Intramural Gas Research Articles

A weighted and cumulative point system for accurate scoring of intestinal pathology in a piglet model of necrotizing enterocolitis

Necrotizing enterocolitis (NEC) is a serious condition in premature infants, in which a portion of the intestine undergoes inflammation and necrosis. The preterm pig develops NEC spontaneously, making it a suitable model for exploring novel NEC treatments. We aimed to revise the intestinal scoring system to more accurately describe the diversity of NEC lesions in the preterm piglet model. We included 333 preterm piglets from four experiments, each delivered via cesarean section. The piglets were fed either a gently processed (GP) or harshly processed (HP) milk formula for 96 h before euthanasia. At necropsy, the gastrointestinal tract was assessed with 1) an established 6-grade score and 2) a descriptive approach focusing on the distribution and severity of hyperemia, hemorrhage, pneumatosis intestinalis (intramural gas), and necrosis. Subsequently, the descriptive registrations were converted into a weighted and cumulative point (WCP) score. Compared to the 6-grade score, the WCP score enabled a greater segregation of severity levels, especially among organs with more prominent NEC lesions. IL-1β in small intestinal lesions and both IL-8 and IL-1β in colon lesions correlated positively with the WCP scale. A histopathological grade system (0–8) was established and revealed mucosal pathology in lesion biopsies, which were not recognized macroscopically. Finally, the WCP score showed a higher NEC-promoting effect of the HP formula compared to the GP formula. The descriptive registrations and extended score range of this revised intestinal scoring system enhance the accuracy of describing NEC lesions in preterm pigs. This approach may increase the efficiency of preclinical NEC experiments.

Spontaneous Bladder Wall Rupture Due to Emphysematous Cystitis in a Diabetic Patient: A Case Report

Spontaneous rupture of the urinary bladder (SRUB) secondary to emphysematous. Cystitis (EC) in diabetic patients is extremely rare. Emphysematous cystitis is a relatively rare disease entity characterized by intramural and/or intraluminal bladder gas best depicted by cross-sectional imaging. Its disease mechanism is not well understood. Case report: A 61-year-old diabetic woman presented to the emergency department with diffuse abdominal pain and hematuria of tree hours duration. Physical examination revealed generalized abdominal tenderness. Multi-slice abdominal and pelvic CT scans showed parietal pneumatosis of bladder and communicating continuity solutions with a pre-vesical collection (extravasation of PDC into the collection). After proper resuscitation, the patient was transferred to the operating room for exploratory laparotomy. A thickness bladder rupture was noted, which was repaired. Conclusions: SRUB in patients with poorly controlled diabetes and EC is highlighted in this case study. Urinary bladder rupture secondary to EC should be considered when a diabetic patient with a history of urinary symptoms presents with an acute onset of abdominal pain. Uneventful recovery from SRUB is dependent on early diagnosis and treatment.

Endoscopic and clinical features of gastric emphysema

Gastric emphysema is characterized by the presence of intramural gas in the stomach without bacterial infection. Due to its rarity, most reports on gastric emphysema have been limited to single-case studies, and this condition’s clinical and endoscopic features have not been thoroughly investigated. In this study, we analyzed 45 patients with gastric emphysema from 10 institutions and examined their characteristics, endoscopic features, and outcomes. The mean age at diagnosis of gastric emphysema in our study population (35 males and 10 females) was 68.6 years (range, 14–95 years). The top five underlying conditions associated with gastric emphysema were the placement of a nasogastric tube (26.7%), diabetes mellitus (20.0%), post-percutaneous endoscopic gastrostomy (17.8%), malignant neoplasms (17.8%), and renal failure (15.6%). Among the 45 patients, 42 were managed conservatively with fasting and administration of proton pump inhibitors. Unfortunately, seven patients died within 30 days of diagnosis, and 35 patients experienced favorable recoveries. The resolution of gastric emphysema was confirmed in 30 patients through computed tomography (CT) scans, with a mean duration of 17.1 ± 34.9 days (mean ± standard deviation [SD], range: 1–180 days) from the time of diagnosis to the disappearance of the gastric intramural gas. There were no instances of recurrence. Endoscopic evaluation was possible in 18 patients and revealed that gastric emphysema presented with features such as redness, erosion, coarse mucosa, and ulcers, with fewer mucosal injuries on the anterior wall (72.2%), a clear demarcation between areas of mucosal injury and intact mucosa (61.1%), and predominantly longitudinal mucosal injuries on the stomach folds (50.0%). This study is the first English-language report to analyze endoscopic findings in patients with gastric emphysema.

