Abdominal Free Air Research Articles

Reassessing acquired neonatal intestinal diseases using unsupervised machine learning.

Acquired neonatal intestinal diseases have an array of overlapping presentations and are often labeled under the dichotomous classification of necrotizing enterocolitis (which is poorly defined) or spontaneous intestinal perforation, hindering more precise diagnosis and research. The objective of this study was to take a fresh look at neonatal intestinal disease classification using unsupervised machine learning. Patients admitted to the University of Florida Shands Neonatal Intensive Care Unit January 2013-September 2019 diagnosed with an intestinal injury, or had imaging findings of portal venous gas, pneumatosis, abdominal free air, or had an abdominal drain placed or exploratory laparotomy during admission were included. Congenital gastroschisis, omphalocele, intestinal atresia, malrotation were excluded. Data was collected via retrospective chart review with subsequent hierarchal, unsupervised clustering analysis. Five clusters of intestinal injury were identified: Cluster 1 deemed the "Low Mortality" cluster, Cluster 2 deemed the "Mature with Inflammation" cluster, Cluster 3 deemed the "Immature with High Mortality" cluster, Cluster 4 deemed the "Late Injury at Full Feeds" cluster, and Cluster 5 deemed the "Late Injury with High Rate of Intestinal Necrosis" cluster. Unsupervised machine learning can be used to cluster acquired neonatal intestinal injuries. Future study with larger multicenter datasets is needed to further refine and classify types of intestinal diseases. Unsupervised machine learning can be used to cluster types of acquired neonatal intestinal injury. Five major clusters of acquired neonatal intestinal injury are described, each with unique features. The clusters herein described deserve future, multicenter study to determine more specific early biomarkers and tailored therapeutic interventions to improve outcomes of often devastating neonatal acquired intestinal injuries.

Repeated intestinal perforations in vascular Ehlers-Danlos syndrome: a case report of a novel mutation in the COL3A1 gene

BackgroundEhlers-Danlos syndrome is an inherited connective-tissue disorder characterized by skin hyperextensibility, joint hypermobility, and tissue fragility. Intestinal perforation is one of the fatal manifestations of this syndrome, and its management is complicated.Case presentationA 58-year-old woman with a familial history of Ehlers-Danlos syndrome visited the emergency department due to a sudden onset of lower abdominal pain. Plain abdominal computed tomography showed abdominal free air. We found a perforated descending colon and subsequently resected this lesion and performed ileostomy. Fifty-one days after this first operation, the patient had transverse colon perforation and thus underwent the Hartmann procedure as the second operation. In addition, she was diagnosed with small bowel perforation 53 days after the first operation and consequently underwent a third operation—partial resection of the jejunum with functional end-to-end anastomosis. Fifty-eight days after the first operation, she complained of acute abdominal pain. Plain abdominal computed tomography showed fluid collection near the jejunojejunal anastomosis. We detected dehiscence at the entry hole of the linear stapler during the operation and thus performed partial resection of the affected jejunum, followed by jejunostomy. The postoperative course of the fourth operation was uneventful. Genetic testing revealed a novel missense mutation (c.2095G>T, p.Gly699Cys) in the COL3A1 gene, which is presumed to be a pathogenic variant of vascular Ehlers-Danlos syndrome.ConclusionVascular Ehlers-Danlos syndrome should be considered in the case of repeated intestinal perforation. The identified missense mutation in the COL3A1 gene (c.2095G>T, p.Gly699Cys) might be a novel pathogenic variation causing vascular Ehlers-Danlos syndrome. Careful postoperative screening and multidisciplinary management are required.

The role of multidetector computed tomography in predicting the site of gastroduodenal perforation.

