenchymal liver disease. Due to the temporality of levofloxacin prescription, elevated liver enzymes were attributed to drug-induced liver injury. Patient was treated with N-acetylcysteine. Despite initial improvement of liver enzymes, abdominal pain persisted with pain out of proportion to exam. She developed hypotension, and AST and ALT abruptly rose to 3181 units/L and 2701 units/L, respectively, with lactic acid of 13.5 mmol/L. CT abdomen without contrast showed extensive pneumatosis intestinalis with portal venous gas and diffuse colonic wall thickening, consistent with ischemia and necrosis. A CMT with significant atherosclerosis was noted. Given her critical condition, she was transitioned to comfort care and later expired. She was diagnosed with acute mesenteric ischemia due to CMT occlusion from severe atherosclerotic disease and ischemic hepatitis. Discussion: CMT is usually discovered incidentally during imaging, vascular surgery, or anatomic dissection with a prevalence of 0.5-2.7%. In patients with CMT, vessel occlusion can reduce blood supply to both the foregut and midgut, which can lead to life-threatening mesenteric ischemia, as it did in our patient. Our patient's severe atherosclerotic disease likely progressed to CMT occlusion, possibly exacerbated by COVID-19 coagulopathy. Compromised blood flow from the CMT to hepatic artery likely contributed to ischemic hepatitis as well. Gastroenterologists should be cognizant of CMT variant occlusion as a cause of mesenteric ischemia..

Mycophenolate Adverse Effect Masquerading as Extensive Pneumatosis Intestinalis (PI) after Lung Transplantation

Pneumatosis Intestinalis (PI) is a rare post lung transplant complication which is characterized by the presence of gas within the wall of the small and large intestine. PI in lung transplant recipients has been previously described and is associated with disease of varying clinical trajectories. Here we describe a case of PI in a lung transplant recipient that was attributed to immunosuppression with Mycophenolate Mofetil (MMF) as evidenced by the presence of increased crypt epithelial apoptosis on biopsy of the duodenum and clinical improvement with withdrawal of the offending agent. This case demonstrates that medication adverse effects are an important differential to consider in lung transplant recipients with PI.

An Unusual Cause for Recurrent Pneumatosis Intestinalis and Asymptomatic Pneumoperitoneum

CASE REPORT: A 65 y.o. woman with h/o mixed connective tissue disease was admitted to the hospital with mild epigastric pain and persistent N/V. Apart from MCTD, she had h/o SBO s/p symphysiolysis x 2, HTN, rec. DVTs on anticoagulation, CRD, chronic functional diarrhea and GERD. Her home medications included: ibuprofen/acetaminophen prn, prednisone 10 mg po qd, metoprolol, lisinopril, PPI, amlodipine, rivaroxaban and tofacitinib (Xeljanz) 5 mg po bid. CT scan revealed extensive pneumatosis intestinalis (including the stomach) and pneumoperitoneum. Surgical and GI consultations were requested. Because of her benign clinical picture and multiple comorbidities, conservative management with bowel rest and IV antibiotics was recommended. EGD was negative for PUD. NSAID and steroids were considered the probable culprit and were stopped. Perforation was not mentioned as one of the possible adverse reactions of tofacitinib at the time. She was discharged home after 8 days. She presented again with similar symptoms one month later in clinic, and a repeat CT scan showed recurrence of diffuse PI and pneumoperitoneum. She was admitted and started on TPN and antibiotics with bowel rest for 4 weeks. In discussion with Rheumatology we decided to stop tofacitinib after we found case reports of perforation while on a JAK inhibitor. She had no recurrence. Currently there is a black box warning for the association of tofacitinib with gastrointestinal perforations. DISCUSSION: Pneumatosis intestinalis (PI) is idiopathic (15%) or secondary (85%) to a wide variety of illnesses including intraabdominal catastrophes (e.g. ischemia, infarction, typhlitis), mucosal disruption (e.g. PUD, IBD, ruptured diverticulum), infection (e.g. C. difficile, TB, Whipple's, HIV/AIDS), pulmonary disorders (e.g. CF, COPD, mechanical ventilation), endoscopic procedures, motility disorders (e.g. DM, scleroderma) and immunological disturbances (e.g. chemotherapy, steroids, HIV/AIDS, GvH disease, post transplant). The mechanism that tofacitinib/JAK inhibition causes PI and perforation is unknown. In the clinical trials, this was seen on patients with RA that were also taking NSAIDs. There was no discernable difference in frequency of GI perforation between the placebo and the tofacitinib arms in clinical trials of patients with UC, and many of them were receiving background steroids.Tofacitinib should be used with caution in patients who may be at risk perforation (e.g. history of diverticulitis).

Pneumatosis intestinalis in HIV patient with gastric outlet obstruction

We report the case of a 39-year-old HIV positive female with gastric outlet obstruction. At laparotomy, she had extensive pneumatosis intestinalis (PI) of the ileum. This incidental finding of extensive PI in an HIV positive patient who was being managed non-operatively supports that the mere presence of PI is not an absolute indication for bowel resection in the absence of necrosis, perforation, or obstruction.

Massive Retro-Pneumoperitoneum and Lower Limb Subcutaneous Emphysema After Pediatric Heart Transplantation: A Case Report

An emphysema in a lower limb is usually a clinical sign of a severe and life-threatening infection. We report a rare case of subcutaneous emphysema of the left lower limb associated with a massive retro-pneumoperitoneum and pneumatosis intestinalis after cardiac transplantation in a 4-year-old girl. The child was nearly asymptomatic beside an abdominal distension. A benign pneumoperitoneum associated with an extensive pneumatosis intestinalis is a rare complication after organ transplantation and should be treated conservatively. The association with an emphysema in a lower limb in a child has not been previously reported to our knowledge in the literature.

