Pneumatosis Intestinalis Research Articles

Pneumatosis cystoides intestinalis: a case report and literature review

BackgroundPneumatosis cystoides intestinalis (PCI) is a low-incidence disease that confuses many doctors. A vast number of factors are suspected to contribute to its pathogenesis, such as Crohn’s disease, intestinal stenosis, ulcerative colitis, drug use, extra-gastrointestinal diseases, and chronic obstructive pulmonary disease. Most consider its pathogenesis interrelated to an increase in intra-intestinal pressure and the accumulation of gas produced by aerogenic bacteria, and patients with atypical symptoms and imaging manifestations tend to be misdiagnosed.Case presentationA 64-year-old man complained of a 3-month history of bloody stool without mucopurulent discharge, abdominal pain, or diarrhea. Colonoscopy revealed multiple nodular projections into the segmental mucosa of the sigmoid colon. Crohn’s disease and malignant disease ware suspected first according to the patient’s history, but laboratory examinations did not confirm either. Endoscopic ultrasound (EUS) revealed multiple cystic lesions in the submucosa. Moreover, computer tomography scan showed multiple bubble-like cysts. Combined with ultrasonography, computed tomography, and pathology findings, we ultimately made a diagnosis of PCI. Instead of surgery, we recommended conservative treatment consisting of endoscopy and oral drug administration. His symptoms improved with drug therapy after discharge, and no recurrence was noted on follow-up.ConclusionsThe incidence of PCI is low. Due to a lack of specificity in clinical manifestations and endoscopic findings, it often misdiagnosed as intestinal polyps, tumors, inflammatory bowel disease, or other conditions. Colonoscopy, computed tomography, and ultrasonography have demonstrated benefit in patients with multiple nodular projections in colon. Compared to the treatment of the above diseases, PCI treatment is effective and convenient, and the prognosis is optimistic. Therefore, clinicians should increase their awareness of PCI to avoid unnecessary misdiagnosis.

Presentation and outcomes among inflammatory bowel disease patients with concurrent pneumatosis intestinalis: a case series and systematic review.

Background/AimsInflammatory bowel disease (IBD) involves chronic inflammation of the colon with ulcerative colitis (UC), and the colon and/or small intestine with Crohn’s disease (CD). Pneumatosis intestinalis (PI), characterized by compromise of the intestinal wall with gas-filled cysts, has rarely been reported with IBD. The presentation, best management and outcomes of PI with IBD are poorly defined.MethodsWe conducted a search for PI in all abdominal computed tomography (CT) reports at 2 large tertiary care hospitals from January 1, 2010 to December 31, 2017, cross referenced to ICD codes for IBD. CT and chart review was performed to confirm PI and IBD respectively. A systematic review excluding case reports was performed for PI with IBD for comparison.ResultsOf 5,990 patients with a CT abdomen report mentioning PI, we identified 11 cases of PI with IBD, 4 UC, 6 CD, and 1 indeterminate colitis. PI was limited to the small bowel in 5 patients, the right colon in 5, and small bowel and colonic in 1. All 3 mortalities had CD, small intestinal PI and portal/mesenteric venous gas. The systematic literature search identified 9 articles describing 58 patients with IBD and PI. These cases were mostly included in larger cohorts of PI patients without extractable data on presentation or outcomes in the IBD subpopulation.ConclusionsOurs appears to be the first reporting of presentations and outcomes, outside of case reports, for those with PI and IBD. The high mortality for those with CD and PI of the small bowel appears to define a group requiring more than supportive medical care.

腸管気腫を伴わない腹腔内遊離ガスを呈し，保存的に加療した強皮症の1例(Nonsurgical pneumoperitoneum without pneumatosis cystoides intestinalis in a woman with systemic sclerosis)