This study aims to evaluate the value of multidetector computed tomography (MDCT) in detecting the location of gastroduodenal perforation. This cross-sectional descriptive study was conducted with 47 patients who underwent contrast-enhancing MDCT and were diagnosed with gastroduodenal perforation during surgery between July 2021 and June 2022. Radiologic findings included pneumoperitoneum (distribution and quantity) and analyzed the image findings for localizing the site of gastroduodenal perforation. Pneumoperitoneum was the most common finding [95.74% (45 out of 47 patients)]. Regarding air distribution, the sensitivity (Se) and negative predictive value (NPV) of abdominal free air and supramesocolic free air were the highest (100% for both). The accuracy (Acc) of supramesocolic free air was the highest (93.6%), followed by abdominal free air (89.4%). Subphrenic free air also had a high Acc value (89.4%), with Se, specificity (Sp), and positive predictive value (PPV) being 90%, 85,7%, and 97.3%, respectively. The Sp PPV of falciform ligament/ligamentum teres sign, and periportal free air were also high (100% for both). In contrast, retroperitoneal free air was valuable in determining retroperitoneal duodenal perforation with an Sp, Se of 100%, and Acc of 89.4%. The thickness of abdominal free air was ≥5.5 mm, suggesting gastroduodenal perforation with a Se, Sp, PPV, NPV, and Acc of 82.5%, 100%, 100%, 50%, and 85.1%, respectively. Subphrenic free air, periportal free air, falciform ligament sign, and the air above transverse mesocolon were correlated to gastric and duodenal bulb perforation. Retroperitoneal air indicates the perforation at the retroperitoneal duodenum. The thickness of abdominal free air ≥5.5 mm indicates gastric and duodenal bulb perforation.

Transpyloric misplacement and intramural dislocation: two novel complications related to balloon-type G-tubes.

To the Editor: Percutaneous endoscopic gastrostomy (PEG) remains the standard enteral nutrition access in clinical practice with limited complication potential. Beyond mushroom and/or disk-tip tubes (pull technique), in the introducer technique balloon-type G-tubes are implanted, warranting regular, often nurse-led exchanges. Herein, two novel complications related to tube exchange are presented. A frail male patient with advanced diffuse idiopathic skeletal hyperostosis (DISH)–related dysphagia reported on worsening enteral nutrition tolerance (intermittent administration) due to abdominal pain since the last bedside tube exchange by a specialized nutrition team in the nursing home. On endoscopy, transpyloric misplacement likely related to inadvertent duodenal guidewire insertion (Fig. 1A), resistant to repositioning by external traction (Fig. 1B), was detected. Endoscopy-directed repositioning was easily performed after balloon deflation and withdrawal into the stomach, and other potential causes for deterioration of nutrition tolerance, such as ulcer disease, were excluded. In retrospective, this uncommon and as yet unreported complication may have been avoided by strictly keeping attention to the distance markings during tube exchange, although the mere distance between the PEG exit point and the pylorus was indeed short.Figure 1.: Patient 1: (A) Endoscopic visualization of transpyloric misplacement of a balloon-type G-tube, causing discomfort due to inadvertent duodenal instead of gastric administration of the enteral nutrition regimen. (B) Failed repositioning by external pulling without balloon deflation (not shown uncomplicated repositioning under endoscopic guidance after balloon deflation). Patient 2: (C) Marked edema and hyperemia along endoscopic impression of a “subepithelial lesion” consistent with intramural balloon dislocation. (D) The latter was confirmed after balloon deflation, resulting in collapse of the lesion, and the PEG tract became visible in the vicinity.The second patient with a history of head and neck cancer presented with high-grade abdominal pain. Of note, the patient had only been discharged from a nearby hospital the same day after reinsertion of a balloon-type G-tube using the same PEG stoma after external loss of the previous tube during care measures. CT scans indicated minor free abdominal and intramural air in the stomach along suspected tube dislocation. This was confirmed during urgent endoscopy under CO2, revealing a markedly edematous and hyperemic “pseudotumor” in the antrum (Fig. 1C). After balloon deflation, the stoma entry site was found in the vicinity (Fig. 1D), and the balloon-type tube was repositioned correctly under endoscopic vision, obviating the need for surgery. It remains unclear why this complication occurred despite endoscopic guidance of tube exchange. On a speculative basis, incomplete balloon blocking and/or too aggressive tube retraction during care measures postendoscopy might be discussed. To the best of our knowledge, transpyloric misplacement and intramural dislocation have not yet been reported in the literature and represent two novel, clinically relevant complications related to balloon-type G-tubes.1 Nevertheless, similar to more common G-tube–related complications, such as buried bumper syndrome, strict adherence to tube exchange protocols and proper tube care are of utmost importance. Conflicts of interest The authors report no conflicts of interest.