A rare case of segmental small bowel pneumatosis intestinalis: A case report

IntroductionPneumatosis intestinalis is a rare condition affecting 0.03% of the population. It has a myriad of aetiological causes and hence presentation can vary immensely. The management of symptomatic pneumatosis intestinalis in an acute and outpatient setting remains a challenge to both physicians and surgeons. Case presentationWe present a case of a 79 year old who presented in a gastroenterology outpatients department with a history suggestive of intermittent small bowel obstruction associated with abdominal pain aggravated by eating and posture. He was found to have signs suggestive of Marfan's syndrome. Computed tomography demonstrated extensive pneumatosis intestinalis of the small bowel. Due to deterioration in symptoms, an exploratory laparotomy was performed demonstrating segmental small bowel pneumatosis intestinalis secondary to a hypermobile mesentery. ConclusionThis case highlights the importance of both surgical and gastroenterology expertise in successfully managing symptomatic pneumatosis intestinalis.

Pneumatosis intestinalis after adult liver transplantation

Pneumatosis intestinalis is an uncommon disorder characterized by an accumulation of gas in the bowel wall. We described three cases undertaking liver transplantation. The patients developed diarrhea in three cases and high fever in two. An abdominal X-ray and computed tomography scan demonstrated extensive pneumatosis intestinalis in the colon with pneumoperitoneum mimicking hollow organ perforation. However, the patients had no abdominal symptoms and there was no evidence of peritonitis. The infection work-up was negative except one case with cytomegalovirus antigenemia. After one week of conservative management including bowel rest and antibiotic therapy, their pneumoperitoneum resolved spontaneously without any complication. Pneumatosis intestinalis should be considered as a differential diagnosis after adult liver transplantation with patients suffering from watery diarrhea and fever. Pneumoperitoneum, air-density in mesentery and retroperitoneum in patients with pneumatosis intestinalis without signs of peritonitis improved with conservative management, which included bowel rest and antibiotic therapy.

Pneumatosis intestinalis in a child with nephrotic syndrome and norovirus gastroenteritis

We report a child with idiopathic nephrotic syndrome whose condition was complicated by extensive pneumatosis intestinalis during a nephrotic relapse. The concomitant use of steroid and immunosuppressive agents and a preceding norovirus gastroenteritis infection were identified as risk factors.

Pneumatosis intestinalis and portal‐venous gas: An unusual presentation of acute appendicitis

Pneumatosis Intestinalis in association with portal venous gas is a very rare finding in children and young adults. When present, it is typically associated with bowel infarction and carries a poor prognosis. We present an extremely unusual case where imaging revealed extensive pneumatosis intestinalis and portal venous gas in a patient with acute appendicitis.

Necrotizing enterocolitis: an overlooked life-threatening complication of acute diarrhoeal illness in infants and children

A 7-month-old girl developed necrotizing enterocolitis with extensive pneumatosis intestinalis following an acute diarrhoeal illness. This was preceded by the use of an anti-motility drug and repeated attacks of paralytic ileus. It is noteworthy that all the published cases of necrotizing enterocolitis following acute diarrhoeal illness in infants and children are from tropical countries. This might be related to the use of anti-diarrhoeal drugs and associated malnutrition resulting in hypokalaemia and hypoalbuminaemia.

Clostridial necrotizing enterocolitis

In a bacteriologic investigation of infants with necrotizing enterocolitis (NEC), 16 of 50 infants had clostridia in cultures of blood or of peritoneal fluid obtained by paracentesis. Twenty-eight of the 50 infants had enteric bacteria other than clostridia, and six infants had sterile cultures. Of the 16 infants with clostridia, nine had C. perfringens and seven had other species of clostridia. Compared to infants with nonclostridial NEC, those with clostridial NEC were larger and more mature, had more extensive pneumatosis intestinalis and gangrene and more rapid progression of NEC. The nine infants with C. perfringens had a fulminant form of NEC, analogous to gas-gangrene of the intestine. Mortality in this group was 78% (7/9). The seven infants with clostridial species other than C. perfringens had a mortality comparable to that of infants with nonclostridial NEC (32%). Improved survival from NEC associated with C. perfringens may be possible only by prevention, rather than earlier diagnosis and improved heroic treatment.

A bacteriologic basis for the clinical presentations of necrotizing enterocolitis

A study to identify putative bacterial pathogens in infants with necrotizing enterocolitis (NEC) was begun in 1976. Cultures of blood and of peritoneal fluid obtained by paracentesis were carried out in 25 infants with NEC. Segments of intestine excised at operation were Gram stained. Of the 25 infants, 8 recovered with medical management and 17 required operations. The 8 medically treated infants had sterile peritoneal fluid and, with 2 exceptions, sterile blood cultures. Of the 17 operated infants, 16 had bacteria in their blood and/or peritoneal fluid. The majority of resected bowel specimens from these infants contained a confirmatory morphologic type of bacterium within the wall. The clinical course of 8 infants with clostridia was compared to that of 8 infants with gram-negative enteric bacteria (Klebsiella, E. coli, or Bacteroides fragilis). The infants with clostridia were sicker. They had more extensive pneumatosis intestinalis, a higher incidence of portal venous gas, more rapid progression to gangrene, and more extensive gangrene. Infants with gram-negative rods had lower birth weights and lower platelet counts than the clostridial group. The difference in mortality between the two groups was not significant. The inherent pathogenicity of the gut flora may influence the clinical course of NEC. Among infants who develop intestinal gangrene, the clostridia appear to be more virulent than gram-negative enteric bacteria.