要旨 救急医療の現場で腹腔内遊離ガスを認めた際には消化管穿孔を念頭に対応するが，まれに外科的処置を要さないnonsurgical pneumoperitoneumと呼ばれる病態に遭遇する。われわれは腸管気腫を伴わない腹腔内遊離ガスを呈した患者を保存的に治療し，原因として強皮症の診断に至った1例を経験したので報告する。症例は70歳代の女性。全身の浮腫と腹部膨満を主訴に救急搬送された。CTでは上腹部にわずかな腹腔内遊離ガスを認め，腹水と麻痺性イレウスを伴っていたが，呼吸循環は安定していた。腹部所見に乏しいことから上部消化管穿孔疑いとして保存的加療を行った。しかし上部消化管内視鏡やCTの再検でも穿孔部位は特定できなかった。その後，症状の経過，血清学的マーカーや皮膚所見から強皮症の診断に至った。経過は良好で浮腫は消失し退院した。強皮症の患者では，腸管の硬化や繊維化により麻痺性イレウスや腸管気腫症を生じ，ときに腹腔内遊離ガスを来す。本例は腸管気腫症を認めないにも関わらず腹腔内遊離ガスを呈している点が特徴的であった。nonsurgical pneumoperitoneumの症例においては，背景疾患として強皮症を鑑別にあげることは重要である。また，強皮症に特徴的な腸管気腫症を認めずに腹腔内遊離ガスのみを認める非典型例が存在することにも留意する必要がある。

Radiographic predictors determined with an objective assessment tool for neonatal patients with necrotizing enterocolitis

ObjectiveThe objective of this study was to develop and validate a computational tool to assist radiological decisions on necrotizing enterocolitis. MethodologyPatients that exhibited clinical signs and radiographic evidence of Bell's stage 2 or higher were included in the study, resulting in 64 exams. The tool was used to classify localized bowel wall thickening and intestinal pneumatosis using full‐width at half‐maximum measurements and texture analyses based on wavelet energy decomposition. Radiological findings of suspicious bowel wall thickening and intestinal pneumatosis loops were confirmed by both patient surgery and histopathological analysis. Two experienced radiologists selected an involved bowel and a normal bowel in the same radiography. The full‐width at half‐maximum and wavelet‐based texture feature were then calculated and compared using the Mann–Whitney U test. Specificity, sensibility, positive and negative predictive values were calculated. ResultsThe full‐width at half‐maximum results were significantly different between normal and distended loops (median of 10.30 and 15.13, respectively). Horizontal, vertical, and diagonal wavelet energy measurements were evaluated at eight levels of decomposition. Levels 7 and 8 in the horizontal direction presented significant differences. For level 7, median was 0.034 and 0.088 for normal and intestinal pneumatosis groups, respectively, and for level 8 median was 0.19 and 0.34, respectively. ConclusionsThe developed tool could detect differences in radiographic findings of bowel wall thickening and IP that are difficult to diagnose, demonstrating the its potential in clinical routine. The tool that was developed in the present study may help physicians to investigate suspicious bowel loops, thereby considerably improving diagnosis and clinical decisions.

1642 Pelvic Congestion Syndrome: An Unusual Manifestation of Sigmoid Pneumatosis Cystoides Intestinalis

INTRODUCTION: Pneumatosis cystoides intestinalis (PCI) is a rare condition characterized by gas-filled cysts in the intestinal subserosa and submucosa. We present a rare case of primary PCI affecting sigmoid colon complicated by pelvic congestion syndrome (PCS). CASE DESCRIPTION/METHODS: A 34-year-old morbidly obese female presented with diffuse lower abdominal pain and intermittent foamy diarrhea without blood or mucus for the past 5 months. CT abdomen showed small bubbles of gas in the peritoneum in the left upper quadrant and large amount of cystic pneumatosis in a loop of sigmoid colon. Lab work was unremarkable. She was given one week course of antibiotics. A repeat CT scan 5 months later showed interval resolution of free intraperitoneal air but pneumatosis bubbles had enlarged in size. A colonoscopy was performed which showed large cystic-appearing air-filled bullae in sigmoid colon causing some luminal narrowing and the scope could not be safely advanced beyond mid-transverse colon. Patient underwent laparoscopic sigmoid colectomy and intraoperatively noted to have dilated and tortuous bilateral gonadal veins. Surgical pathology showed multiple clear fluid-filled cysts throughout the length of the specimen with viable and unremarkable proximal and distal resection margins. Patient recovered well from surgery and was discharged with no further complaints. DISCUSSION: PCI is an unusual condition caused by a myriad of underlying pathophysiological processes that range from benign to life-threatening conditions. Primary PCI is rare (15%), while underlying conditions for secondary PCI can be divided into several groups; traumatic, mechanical, inflammatory, autoimmune, infectious, pulmonary and drug (steroids and chemotherapeutic agents) induced. Conservative management is preferable except in cases of clinical deterioration. This case is unique because even after the resolution of free intraperitoneal air the patient continued to have lower abdominal and pelvic pain with worsening of pneumatosis on repeat CT scan several months later. It is possible that sigmoid anatomic changes due to pneumatosis resulted in chronic intermittent venous obstruction of pelvic veins leading to gonadal veins dilation and tortuosity and hence secondary PCS which resulted in ongoing lower abdominal pain. This case highlights the fact that persistent PCI, with ongoing abdominal symptoms even in the absence of any obvious etiology warrants laparoscopic exploration to rule out any underlying disease process.