Non-resection management of intestinal perforation associated with neutropenic enterocolitis in adolescent leukemia

Neutropenic enterocolitis (NE) is a necrotizing inflammatory disease of the cecum or colon that develops during severe neutropenia. We present a leukemic patient who developed multiple intestinal perforations associated with NE and recovered by surgical intervention without bowel resection. A 16-year-old girl was diagnosed with acute lymphoblastic leukemia. During induction therapy, she had been developing severe neutropenia and started to complain of abdominal pain. On day 36, she was experiencing severe abdominal pain with distention, and computed tomography showed abdominal free air and the thickened cecum wall. Emergency surgery revealed multiple perforations on the cecum with patchy necrosis. Abdominal drainage by tube-cecostomy and ileostomy were performed, and the patient gradually recovered. Two months later, the affected cecum was found recovered on second surgery, the ileostomy was closed, and the cecostomy was removed. Eight months after the first surgery, the patient was discharged after maintenance therapy. NE must be suspected in neutropenic patients with abdominal pain. In cases presenting severe complications such as intestinal perforation, abdominal drainage with ostomy can be a promising and minimally invasive option which may contribute to the bowel salvage and avoiding unnecessary bowel resection. • A report of neutropenic enterocolitis associated with multiple intestinal perforations. • Successful abdominal drainage avoided unnecessary bowel resection. • Abdominal drainage with ostomy can be a promising and minimally invasive option.

INTRAMEDULLARY GAS: A NEW FEATURE THAT PORTENDS A POOR PROGNOSIS IN COVID-19?

INTRAMEDULLARY GAS: A NEW FEATURE THAT PORTENDS A POOR PROGNOSIS IN COVID-19?

Diagnostic accuracy of computed tomography findings for hollow viscus injuries following thoracoabdominal gunshot wounds.

Selective nonoperative management (SNOM) of abdominal gunshot wounds (GSWs) is increasingly used as computed tomography (CT) has become a diagnostic adjunct for the evaluation of intraabdominal injuries including hollow viscus injuries (HVIs). Currently, there is scarce data on the diagnostic accuracy of CT for identifying HVI. The purpose of this study was to determine the diagnostic accuracy of different CT findings in the diagnosis of HVI following abdominal GSW. This retrospective single-center cohort study was performed from January 2015 to April 2019. We included consecutive patients (≥18 years) with abdominal GSW for whom SNOM was attempted and an abdominal CT was obtained as a part of SNOM. Computed tomography findings including abdominal free fluid, diffuse abdominal free air, focal gastrointestinal wall thickness, wall irregularity, abnormal wall enhancement, fat stranding, and mural defect were used as our index tests. Outcomes were determined by the presence of HVI during laparotomy and test performance characteristics were analyzed. Among the 212 patients included for final analysis (median age: 28 years), 43 patients (20.3%) underwent a laparotomy with HVI confirmed intraoperatively whereas 169 patients (79.7%) were characterized as not having HVI. The sensitivity of abdominal free fluid was 100% (95% confidence interval [CI]: 92-100). The finding of a mural defect had a high specificity (99%, 95% CI: 97-100). Other findings with high specificity were abnormal wall enhancement (97%, 95% CI: 93-99) and wall irregularity (96%, 95% CI: 92-99). While there was no singular CT finding that confirmed the diagnosis of HVI following abdominal GSW, the absence of intraabdominal free fluid could be used to rule out HVI. In addition, the presence of a mural defect, abnormal wall enhancement, or wall irregularity is considered as a strong predictor of HVI. Diagnostic Test or Criteria; Level II.

Shanghai fever, a fatal enteric illness, in an adult patient with neutropenia caused by treatment-related myelodysplastic syndrome: a case report

BackgroundShanghai fever is a rare community-acquired enteric illness with sepsis caused by Pseudomonas aeruginosa. Cases of Shanghai fever in pediatric patients have been reported; however, to the best of our knowledge, there are no reports of adult cases.Case presentationA 65-year-old man visited the emergency department with sudden onset of abdominal pain. He was diagnosed as treatment-related myelodysplastic syndrome after treatment of follicular lymphoma. Moderate tenderness in the middle right abdominal quadrants was noted. Computed tomography showed abdominal free air with a small amount of effusion to the surrounding edematous small intestine, and we performed emergency exploration. During operation, we found multiple bowel perforations with patchy necrotic lesions. The patient was admitted to an intensive care unit postoperatively. Blood culture showed Pseudomonas aeruginosa. His condition improved; however, on the 8th postoperative day, the abdominal drain tube showed turbid drainage. We performed re-operation and found anastomotic leakage with two new bowel perforations. After the re-operation, the patient showed signs of septic shock and his general condition got worse, and the patient died due to multiple organ failure on the 12th postoperative day.ConclusionShanghai fever may occur in an adult patient with neutropenia.