A Comprehensive Case of Emphysematous Gastritis in A Young Patient-Case Report

Gastric emphysema is caused by traumatic mucosal injury. A rare condition called emphysematous gastritis is characterized by intramural gas in the stomach and symptoms of systemic poisoning. It has a mortality rate of between 45% and 60%, thus early diagnosis and rapid treatment, such as fluid resuscitation, nil by mouth, broad-spectrum antibiotics, and bowel rest, are essential to halting the spread of this lethal condition. Surgery is only recommended in cases of stomach perforation. Rare and severe, emphysematous gastritis is characterized by indications of systemic poisoning and air in the stomach wall. It is often brought on by a mucosal defect that allows gas-forming organisms to infect the area, or by hematogenous dissemination from a distant centre. Emphysematous gastritis has a fulminant course, and a 60% death rate, thus early diagnosis and treatment are essential. Here we describe a case of a 17-year-old guy who complained of stomach pain; a CT scan revealed emphysematous gastritis, which is compatible with the diagnosis. Antibiotics were administered to him, and he recovered quickly. It is associated with good prognosis. Keywords: Emphysematous Gastritis; NSAIDS; Ulcer; Gastric Emphysema; Pathophysiology; Ischemic Injury

Factors associated with the increased incidence of necrotising enterocolitis in extremely preterm infants in Sweden between two population-based national cohorts (2004–2007 vs 2014–2016)

ObjectiveTo investigate potential risk factors behind the increased incidence of necrotising enterocolitis (NEC) in Swedish extremely preterm infants.DesignRegistry data from two population-based national cohorts were studied. NEC diagnoses (Bell stage...

Gastric pneumatosis in a preterm infant: A case report

Background: Gastric pneumatosis is a rare condition characterized by the presence of intramural gas in the stomach wall. It is uncommon in infants and is usually caused by proximal intestinal obstruction or necrotizing enterocolitis, a serious condition typically seen in preterm babies. Case Presentation: An extremely preterm baby born at 23 weeks of gestation weighing 640 grams, with bronchopulmonary dysplasia and other comorbidities like patent ductus arteriosus, staph aureus sepsis, developed abdominal distension and non-bilious vomiting at 4 months of age. X-ray abdomen revealed gastric pneumatosis. The condition was managed with conservative measures. Conclusion: Gastric pneumatosis secondary to necrotizing enterocolitis is uncommon in infants and needs prompt evaluation and management to prevent further deterioration.

Bowel inflammatory presentations on computed tomography in adult patients with severe aplastic anemia during flared inflammatory episodes.