1918 A Case of Recurrent Pneumatosis Intestinalis and Portal Venous Gas

INTRODUCTION: Mesenteric ischemia (MI) is caused by inadequate blood flow through the mesenteric vessels resulting in ischemic bowel. The most serious cases cause gangrenous bowel, leading to pneumatosis intestinalis (PI) and portal venous gas (PVG), often an ominous sign. CASE DESCRIPTION/METHODS: This is a case of a 63-year-old male who presented to the hospital with hematemesis and severe anemia. After massive transfusion, an EGD revealed actively bleeding gastric ulcers, requiring serial EGDs for successful control of bleeding. A CT revealed gastric distention with thickening of the duodenum and bilateral femoral vein opacities, later confirmed as deep vein thromboses. An IVC filter was subsequently placed, as he was not a candidate for anticoagulation. The patient was subsequently discharged on oral pantoprazole. Of note, there was no history of NSAID use or evidence of H. pylori. Repeat EGD 2 months later noted mild gastritis, but no ulcers were seen. A screening colonoscopy at the time noted only diverticulosis. He was continued on pantoprazole. 3 months later he presented to the hospital with acute onset nausea, vomiting, and diarrhea. A CT revealed PI at the gastric fundus, as well as PVG. An infectious work-up was negative, lactate was normal, and his symptoms resolved quickly. A subsequent repeat CT noted resolution of the PVG and reduction in PI. He represented to the hospital 1 month later again with nausea, vomiting, and diarrhea. A CT noted small bowel dilatation with air fluid levels, PI at the esophagus, stomach, and jejunum, and significant PVG. The initial lactate level was mildly elevated and his symptoms resolved quickly after bowel decompression. A subsequent CTA noted a significant reduction in PVG without evidence of vascular occlusion. A follow up EGD showed diffuse subepithelial hemorrhages without any evidence of recurrent ulcers. A subsequent CTE noted a thrombus above the IVC filter and an evolving hepatic infarction. He was asymptomatic at the time, however, he was admitted to the hospital for anticoagulation. He has since remained on warfarin without any recurrence of symptoms, PI, or PVG. A follow-up CTA showed a full resolution of venous thromboses. DISCUSSION: Previous case reports have described the development of PI and PVG secondary to underlying MI. This case highlights an example of MI secondary to an increase in the resistance of mesenteric blood flow due to venous thromboses. When investigating IP and PVG, underlying venous thromboses should always be considered.

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.

Relative factors of transmural intestinal necrosis in acute superior mesenteric vein thrombosis

