Findings Of Pneumatosis Intestinalis Research Articles

Pseudo-‘Pneumatosis intestinalis’ sign: A case of parasite uniquely depicted on postmortem CT

Abstract Only a few reports have described radiological findings of parasite depicted by postmortem computed tomography (PMCT). We herein present a case in which the PMCT of a 29-year-old man revealed Taenia saginata, a species of tapeworms, inside the intestine. The image of the parasite appeared as a low-density linear or cystic pattern of gas bubbles located within the lumen of the small bowel. We named this finding as ‘Pseudo-Pneumatosis intestinalis’ sign, since which mimicked the findings of Pneumatosis intestinalis in a clinical setting. In this report, we present the image and discuss the importance of the findings of parasites on PMCT performed before autopsy.

PS02.152: DEVELOPMENT OF INTESTINAL PNEUMATOSIS AND PORTAL VENOUS GAS AFTER ESOPHAGECTOMY IS NOT INDICATIVE OF ISCHEMIC BOWEL AND CAN BE SUCCESSFULLY MANAGED NON-OPERATIVELY

Abstract Background Pneumatosis intestinalis has long been a marker of advanced bowel ischemia and prompts urgent laparotomy. In post-operative settings, the presence of pneumatosis represents a significant management dilemma. We share a case-series of post-esophagectomy patients with pneumatosis intestinalis and no corollary intra-abdominal pathologic findings on re-exploration. Methods January 2000 to December 2017, 1760 patients underwent Ivor-Lewis esophagectomy or gastrectomy with jejunostomy-tube placement. Charts were reviewed retrospectively to identify patients with pneumatosis intestinalis discovered in the post-operative period. Demographic data, operative details and postoperative course were reviewed including incidence and details of re-exploration. Results Eleven patients met inclusion criteria. Nine were male (81.8%) and mean age was 69 years. All patients had radiographic confirmation of pneumatosis intestinalis and in many cases portal venous gas (Figure 1). Clinical course was variable without discernable trends in vitals or laboratory values. Development of significant postoperative ileus along with delivery of enteral tube feeds through a jejunostomy tube preceded development of the pneumatosis in all patients. Nine patients were re-explored and none had evidence of bowel ischemia. Conclusion The finding of pneumatosis intestinalis in the post-operative setting can be alarming and pose a management dilemma. With the advent of improved and readily available imaging, there has been an increase in findings that have no corollary physical symptomatology. In this series of patients, despite dramatic radiographic findings, none had ischemic bowel. Pneumatosis intestinalis alone in patients who have undergone esophagectomy should not be considered an indication for emergency re-exploration. Disclosure All authors have declared no conflicts of interest.

An Interesting Case of Gastric Pneumatosis Masking Acute Appendicitis

Gastric pneumatosis, which is defined as the finding of gas within the gastric wall, is one of the least common presentations seen in the spectrum of pneumatosis intestinalis (finding of gas within the gastrointestinal tract). In the majority of these cases, bowel ischemia or necrosis such as necrotizing enterocolitis, volvulus, or ischemic bowel disease has been identified as the cause. To our knowledge, only a few cases of pneumatosis intestinalis secondary to acute appendicitis have been reported in the literature. We present the case of a 66-year-old woman with history of gastro-esophageal reflux disease who presented with two week history of constant chest pain associated with severe epigastric pain radiating to the back. Her abdominal pain was alleviated by proton pump inhibitors and antacids that she received in the Emergency Room. A complete cardiac work up was found to be unremarkable. Subsequent work up also included an abdominal computed tomography angiography (CTA) to rule out an aortic dissection, which revealed gastric fundus intramural gas without evidence of extraluminal or portovenous air. The appendix was not visualized in this study. Initial differential diagnoses of gastric pneumatosis in this patient included acute pancreatitis, peptic ulcer disease, gall bladder disease. The following day, the patient became febrile with a new leukocytosis (WBC count of 16,000) and complained of epigastric pain migrating to her right lower abdomen. Abdominal computed tomography (CT) with contrast was then obtained and conclusively confirmed the presence of a dilated appendix measuring 1.4 cm, along with significant diffuse adjacent inflammatory changes. She then underwent emergent laparoscopy with excision of a ruptured appendix. Fortunately, subsequent esophagogastroduodenoscopy did not reveal any evidence of bowel ischemia or infarction. The patient recovered well following the surgery and made a full recovery. This case suggests that the presence of gastic pneumatosis may not always be an ominous sign that indicates bowel infarction. This finding in the context of an atypical presentation should not delay the diagnosis of acute appendicitis. As the finding of pneumatosis intestinalis may be innocuous or indicate the presence of a life-threatening abdominal catastrophe, it is therefore important to make this crucial distinction through the interpretation of clinical information obtained from a thorough history, physical examination, laboratory and radiographic data.Figure 1

Conservative management of pneumatosis intestinalis

Background. Pneumatosis intestinalis is a rare condition characterized by subserosal and submucosal gas-filled cysts in the gastrointestinal tract; it may be associated with bowel ischemia, perforation, and a high mortality rate. As a result, many authorities advocate an aggressive surgical approach in patients with pneumatosis intestinalis. Case. A 53-year-old female with recurrent, metastatic uterine leiomyosarcoma underwent resection of the pelvic recurrence, low anterior rectal resection with primary anastomosis, and partial hepatectomy for liver metastasis. Her postoperative course was notable for a small bowel obstruction and the finding of pneumatosis intestinalis on radiologic studies. The patient developed mild abdominal pain. She did not develop tenderness or fevers. She was managed with bowel rest, nasogastric tube decompression, total parenteral nutrition, and broad-spectrum antibiotics. The finding of pneumatosis intestinalis resolved over the ensuing 6 days. Her diet was slowly advanced, and she was discharged home in stable condition without further surgical intervention or recurrence of the obstruction or pneumatosis. Currently, her only evidence of disease is pulmonary metastases. Conclusions. In select patients, the outcome of a conservative approach to the management of pneumatosis intestinalis is not much different than surgical re-exploration for highly selected patients. The clinical condition of the patient, not solely the finding of pneumatosis intestinalis, should drive management in these cases.