Patients with severe aplastic anemia (SAA) frequently present with inflammatory episodes, and during flared inflammatory episodes, hematopoietic function is further exacerbated. The gastrointestinal tract is the most common site for infectious and inflammatory diseases, and its structural and functional features confer on it the most potent capacity to affect hematopoietic and immune functions. Computed tomography (CT) is a readily accessible approach to provide highly useful information in detecting morphological changes and guiding further work-ups. To explore CT imaging presentations of gut inflammatory damage in adult SAA patients during inflammatory episodes. We retrospectively evaluated the abdominal CT imaging presentations of 17 hospitalized adult patients with SAA in search of the inflammatory niche when they presented with systemic inflammatory stress and exacerbated hematopoietic function. In this descriptive manuscript, the characteristic images that suggested the presence of gastrointestinal inflammatory damage and related imaging presentations of individual patients were enumerated, analyzed and described. All eligible patients with SAA had CT imaging abnormalities that suggested the presence of an impaired intestinal barrier and increased epithelial permeability. The inflammatory damages were concurrently present in the small intestine, the ileocecal region and the large intestines. Some readily identified imaging signs, such as bowel wall thickening with mural stratification ("water holo sign", "fat holo sign", intramural gas and subserosal pneumatosis) and mesenteric fat proliferation (fat stranding and "creeping fat sign"), fibrotic bowel wall thickening, "balloon sign", rugged colonic configuration, heterogeneity in the bowel wall texture, and adhered and clustered small bowel loop (including various patterns of "abdominal cocoon"), occurred at a high incidence, which suggested that the damaged gastrointestinal tract is a common inflammatory niche responsible for the systemic inflammatory stresses and the exacerbated hematopoietic failure in patients with SAA. Particularly, the "fat holo sign" was present in 7 patients, a rugged colonic configuration was present in 10 patients, the adhesive bowel loop was present in 15 patients, and extraintestinal manifestations suggestive of tuberculosis infections were present in 5 patients. According to the imaging features, a suggestive diagnosis of Crohn's disease was made in 5 patients, ulcerative colitis in 1 patient, chronic periappendiceal abscess in 1 patient, and tuberculosis infection in 5 patients. Other patients were diagnosed with chronic enteroclolitis with acutely aggravated inflammatory damage. Patients with SAA had CT imaging patterns that suggested the presence of active chronic inflammatory conditions and aggravated inflammatory damage during flared inflammatory episodes.

Emphysematous gastritis in a newborn: Is it very rare or do we just miss it?

Emphysematous gastritis is a rare and life-threatening condition caused by gastric inflammation and intramural gas formation, most often diagnosed through radiological evidence of a radiolucent shadow in the stomach wall in the clinical scenario of severe sickness. We report a case of emphysematous gastritis secondary to early-onset neonatal sepsis in a newborn which, to the best of our knowledge, has not otherwise been reported. Is it very rare or do we just miss it?

Oesophageal pneumatosis: computed tomographic characteristics in three dogs (2018-2021).

Oesophageal pneumatosis (OP) is defined as the presence of gas within the oesophageal wall. The description of this condition in veterinary medicine is currently lacking. The pathogenesis of alimentary tract pneumatosis remains unclear. Current literature describes that access of gas into the oesophageal wall may occur by one or a combination of the following mechanisms: mucosal disruption, increased intra or extra-luminal pressure or dissection of gas from an extra-oesophageal source. The aim of this multi-centric case series was to describe the computed tomography (CT) findings of OP in dogs. Three adult dogs were included. One dog presented with gastrointestinal signs and general malaise while the other two presented with spontaneous facial and cervical subcutaneous emphysema. CT revealed different degrees of intramural gas along the oesophageal wall in all cases. The first dog was diagnosed with emphysematous gastritis based on the presence of gastric pneumatosis paired with compatible clinicopathological and endoscopic findings. This dog was successfully treated with antibiotics. The remaining two dogs were diagnosed with spontaneous pneumomediastinum and required no surgical or medical treatment. In all cases with OP, there was concurrent gastric pneumatosis. Gas extensively and circumferentially distributed with a banded shape along the oesophageal wall was present in patients with presumed mural gas dissection because of pneumomediastinum. Conversely, a focal and mild amount of mural gas with a tubular shape was identified in the distal segment of the oesophagus in the patient with emphysematous gastritis.

Gastric pneumatosis in a child with congenital duodenal obstruction

Pneumatosis of the foregut is an extremely rare finding which may indicate a potentially serious condition. In newborn the presence of gastric intramural gas is mainly associated to necrotizing enterocolitis and is considered a condition which correlates with a poor prognosis. In infant and children pneumatosis of foregut may be secondary to several causes such as infection, mucosal ischemia, caustic ingestion, gastrointestinal obstruction or mucosal injury occurred during endoscopic procedure. Intramural gastric gas can be classified as “gastric emphysema” (GE) when a mechanical injury is the main causal factor or as “emphysematous gastritis” (EG) in cases of underlying gastrointestinal infection. Portal venous gas is also a rare condition. Necrotic bowel wall dues to infection or ischemia, associated with increased intraluminal pressure, seems to favor the entry of the air into portal venous system. We report a case of gastric pneumatosis associated to portal venous gas in a child affected by Down's Syndrome with a duodenal web and concomitant bacterial and mycotic gastric colonization.