WHERE IS THE AIR? THE CASE OF A NON-ISOLATING AIR LEAK IN A 19-YEAR-OLD THORACIC STAB WOUND PATIENT

TOPIC: Procedures TYPE: Fellow Case Reports INTRODUCTION: Unidirectional bronchoscopically deployed endobronchial valves have been are indicated for emphysematous disease as an alternative to lung volume reduction surgery. These valves have found a second indication in the treatment of bronchopleural fistulas. CASE PRESENTATION: A 19 year-old male presented with multiple stab wounds after a homicide attempt. The patient had a series of intra-thoracic surgeries including partial wedge resection of the left upper lobe, removal of impaled knife from thoracic vertebra, several orthopedic procedures, and an esophageal repair. The two left sided large bore chest tubes placed intraoperatively had persistent air leaks on post-operative day 6 (image 1). We attempted a bronchoscopic balloon occlusion of the airway to isolate a suspected bronchopleural fistula with the intent to place a unidirectional endobronchial valve. However, balloon occlusion of the left upper lobe and then the left lower lobe did not result in an appreciable decrease in air leak. The entire left mainstem bronchus was then occluded without a decrease air leak (image 2). As such no valve could be deployed and the procedure was aborted. Careful consideration was given to the alternative sources of intra-thoracic air including fistulation from the esophagus or mediastinum. We considered abdominal free air crossing the diaphragm and even free air crossing the contralateral hemithorax. After these had been carefully ruled out with contrast studies and imaging, the patient was scheduled for video-assisted thoracic surgery (VATS) with wedge resection. On the morning of surgery, we noted that the patient's chest tubes were leaking around the insertion site. Furthermore there was fluid bubbling around the insertion site suggesting that the site itself was the origin of the patient's intrathoracic air. Both chest tubes were then removed and replaced with a small-bore pigtail chest tube resulting in complete resolution of air leak (image 3). DISCUSSION: The technique for placing unidirectional endobronchial valves for a bronchopleural fistula first involves isolating the source of the air leak. Segments of the affected lung are occluded using a sizing balloon starting proximally. When the segment where the bronchopleural fistula originates is occluded, the air leak will diminish indicating a decrease in airflow distally. A unidirectional endobronchial valve can then be deployed resulting in occlusion of the diseased airway, distal atelectasis, and a resolution of the bronchopleural fistula. This algorithmic approach will identify the diseased segment unless there is significant collateralization of airways, in which case a VATS is indicated. Our case highlights how alternative sources of air leak should be entertained prior to more aggressive surgical intervention. CONCLUSIONS: The patient's VATS was canceled and he has made a full recovery. REFERENCE #1: Mahajan AK, Khandhar SJ. Bronchoscopic valves for prolonged air leak: current status and technique. J Thorac Dis. 2017;9(Suppl 2):S110-S115. doi:10.21037/jtd.2016.12.63 REFERENCE #2: Travaline JM, McKenna RJ, Jr, De Giacomo T, et al. Treatment of persistent pulmonary air leaks using endobronchial valves. Chest 2009;136:355-60. 10.1378/chest.08-2389 REFERENCE #3: Reed MF, Gilbert CR, Taylor MD, et al. Endobronchial Valves for Challenging Air Leaks. Ann Thorac Surg 2015;100:1181-6. 10.1016/j.athoracsur.2015.04.104 DISCLOSURES: No relevant relationships by Jonathan Xian, source=Web Response

Comparison of conventional chest x ray with a novel projection technique for ultra-low dose CT.