Objective: To examine the relative factors of transmural intestinal necrosis (TIN) during multidisciplinary stepwise management facilitating the decision making in patients with acute superior mesenteric vein thrombosis (ASMVT). Methods: Clinical data of patients with ASMVT admitted to Department of General Surgery, Jinling Hospital from January 2009 to June 2017 were reviewed retrospectively. There were 52 males and 37 females, aging (45.9 ± 12.6) years (range: 20 to 69 years). According to the postoperative pathological results and follow-up, the patients were divided into TIN group (n=31) and non-TIN group (n=58, including 18 cases of intestinal stricture). The related factors were compared between ASMVT patients with TIN and patients without TIN by univariate analysis using t test, U test and χ(2) test accordingly, and factors with statistically significance were subsequently submitted to binary Logistic regression analysis. The predictive value and cut-off point of factors were evaluated by receiver operator characteristic (ROC) curve and area under the curve. Results: In univariate analysis, smoking, hypertension, peritonitis, white blood cell count,haemoglobin, international normalized ratio, blood albumin, thrombosis of superior mesenteric branches vein, free intraperitoneal fluid, decrease of bowel wall enhancement and pneumatosis intestinalis were TIN risk factors (all P<0.05). According to the binary Logistic regression analysis, white blood cell count (OR=1.093, 95%CI: 1.010 to 1.182, P=0.027), thrombosis of the superior mesenteric branches vein (OR=11.519, 95%CI: 1.906 to 69.615, P=0.008), pneumatosis intestinalis (OR=11.140, 95%CI: 2.360 to 52.585, P=0.002) were independent relative factors of TIN in patients with AMI, and the area under the ROC curve of the above factors and predictive model was 0.759 (95%CI: 0.647 to 0.871), 0.745 (95%CI: 0.641 to 0.848), 0.737 (95%CI: 0.621 to 0.854), 0.909 (95%CI: 0.847 to 0.971), respectively. The cutoff value of white blood cell count was 18.1 × 10(9)/L. Conclusion: White blood cell levels, superior mesenteric vein branch thrombosis and pneumatosis intestinalis are independent predictors of TIN in ASMVT.

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.

1854 Conservative Management of Pneumatosis Cystoides Intestinalis With Pneumoperitoneum in a Scleroderma-Related Illness

INTRODUCTION: Pneumatosis Cystoidea Intestinalis with pneumoperitoneum in scleroderma-related illness could mimic an acute abdomen, presenting with pseudo-obstruction and gas within and outside the intestinal wall in the absence of a true perforation of the intestinal wall. The recognition of the clinical presentation of pseudoobstruction with pneumoperitoneum, due to Pneumatosis Cystoidea Intestinalis is paramount for the clinical decision to manage conservatively and avoid a surgical intervention. CASE DESCRIPTION/METHODS: A 30-year-old female with a 3-year history of limited scleroderma and myositis overlap presented with worsening nausea, vomiting, abdominal pain and bloating for about a week. She had a similar episode about a month prior to presentation, with abdominal imaging showing intestinal wall blebs with pneumoperitoneum, and had undergone an exploratory laparotomy. There was no bowel perforation on exploratory laparotomy and biopsy results showed fibrous tissues lined by reactive mesothelial cells and chronic inflammation. On examination, her abdomen was distended with epigastric tenderness, without guarding or rebound tenderness. An abdominal x-ray and CT scan revealed small bowel obstruction with pneumoperitoneum, features characteristic of Pneumatosis Cystoidea Intestinalis. She was evaluated by gastroenterology, surgery and the rheumatology team, and managed conservatively with intravenous fluids, nasogastric tube decompression, and administration of proton pump inhibitor. Her vital signs were normal and abdominal distension subsided with a resolution of her symptoms after 24 hours of conservative management. She was subsequently able to tolerate diet and was discharged on day 2 of admission with a plan for outpatient follow up. DISCUSSION: The presence of pneumoperitoneum portends a sinister finding in a patient with intestinal obstruction, often requiring surgical intervention. Pneumatosis Cystoides Intestinalis is characterized by micro-perforations of intestinal wall blebs which give rise to pneumoperitoneum, without a true perforation of the intestinal wall. The bacterial overgrowth and mechanical theory are both highlighted as mechanisms for the loss of integrity of the intestinal intimal layer, resulting in leakage and formation of gas within the intestinal wall. However, in the absence of acute peritonitis, abdominal abscess, and a worsening clinical status, Pneumatosis Cysotiodea Intestinalis can be managed conservatively in spite of a pseudo-obstruction with pneumoperitoneum.