758 Unique Case of Recurrent Non-Neutropenic Typhlitis

Abstract Tacrolimus is an important component of the immunosuppressive regime used after solid organ transplantation. It is known to predispose patients to typhlitis also known as neutropenic enterocolitis, which presents with the characteristic triad of abdominal pain, fever, and neutropenia. A 66-year-old lady was referred with vomiting, abdominal pain, and passage of blood per ileostomy. The patient had an extensive medical history including a panproctocolectomy for Crohn's disease, cholecystectomy and a liver transplant. Her immunosuppressive regime included prednisolone, azathioprine, and tacrolimus. Based on her presentation, a presumptive diagnosis of ischemic bowel was made, and non-contrast (due to AKI) CT scan demonstrated evidence of intramural gas with marked mesenteric and portal venous gas. The decision was made to proceed to laparotomy, the findings of which included dense adhesions but with normal healthy small bowel. After several investigations, it was concluded that her symptoms were caused by typhlitis secondary to her tacrolimus therapy. In 2020, the patient presented with similar symptoms. She was able to undergo a contrast-enhanced CT scan during this episode as she had presented early with preserved renal function. Her radiological findings were similar to the previous episode. However, owing to her known past history, she was managed conservatively. To the authors knowledge, no similar cases have been reported so far, which makes this case unique and makes a strong motion for the clinicians to maintain a high suspicion for typhlitis inmmunocompromised patients, even in absence of classical feature of neutropenia

EP-277 Emphysematous cholecystitis: A diagnostic dilemma and treatment challenge

Abstract Background Emphysematous cholecystitis (EC) is a rare life-threatening variant of acute cholecystitis. It is commonly seen in elderly men who are immunocompromised, known diabetes mellitus or peripheral vascular disease. EC is caused by gas-forming organisms such as Escherichia coli, Clostridium perfringens and Bacteroides fragilis and has a reported mortality of up to 25%. Computed Tomography is the most sensitive diagnostic imaging study for the detection of intraluminal or intramural gallbladder gas. Methods We report a diagnostic dilemma and multidisciplinary management of a case of emphysematous cholecystitis with unusual presentation in a young, healthy patient with no risk factors. Results A 47-year-old male chef, otherwise fit and well, presented with a clinical picture of sepsis and abdominal pain. Initial investigations were normal apart from bilateral basal atelectasis, hence he was treated for pneumonia, although without clinical improvement. Due to persistent fever, patient underwent further investigations that established the diagnosis of emphysematous cholecystitis. His clinical condition improved dramatically after urgent laparoscopic cholecystectomy with patient being safely discharged home 6 days post-op, with an uneventful postoperative recovery. Conclusion A high index of clinical suspicion and multidisciplinary team management including surgery, radiology, and microbiology is crucial for early diagnosis of the rare life-threatening condition of EC. Our clinical case highlights that EC is not limited to elderly morbid patients and urgent laparoscopic cholecystectomy is the best treatment when feasible.

Gastric pneumatosis: An unexpected complication in multiple myeloma patient

Gastric pneumatosis is an unusual and rare condition with unclear management recommendations. We report a case of gastric pneumatosis in an adult patient with multiple myeloma on chemotherapy with concomitant fungemia. Patient presented with right lower abdominal pain and subsequently developed spinal cord compression and got treated with high dose dexamethasone and chemotherapy. Patient developed upper GI symptoms and diagnostic imaging was ordered. A CT scan of the abdomen and pelvis was done which showed intramural gas in the gastric and esophageal wall along with positive blood cultures for candida krusei. Our patient was managed conservatively with antifungal, antibacterial therapy along with decompression via nasogastric tube but failed to improve. General surgery team recommended operative management, but the patient and family opted for comfort measures.

Portal Vein Gas in Neonates: Predicting Clinical Treatment Outcomes From Ultrasound Findings.