To compare a novel thick-slab projection technique for ultra-low dose computed tomography (CT; thoracic tomogram) with conventional chest x ray with respect to 13 diagnostic categories. With the approval of the institutional ethics board, a dataset was retrospectively collected of 22 consecutive patients who had undergone a clinically requested emergency room conventional chest x ray (CXR) and a same-day standard-of-care non-contrast CT. Scanner specific noise was added to the CT images to simulate a target dose of 0.18mSv. A novel algorithm was used to post-process CT images as coronal isotropic reformats by applying a voxel-based, locally normalized weighted-intensity projection to generate 2cm thick slabs with 1cm overlap. Three chest radiologists with no prior training for the study reviewed the CXR and thoracic tomogram for each case and assessed each diagnostic category (pneumonic infiltrates, pulmonary edema, interstitial lung disease, nodules>5mm, nodules<5mm, pleural effusion, pericardial effusion, heart size, acute bone fractures, foreign bodies, pneumothorax, mediastinal vessel diameter, free abdominal air) on a Likert scale from -4 (definitely absent/normal) to +4 (definitely present/abnormal). MRMC ROC curves were generated for each category. Time for interpretation and subjective image quality score (0-10) were also assessed. For focal lung disease (pneumonic infiltrates, nodules<5mm, nodules>5mm), the area under the ROC curve (AUC) was significantly higher for thoracic tomograms than CXR (0.803 vs 0.648, respectively, P=0.02). For non-focal lung disease (pulmonary edema, interstitial lung disease) and effusions (pulmonary, pericardial), the AUC was larger for thoracic tomograms than CXR but the difference did not reach significance (0.870 vs 0.833, P=0.141; and 0.823 vs 0.752, P=0.296, respectively). For acute bone fractures and foreign bodies, the AUC was smaller for thoracic tomograms than CXR, the difference was however not significant (0.491 vs 0.532, P=0.42; and 0.871 vs 0.971, P=0.39, respectively). Other diagnostic categories had no true positive cases in the dataset. The mean time for interpretation for each was 36.9 and 24.0s with standard deviations of 0.857 and 5.977. The image quality score for each was 8.2 and 7.8 with standard deviations of 0.970 and 1.614. Thoracic tomograms were found to be diagnostically superior to CXR for focal lung disease, at no increased radiation dose. The thoracic tomogram presents an opportunity to improve the standard-of-care for patients who would otherwise receive a conventional CXR.

Cessation of methotrexate and a small intestinal resection provide a good clinical course for a patient with a jejunum perforation induced by a methotrexate-associated lymphoproliferative disorder: a case report

BackgroundMethotrexate (MTX) is a frequently used drug in the treatment of rheumatoid arthritis (RA), but occurrences of lymphoproliferative disorders (LPD) have been reported in patients undergoing an MTX regimen. Almost half of the patients with methotrexate-associated lymphoproliferative disorders (MTX-LPD) have extranodal lesions; moreover, although extremely rare, digestive tract perforations resulting from the extranodal lesions of MTX-LPD have also been reported.Case presentationWe describe the case of an 81-year-old woman with RA who had been prescribed MTX at 6 mg per week for the past 11 years. She was admitted to our hospital with occasional abdominal pain and was first diagnosed with enteritis. Her abdominal pain did not improve, and a computed tomography scan showed abdominal effusion and free air in the abdominal cavity. She was diagnosed with a digestive tract perforation and underwent emergency surgery. The perforation site was identified in the jejunum, and she underwent small intestinal resection around the perforated region. The pathological findings showed an ulcer in the jejunum and infiltration of large atypical lymphocytes around the perforated region. An immunohistochemical examination revealed the expression of a cluster of differentiation 20 and latent membrane protein 1. Considering the patient’s history of RA treated with MTX, she was diagnosed as having Epstein–Barr virus (EBV)-related MTX-LPD with a histological diagnosis of EBVMCU. MTX was discontinued after the surgery, and her soluble interleukin-2 receptor (sIL-2R) levels had returned to normal 1 year later. She has had a good course for the 2 years since surgery and remains asymptomatic with no recurrence of MTX-LPD, as confirmed by the sIL-2R levels.ConclusionWe experienced a rare case of the jejunum perforation induced by MTX-LPD. Since only a few cases have been reported of a patient with small intestinal perforation induced by MTX-LPD, further research is necessary to evaluate the clinicopathological features of MTX-LPD. The patient had disease remission after surgery and by discontinuing MTX treatment; our case did not require chemotherapy. EBV-positive patients, especially those with a pathological presentation of EBVMCU, could have a higher likelihood of remission, which could have been a factor in the present case.