2615 Treating Gas With Gas: A Case of Benign Extensive Pneumatosis Intestinalis

INTRODUCTION: Radiological evidence of extensive gas collections in the bowel wall and, particularly, the portal vein commonly suggests a life-threatening process. We present a patient with massive intramural and portal gas that was adjudged to be of benign origin and managed conservatively with high flow nasal oxygen. CASE DESCRIPTION/METHODS: A 74-year-old male with a history of coronary artery bypass surgery and a 40 pack-year history of smoking was admitted with a two-week history of abdominal discomfort with food ingestion, bloating and belching. History was negative for gastrointestinal bleeding, prior abdominal surgeries or fever. On examination, he was afebrile, hemodynamically stable, and had no abdominal tenderness, rebound or guarding. Initial laboratory measurements were normal and notable for normal white blood cell count of 9180/mm3 and a lactic acid of 1.8 mmol/L. A stool exam for pathogens was obtained. A Computed tomography (CT) scan of the abdomen showed extensive pneumatosis involving the upper small intestine and the stomach, and a relatively massive collection of portal venous gas (see Figure 1). He was admitted to the hospital with the diagnosis of possible ischemia of the small bowel and/or stomach. Despite the ominous abdominal imaging findings, he had a normal physical exam and lack of evidence of sepsis which suggested a benign etiology of the pneumatosis. The patient was essentially asymptomatic throughout his 6-day hospital course. The stool screen for 20 pathogens revealed enteropathogenic E. coli. On the second day of hospitalization, high inhalational oxygen (&gt;50%) via nasal cannula was instituted in addition to an elemental diet. A repeat CT scan on day 5 of hospitalization showed virtually complete resolution of intramural small bowel and gastric gas, and only small residual portal venous gas remained. He was discharged home on antibiotics for 3 weeks and has continued to do well DISCUSSION: Pneumatosis intestinalis should be recognized as a clinical sign and not a diagnosis and should warrant careful review of the clinical context, signs/symptoms and laboratory data. The counter-perfusion supersaturation theory has been proposed as the pathophysiology in most benign cases. It involves increased hydrogen production by intestinal bacteria which supersedes the nitrogen tension in the blood stream. High flow or hyperbaric oxygen may help in the establishment of a nitrogen gradient between intramural gas and blood with improvement of intramural gas

1619 Not All Intra-Peritoneal Free Air Is Created Equal. Pneumatosis Cystoides Intestinalis Causing Massive Pneumoperitoneum After a Colonoscopy, a Benign Finding

INTRODUCTION: Pneumoperitoneum is the presence of free air in the peritoneal cavity. Visceral perforation, obstruction, and infection are the most ominous causes and usually present with signs of acute peritonitis requiring emergent surgery. CASE DESCRIPTION/METHODS: A 60-year-old man was found to have extensive colonic wall bullae (pneumatosis coli) in the transverse colon during a colonoscopy (Figure 1). Contrast-enhanced abdominal computed tomography (CT) 6 days later detected free air in the peritoneal cavity, the umbilical subcutaneous fat, and pneumatosis intestinalis in the distal transverse colon (Figure 2). Patient reported mild abdominal distension which quickly improved, otherwise he was asymptomatic. His abdomen was distended, but benign with no signs of peritoneal irritation. His laboratory work was unremarkable with normal white blood cell count and lactic acid. He was managed conservatively with nothing by mouth, intravenous fluids and systemic antibiotic therapy. He completed a 10-day course of antibiotics at home. A CT abdomen 2 months later showed complete resolution of the pneumoperitoneum (Figure 3). DISCUSSION: Prompt diagnosis of pneumoperitoneum and its cause is crucial, and it may require timely surgical intervention. However, there are causes of pneumoperitoneum that do not require surgery; these cases must be readily distinguished. One of the etiologies of asymptomatic pneumoperitoneum is rupture of the sub-serosal cysts present in the colonic wall of patients with idiopathic pneumatosis cystoides intestinalis. Primary pneumatosis intestinalis (15% of cases) is a benign idiopathic condition in which thin-walled cysts develop in the submucosa or subserosa of the colon. The secondary form (85% of cases) is associated with obstructive pulmonary disease, as well as with obstructive and necrotic gastrointestinal disease, infection, inflammatory bowel disease, medication-induced (chemotherapy and steroid), autoimmune disease, immunosuppression, and connective tissue disorders. In conclusion, intraperitoneal air is not always related to life-threatening conditions e.g. visceral perforation requiring invasive interventions; sometimes it is related to benign causes, one of them which we mentioned in our case. Therefore, the correlation should be made with the clinical presentation, frequent abdominal exams, imaging findings, and laboratory tests to prevent unnecessary interventions.