To identify sonographic findings that predict clinical outcomes in neonates with portal vein gas. This retrospective study included neonates with portal vein gas detected using ultrasound (US). The US images were reviewed by a pediatric radiologist. US findings included the extent and amount of portal vein gas, mesenteric vein gas, intramural gas, bowel wall thickening or thinning, focal discontinuity of the bowel wall, ascites, free intra-abdominal gas, pseudocyst, gas in the other solid organs, and bowel distension. The imaging findings and demographic factors between survivors and non-survivors were statistically compared. The mortality rate was 26% (39 survivors, 14 non-survivors) when iatrogenic and idiopathic causes were excluded. The causes of portal vein gas were determined to be necrotizing enterocolitis (n=33), bowel distension or obstruction (n=12), fetal hydrops (n=4), pneumothorax (n=3), immediate postoperative state for bowel perforation (n=1), and umbilical vein catheterization (n=9) based on surgical findings (n=20) and clinical information (n=46). Gas within the mesenteric vein and the other solid organs, gestational age, and birth weight were significantly different between survivors and those who succumbed (P < .05). Gas within the mesenteric vein and other solid organs is a US finding that may predict poor outcomes in neonates with portal vein gas.

Pneumatosis intestinalis in the pediatric oncology population: An 11-year retrospective review at Memorial Sloan Kettering Cancer Center.

Pneumatosis intestinalis (PI) is characterized by the presence of intramural gas in the gastrointestinal (GI) tract. The overall aim of this study was to review risk factors and outcome of pediatric oncology patients at our institution who developed PI. Patients diagnosed with PI between 2007 and 2018 were identified from ICD-10 coding of radiology reports at Memorial Sloan Kettering Kids, a tertiary pediatric oncology center. Outcomes of interest were (a) resolution and time to resolution of PI, (b) surgical intervention within 2weeks of diagnosis of PI, or (c) death secondary to PI. To capture the resolution of PI, we defined the "time to recovery (TTR)" as the time elapsed between date of PI diagnosis and the date of recovery. Forty-two patients were identified. Within 30days of diagnosis of PI, three patients had surgical intervention for PI (7%) and two patients died (5%) due to non-PI causes. Median TTR of PI was 4.5days (95% CI: 3-7days). In univariable and multivariable analyses, only steroid use in the prior 30days was significantly associated with a faster TTR of PI (HR=2.27 [95% CI: 1.17-4.41], p=.02). This is the largest case series of patients with PI in the pediatric oncology population, which reveals significantly lower surgical and mortality rates than other published PI series. For the majority of patients, conservative medical management is indicated. A prospective study is warranted to define diagnosis and management guidelines for PI in the pediatric oncology population in a cooperative group setting.

Emphysematous gastritis.

An 89‐year‐old woman who had type 2 diabetes mellitus suddenly presented with abdominal pain. Abdominal computed tomography showed thickening of the wall and intramural gas in the gastric hilum, suggesting emphysematous gastritis. The patient underwent treatment with a proton‐pump inhibitor and broad‐spectrum antibacterial agents.

Emphysematous cystitis with rare findings of subcutaneous emphysema and extraperitoneal pelvic gas: a case report

Emphysematous cystitis is a rare form of lower urinary tract infection with pathognomonic intramural and intraluminal gas. It commonly occurs in elderly females with uncontrolled diabetes mellitus. Subcutaneous emphysema and extraperitoneal pelvic gas are reported as rare presentations of emphysematous cystitis. Here we report emphysematous cystitis occurring in an elderly male with multiple co-morbidities who presented with fulminant sepsis and rare findings of subcutaneous emphysema and extraperitoneal pelvic gas.

Pseudo-pneumatosis of the gastrointestinal tract: its incidence and the accuracy of a checklist supported by artificial intelligence (AI) techniques to reduce the misinterpretation of pneumatosis.