A case of pneumatosis intestinalis accompanied by intra‒abdominal free air and portal venous gas induced by transient mesenteric ischemia in a hemodialysis patient

A case of pneumatosis intestinalis accompanied by intra‒abdominal free air and portal venous gas induced by transient mesenteric ischemia in a hemodialysis patient

Neonatal and infantile appendicitis still confuses minds: report of two cases

BackgroundAcute appendicitis is extremely rare in the neonatal and infantile periods. The number of cases published in the last century is just over 100. Mortality and morbidity are still high due to diagnostic problems because there are no specific clinical features and reliable investigation for the diagnosis. Herein, we present two patients to remind physicians that the diagnosis of neonatal and infantile appendicitis should always be kept in mind.Case presentationsA 30 3/7-week-old 740-g newborn girl was delivered by cesarean section because of preeclampsia. The newborn was followed in the neonatal intensive care unit and fed with an orogastric catheter. An abdominal distention developed on the 18th day of her life. While following up with a preliminary diagnosis of necrotizing enterocolitis, she was operated on the 4th day due to abdominal free air seen on X-ray. A perforated appendicitis was detected in the abdominal exploration and formal appendectomy was performed. Histology demonstrated marked transmural inflammation and necrosis at the perforated site and there was no evidence of Hirchsprung’s disease. The patient was started on breast milk on the third postoperative day and discharged home on day 98.A 3.5-month-old boy was admitted to our clinic because of abdominal distention, discomfort, and constipation which had been ongoing for 4 days. He was followed up as an outpatient basis for 4 days in another center with the diagnosis of infantile colic. An increase in echogenicity due to intense inflammation was observed in mesenteric plans using USG in the right lower quadrant of the abdomen. Following preoperative preparations, the patient underwent abdominal exploration and appendectomy. He had an uneventful recovery and pathologic examination demonstrated a necrotizing appendicitis with perforation. He was discharged on the fourth postoperative day without any problems.ConclusionIt is a fact that acute appendicitis in neonates and infants may not be diagnosed easily and quickly as in older children because there are no specific clinical features and reliable investigation for the diagnosis. Delay in diagnosis and treatment often results in appendicular perforation and peritonitis. The main safeguard against mortality and morbidity remains a high index of suspicion.

Direct acute respiratory distress syndrome after gastric perforation caused by an intragastric balloon: a case report

BackgroundAcute respiratory distress syndrome (ARDS) is a life-threatening condition and the identification of the underlying direct (pulmonary) or indirect (non-pulmonary) cause is mandatory for a successful treatment. Intragastric balloon (IGB) therapy is a minimal invasive and supposedly harmless option to reduce body weight for the growing number of obese people. We present a case of a young patient who developed a direct ARDS due to initially undiagnosed abdominal pathologies caused by an IGB therapy.Case presentationA 23-year old woman was admitted because of a direct ARDS for extracorporeal membrane oxygenation (ECMO) therapy. Weeks before, an IGB has been removed because of abdominal pain and free intraabdominal air. Diagnostic work-up of free intraabdominal air, previous pain of the left shoulder and newly developed abscess pneumonia revealed a perforation of the posterior wall of the gastral antrum. This resulted in a left subphrenic abscess with destruction of the diaphragm, development of pneumonia per continuitatem and subsequent direct lung injury. The gastric perforation was endoscopically clipped and the ARDS was successfully treated under ECMO therapy.ConclusionThis case illustrates that a patient presenting with direct ARDS may have upper abdominal pathologies caused by a rare complication of a supposedly harmless treatment.

Retroperitoneal Air as First Sign of Sigmoid Perforation in an Octogenarian

Sigmoid perforation is a common surgical problem at the emergency department. It usually appears with abdominal pain of sudden onset and free abdominal air in the X-ray. Nevertheless, there are a few rare cases where retroperitoneal air is the first sign of sigmoid perforation. An 82-year-old female patient visited the emergency department due to abdominal pain and blood in her stool. The patient was afebrile and no signs of rebound tenderness were revealed. The abdominal X-ray did not reveal any sign of free intraperitoneal air. An abdominal computed scan tomography was performed which revealed a large quantity of retroperitoneal air. The patient underwent diagnostic laparotomy. Her sigmoid colon had ruptured toward its mesosigmoid with no indications of diverticulitis. Sigmoidectomy was performed. Her postoperative course was uneventful and the patient was discharged 10 days after. Sigmoid perforation toward the retroperitoneal space is an extremely rare clinical scenario, which can be promptly managed only with high clinical suspicion.