1546 Idiopathic Myointimal Hyperplasia of Mesenteric Veins: A Rare Cause of Treatment Refractory Colitis

INTRODUCTION: Idiopathic myointimal hyperplasia of mesenteric veins (IMHMV) is a rare disease which mimics inflammatory bowel disease (IBD) clinically and endoscopically while showing ischemic changes without classic features of IBD on pathology. Delay in diagnosis is common; definitive diagnosis is usually only feasible after surgical resection. CASE DESCRIPTION/METHODS: A 62-year-old male with a past medical history of hypertension and hyperlipidemia presented with a 1-year history of recurrent abdominal pain, bloody diarrhea, and rectal pain. He was initially evaluated at another hospital and diagnosed with pneumatosis intestinalis and left-sided colitis. Left colon biopsies were suggestive of ischemia but computerized tomography angiogram (CTA) revealed patent mesenteric arteries. Extensive workup for thrombophilia, infectious, inflammatory, and autoimmune etiologies were negative. His symptoms did not respond to antibiotics and oral steroids. He presented to our institution for a second opinion. At presentation, he was diaphoretic, afebrile and in distress. Physical exam was significant for lower abdominal tenderness without peritoneal signs. Laboratory investigations revealed elevated inflammatory markers (Table 1). Repeat CTA showed patent mesenteric arteries. Colonoscopy revealed severe inflammation and congestion extending from the mid-transverse colon to the rectum. The terminal ileum and ascending colon were normal. Biopsies from inflamed mucosa revealed ischemic colitis with fibrinoid microvascular wall necrosis and fibrin thrombi (Figure 1). He was started on IV Methylprednisolone 40 mg daily but symptoms progressed despite IV steroids. He underwent total colectomy with end ileostomy which was curative. Histopathological analysis of the resected colon confirmed IMHMV. DISCUSSION: Current opinion suggests that IMHMV is caused by non-inflammatory, non-thrombotic obliteration of medium-to-large size mesenteric veins. IMHMV is a difficult diagnosis to make preoperatively. However, preoperative diagnosis is suggested by the presence of arterialized capillaries, subendothelial fibrin deposits and fibrin thrombi on endoscopic biopsies. IMHMV is typically refractory to steroids and biologics. Gastroenterologists and pathologists should have a high index of suspicion for IMHMV in patients with treatment refractory colitis, negative mesenteric angiography and colon biopsies showing ischemic changes without classic features of IBD. Colectomy is usually curative without recurrence of symptoms.