To assess the incidence of erroneous diagnosis of pneumatosis (pseudo-pneumatosis) in patients who underwent an emergency abdominal CT and to verify the performance of imaging features, supported by artificial intelligence (AI) techniques, to reduce this misinterpretation. We selected 71 radiological reports where the presence of pneumatosis was considered definitive or suspected. Surgical findings, clinical outcomes, and reevaluation of the CT scans were used to assess the correct diagnosis of pneumatosis. We identified four imaging signs from literature, to differentiate pneumatosis from pseudo-pneumatosis: gas location, dissecting gas in the bowel wall, a circumferential gas pattern, and intramural gas beyond a gas-fluid/faecal level. Two radiologists reevaluated in consensus all the CT scans, assessing the four above-mentioned variables. Variable discriminative importance was assessed using the Fisher exact test. Accurate and statistically significant variables (p-value < 0.05, accuracy > 75%) were pooled using boosted Random Forests (RFs) executed using a Leave-One-Out cross-validation (LOO cv) strategy to obtain unbiased estimates of individual variable importance by permutation analysis. After the LOO cv, the comparison of the variable importance distribution was validated by one-sided Wilcoxon test. Twenty-seven patients proved to have pseudo-pneumatosis (error: 38%). The most significant features to diagnose pneumatosis were presence of dissecting gas in the bowel wall (accuracy: 94%), presence of intramural gas beyond a gas-fluid/faecal level (accuracy: 86%), and a circumferential gas pattern (accuracy: 78%). The incidence of pseudo-pneumatosis can be high. The use of a checklist which includes three imaging signs can be useful to reduce this overestimation.

Anatomy of a steam pop – Acute histopathology in human myocardium after ventricular tachycardia ablation

Despite an improved understanding of the biophysics of radiofrequency (RF) energy delivery, steam pops remain a potentially serious complication of RF catheter ablation. Excessive heating and boiling resulting in intramural gas eruption from myocardial tissue can lead to cardiac perforation and may require emergent surgical repair.1,2 Visualization of the histopathologic changes, the degree of tissue destruction, and comparisons to non–steam pop RF ablation have not been reported in human myocardium in the acute phase.

A141 SPONTANEOUS ESOPHAGEAL PERFORATION: AN UNREPORTED COMPLICATION OF LYMPHOCYTIC ESOPHAGITIS

Abstract Background Lymphocytic esophagitis is a new and rare clinicopathological entity. It is a histological pattern characterized by lymphocytic infiltrate without granulocytes. Its etiology and clinical significance remains unclear. The clinical manifestations are typically mild, with reflux and dysphagia the most commonly reported symptoms. Aims We describe a case report of spontaneous esophageal perforation associated with lymphocytic esophagitis. Methods Case report Results A previously well 31-year-old male presented to the emergency department with acute food impaction. His antecedent symptoms were acute chest discomfort and continuous odynophagia following his most recent meal, with persistent globus sensation. The patient had no reported history of allergies, atopy, rhinitis, or asthma. A previous history of non-progressive dysphagia was noted after resuscitation. Emergent endoscopy revealed no food bolus, but a deep 6 cm mucosal tear in the upper-mid esophagus extending 24 to 30 cm from the incisors. Chest computed tomography observed small volume pneumoperitoneum consistent with esophageal perforation. The patient’s recovery was uneventful; he was managed conservatively with broad-spectrum antibiotics, proton pump inhibitor therapy, and a soft-textured diet. Endoscopy was repeated 48 hours later and revealed considerable healing with only a residual 3-4cm linear laceration. Histology of biopsies taken from the mid and distal esophagus demonstrated marked infiltration of intraepithelial lymphocytes. There were no eosinophils or neutrophils identified, consistent with a diagnosis of lymphocytic esophagitis. Autoimmune indices including anti-nuclear antibodies and immunoglobulins were normal, ruling out a contributory autoimmune or connective tissue process. The patient was maintained on a proton pump inhibitor (pantoprazole 40 mg once daily) following discharge. Nearly six months following his presentation, the patient had a recurrence of symptoms prompting representation to the emergency department. He described acute onset chest discomfort while eating turkey. Computed tomography of the chest redemonstrated circumferential intramural gas in the distal esophagus and proximal stomach. Conclusions Esophageal perforation is a potentially life-threatening manifestation of what had been considered and described as a relatively benign condition. From isolated dysphagia to transmural perforation, this case significantly expands our current understanding of the clinical spectrum of lymphocytic esophagitis. Funding Agencies None