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.

Effect of a novel denoising technique on image quality and diagnostic accuracy in low-dose CT in patients with suspected appendicitis

ObjectivesTo determine the effect of a vendor unspecific, DICOM-based denoising technique on image quality and diagnostic performance in low-dose simulated abdominal computed tomography (CT) examinations in patients with suspected appendicitis. Methods and MaterialsWe included 51 patients who underwent contrast-enhanced abdominal CT with Filtered Back Projection due to suspected appendicitis. Realistic Low-Dose simulation generated low-dose datasets at 25% of the original exposition. QuantaStream Denoising, a novel DICOM-based technique denoised the simulated low-Dose datasets. Original (O100), low-dose (LD25) and denoised (DN25) datasets (n = 153) were evaluated regarding subjective image quality (5-point Likert scale; overall quality/image noise/diagnostic confidence), presence/absence of acute appendicitis, free abdominal air and abscess formation and objective image quality (Signal-to-Noise Ratio (SNR) and noise level) by two independent readers. ResultsSubjective image quality was rated highest for O100, followed by DN25 and LD25 with significant differences (p = 0.001). Appendicitis was correctly identified in all datasets (n = 30). Appendicitis specific diagnostic confidence was highest for O100 (p = 0.001), followed by DN25 and LD25 without significant difference. All complications were correctly identified on O100 and DN25. On LD25, diagnostic accuracy decreased for abscess formations (sensitivity:0.714; specificity:1.0) and for free abdominal air (sensitivity:0.750; specificity:0.936). Regarding noise levels DN25 showed non-inferiority to O100. SNRs of O100 and DN25 showed no significant difference (p = 0.06). ConclusionOur findings indicate that QuantaStream Denoising allows for maintained diagnostic image quality and diagnostic accuracy of low-dose abdominal CT examinations (25% of original exposition) in patients with suspected appendicitis without the need for raw sinogram data.

Computed tomography in suspected anastomotic leakage after colorectal surgery: evaluating mortality rates after false-negative imaging.

We sought to investigate the accuracy of abdominal CT scanning for anastomotic leakage and the effect of false-negative scans on the delay in therapeutic intervention and clinical outcome. Data from a prospectively bi-institutionally maintained database of all patients who underwent elective colorectal surgery with primary anastomosis for malignant or benign disease between 2010 and 2017 were reviewed. Patients with confirmed anastomotic dehiscence at reintervention who underwent a postoperative CT scan for suspected leakage were identified and radiological reports were retrieved. Seventy-six patients with anastomotic dehiscence were included in the study. American Society of Anesthesiologists score, sex, type of surgical procedure, malignancy, and type of anastomosis do not correlate with postoperative false-negative CT imaging. Postoperative false-negative CT scan, however, led to delayed reintervention (3 vs. 6h, p = 0.023) and increased mortality (five deaths vs. no deaths, p = 0.043). Free abdominal air (p = 0.001) and extraluminal contrast extravasation (p = 0.001) were found to be predictive of accuracy in anastomotic leakage diagnosis. The suboptimal specificity of a postoperative CT scan in suspected anastomotic leakage after colorectal surgery can delay reintervention and increase mortality.

Bevacizumab-associated Bowel Microperforation in a Patient With Neuroblastoma

The antivascular endothelial growth factor antibody, bevacizumab, is effective against several malignancies in adults but unproven in pediatric oncology. In early phase pediatric studies toxicities were similar to those in adults. Bowel perforation in adults is a rare but serious toxicity, but has not been hitherto reported in children. A 5-year-old boy with chemoresistant neuroblastoma treated with bevacizumab plus radioimmunotherapy developed acute abdominal pain. Computed tomography scan showed free abdominal air and pneumatosis coli. Emergency laparotomy and bowel diversion were performed leading to complete recovery and timely continuation of antineuroblastoma therapy. Early recognition and rapid intervention can prevent a catastrophic outcome in bevacizumab-related bowel perforation.

Massive pneumatosis intestinalis and free abdominal air: Is surgery always necessary?

Massive pneumatosis intestinalis and free abdominal air: Is surgery always necessary?