Predicting Surgical Intervention in Pneumatosis Intestinalis

Predicting Surgical Intervention in Pneumatosis Intestinalis

2775 Intragastric Balloon Hyperinflation: A Rare Cause of a Palpable Abdominal Mass

INTRODUCTION: Intragastric balloons (IGB) are commonly being used for the treatment of obesity, with increasing data confirming their effectiveness. While usually well tolerated with rare adverse events, IGBs have been associated with complications including visceral perforation, pancreatitis and bowel obstruction. IGB hyperinflation, which occurs due to an abnormal accumulation of gas within IGB is rare. We present a case of a patient with abdominal pain and vomiting after recent IGB placement, found to have a palpable abdominal mass. CASE DESCRIPTION/METHODS: A 35-year-old female with class II obesity (BMI: 33 kg/m2) and recently placed adjustable IGB in the Dominican Republic presented to our emergency department with abdominal fullness, vomiting and inability to keep food down. The IGB had been placed for two months with reported 30 lbs weight loss. She denied fevers, dysphagia, hematemesis, melena or altered bowel movements. She was afebrile with normal vital signs. Physical examination revealed a palpable round-like mass in her epigastric region with tenderness to palpation. Laboratory workup, including complete blood count, basic metabolic panel, liver function tests and lipase were normal. CT scan of the abdomen and pelvis revealed a gas-filled hyperinflated IGB within the distal portion of the stomach with dilation proximally representing possible gastric outlet obstruction. There was no evidence of perforation or pneumatosis intestinalis [Figure 1a–c]. Due to her symptoms, and the patient’s wishes to have the balloon removed, endoscopy was performed. Endoscopy revealed a hyperinflated, adjustable IGB occupying two thirds of the gastric body and obstructing the gastric antrum. The balloon appeared mottled suggesting fungal colonization from the outside with food debris. Attention was then placed on balloon removal. Successful removal of 500cc of blue-colored fluid mixed with air was performed resulting in IGB deflation and subsequent retrieval. The patient did well with resolved symptoms and was discharged the next day. DISCUSSION: Intragastric balloon hyperinflation should be recognized as a possible complication of IGB placement and may be due to balloon permeability or gas-producing anaerobic bacteria. Patients usually present with nausea, vomiting and inability to tolerate oral intake and if left untreated can result in dire consequences. Imaging may assist with diagnosis. Treatment involves endoscopic IGB removal. In cases of adjustable IGB, deflation and fluid exchange can be considered.

Transmural Bowel Necrosis From Acute Mesenteric Ischemia and Strangulated Small-Bowel Obstruction: Distinctive CT Features.

OBJECTIVE. The purpose of this study was to assess whether transmural bowel necrosis has distinct CT features based on the three main causes: occlusive acute mesenteric ischemia (AMI), nonocclusive AMI, and strangulated small-bowel obstruction (SBO). MATERIALS AND METHODS. From January 2010 to December 2017, the records of all patients with a pathologic diagnosis of transmural bowel necrosis were extracted from the pathology department database of a university hospital. The inclusion criteria for the study were presence of transmural bowel necrosis at pathologic examination and available contrast-enhanced CT images obtained within the 24 hours before surgery. Seventy-seven patients were finally included. The CT scans were retrospectively independently reviewed by two abdominal radiologists to identify the classic CT findings of transmural bowel necrosis. Statistical analyses were performed. RESULTS. Pneumatosis intestinalis was statistically more frequent in nonocclusive AMI (59%) than in occlusive AMI (29%) and strangulated SBO (7%) (p < 0.01), as were superior mesenteric venous gas (55%, 29%, and 0%; p < 0.01) and portal venous gas (48%, 10%, and 0%; p < 0.01). Decreased or absent bowel wall enhancement was more frequent in AMI than in SBO (nonocclusive AMI, 83%; occlusive AMI, 81%; SBO, 56%; p = 0.02), as was thinned bowel wall (nonocclusive AMI, 52%; occlusive AMI, 48%; SBO, 18%; p = 0.02). Spontaneous hyperattenuation of the bowel wall was more frequent in strangulated SBO (41%) than in nonocclusive AMI (10%) and occlusive AMI (14%) (p < 0.01). CONCLUSION. Transmural bowel necrosis has distinct CT findings according to its three main causes. Occlusive AMI is characterized by an absence of bowel wall enhancement and less mesenteric fat stranding, nonocclusive AMI by a high prevalence of pneumatosis intestinalis and portal venous gas, and strangulated SBO by spontaneous hyperattenuation of the bowel wall and an absence of pneumatosis intestinalis and portal venous gas.

EFSUMB Gastrointestinal Ultrasound (GIUS) Task Force Group: Celiac sprue and other rare gastrointestinal diseases ultrasound features

Transabdominal gastrointestinal ultrasound (GIUS) is unique in its capacity to examine the bowel non-invasively and in its physiological condition, including extra-intestinal features such as the splanchnic vessels, mesentery, omentum and lymph nodes- even at the bedside. Despite this, and its extensive documentation for its usefulness, it has only been fully implemented in a few European countries and expert centres. Therefore, the European Federation of Societies for Ultrasound in Medicine and Biology (EFSUMB) established a GIUS Task Force Group in 2014 consisting of international experts from 9 European countries with the objectives to standardize and promote the use of GIUS in a clinical setting. This is achieved by publishing clinical guidelines and recommendations on indications and use of GIUS and so far,4 guidelines have been published: first on "examination techniques and normal findings", second on "inflammatory bowel disease", third on "acute appendicitis and diverticulitis" and fourth on "transrectal and perineal ultrasound".This paper describes the ultrasound features of miscellaneous disorders such as celiac disease, cystic fibrosis, omental infarction, Meckel's diverticle, endometriosis, intestinal neoplasia, mucocele, amyloidosis, GVHD, foreign bodies, vasculitis, and pneumatosis cystoides intestinalis. Bowel ultrasound can be indicated in most of these conditions to investigate intestinal symptoms but in other cases the alterations of the bowel can be also an incidental finding that suggest other examinations which finally help to discover an unknown pathological condition.

Gastric and intestinal pneumatosis

Gastric and intestinal pneumatosis

Outcomes and clinical characteristics of transmural intestinal necrosis in acute mesenteric ischemia

Background: Acute mesenteric ischemia (AMI) is a rare life-threatening condition, especially for the patients with transmural intestinal necrosis (TIN). However, the optimal time for surgical intervention is controversial. As a series study, this study aimed to identify the outcomes and clinical characteristic of patients with TIN.Methods: Clinical data of 158 patients with AMI from January 2010 to December 2017 were retrospectively analyzed in a national gastrointestinal referral center in China to confirm the outcomes and identify predictors for TIN.Results: According to the results of pathological assessment and follow-up, 62 patients were TIN and 96 were non-TIN. Patients with TIN have a higher mortality and incidence of severe complications. The significant independent predictors for TIN were arterial lactate level (OR: 4.76 [2.29 ∼ 9.89]), free intraperitoneal fluid (OR: 9.49 [2.56 ∼ 35.24]) and pneumatosis intestinalis (OR: 7.08 [1.68 ∼ 29.82]) in computed tomography (CT) scan imaging. The overall area under the receiver operating characteristics (ROC) curve of the model was 0.934 (95% confidence interval: 0.893 ∼ 0.974). Using ROC curve, the cutoff value of arterial lactate level predicting the onset of TIN was 2.65 mmol/L.Conclusions: Patients concomitant with TIN manifest a higher risk of poor prognosis. The three predictors for TIN were arterial lactate level >2.65 mmol/L, free intraperitoneal fluid and pneumatosis intestinalis. Close monitoring these predictors would help identify AMI patients developed TIN and in urgent need for bowel resection.

Application of abdominal sonography in diagnosis of infants with necrotizing enterocolitis.

The purpose of this study was to explore the diagnostic significance of abdominal sonography (AUS) in infants with Necrotizing enterocolitis (NEC) admitted to a neonatal intensive care unit to better evaluate the ability of AUS to differentiate necrotizing enterocolitis from other intestinal diseases.All patients diagnosed with NEC at the Department of General Surgery and Neonatal Surgery, Qilu Children‘s Hospital between 1st, Jun, 2010 and 30th, Dec, 2015. The logistic regression analysis and the area under receiver operating characteristic (ROC) curve (AUCs) were also used to identify the sonographic factors for diagnosing NEC.For the entire cohort of 91 patients, we divided these patients into suspected NEC (n = 35) group and definite NEC (n = 56) group. After adjusting for competing sonographic factors, we identified that thick bowel wall (more than 2.5 mm) (P = .013, OR: 1.246), intramural gas (pneumatosis intestinalis) (P = .002, OR:1.983), portal venous gas (P = .022, OR:1.655) and reduced peristalsis (P = .011, OR:1.667) were independent diagnostic factors associated with NEC. We built a logistic model to diagnose NEC according to the results of multivariable logistic regression analysis. We found the AUROC for thick bowel wall (more than 2.5 mm), intramural gas (pneumatosis intestinalis), portal venous gas and reduced peristalsis were significantly lower than the AUROC for the logistic model was 0.841 (95% CI: 0.669 to 0.946).We found that thick bowel wall (more than 2.5 mm), intramural gas (pneumatosis intestinalis), portal venous gas and reduced peristalsis were independent diagnostic factors associated with NEC. The logistic model was significantly superior to the single sonographic parameter for diagnosing NEC.