Pneumatosis Intestinalis Research Articles

Hepatisch portaal veneus gas in combinatie met pneumatosis intestinalis op basis van dunnedarmischemie

Hepatic portal venous gas in combination with pneumatosis intestinalis based on small-bowel ischemia: a case-report A 76-year-old man presented with complaints of abdominal pain and vomiting. An urgent CT scan showed pneumatosis intestinalis of the small intestine with air in the portal vein and the portal venules of the left hepatic lobe. Hepatic portal venous gas is a rare radiological finding: gas is found in the portal venous branches. This can be seen in both benign and life-threatening conditions. In most cases, it is accompanied by underlying intestinal ischemia, which was also the case in this patient. The patient underwent urgent surgery with a partial resection of the small intestine. After a brief admission to the intensive care unit, the man recovered well and was able to leave the hospital in good health.

Hepatic Portovenous Gas in a Young Male

Hepatic portal venous gas is diagnosed via computed tomography due to unusual imaging features. Hepatic portal venous gas when linked with pneumatosis intestinalis has a high mortality rate and required urgent intervention. We present a case of a 35 year-old male patient with a 12 hour history of generalised abdominal pain, watery diarrhoea and vomiting. He had a background of gout and alcoholism. He had an unmeasurable blood pressure and sinus tachycardia when he was first seen. The patient was stabilized after undergoing vigorous intravenous fluid resuscitation, and he was then sent for a CT scan. A considerable amount of hepatic portovenous gas was seen on the CT scan, coupled with dilated and diffusely aberrant small and large bowel with mucosal enhancement.

Identifying Preoperative Clinical Characteristics of Unexpected Gastrointestinal Perforation in Infants-A Retrospective Cohort Study.

Infants presenting with unexpected pneumoperitoneum upon abdominal X-ray, indicating a gastrointestinal perforation (GIP), have a surgical emergency with potential morbidity and mortality. Preoperative determination of the location of perforation is challenging but will aid the surgeon in optimizing the surgical strategy, as colon perforations are more challenging than small bowel perforations. Therefore, the aim of this study is to provide an overview of preoperative patient characteristics, determine the differences between the small bowel and colon, and determine underlying causes in a cohort of infants with unexpected GIP. All infants (age ≤ 6 months) who presented at our center with unexpected pneumoperitoneum (no signs of pneumatosis before) undergoing surgery between 1996 and 2024 were retrospectively included. The differences between the location of perforation were analyzed using chi-squared and t-tests. Bonferroni correction was used to adjust for multiple tests. In total, 51 infants presented with unexpected pneumoperitoneum at our center, predominantly male (N = 36/51) and premature (N = 40/51). Among them, twenty-six had small bowel, twenty-two colon, and three stomach perforations. Prematurity (p = 0.001), birthweight < 1000 g (p = 0.001), respiratory support (p = 0.001), and lower median arterial pH levels (p = 0.001) were more present in patients with small bowel perforation compared with colon perforations. Pneumatosis intestinalis was more present in patients with colon perforation (p = 0.004). All patients with Hirschsprung disease and cystic fibrosis had colon perforation. The final diagnoses were mainly focal intestinal perforations (N = 27/51) and necrotizing enterocolitis (N = 9/51). Infants with unexpected GIP, birthweight < 1000 g, and prematurity have more risk for small bowel perforation. In case of colon perforation, additional screening (for Hirschsprung and cystic fibrosis) should be considered.

NSAID-induced gastropathy in a comorbid patient in a multidisciplinary hospital

The purpose of this case report is to demonstrate the importance of outpatient management of nonsteroidal anti-inflammatory drugs (NSAIDs) in patients, especially those at risk (elderly patients, alcohol abusers, patients with a history of peptic ulcer disease, patients taking glucocorticoids or anticoagulants) to avoid life-threatening complications. The following clinical case shows the association between gastric and duodenal mucosal barrier disruption and the use of nonsteroidal anti-inflammatory drugs. Methods: a complete blood count, blood biochemistry test, ultrasound, and abdominal radiography. Results. The clinical case describes a patient with coronary heart disease, ischemic cardiomyopathy, hypertension, permanent atrial fibrillation, impaired glucose tolerance, obesity, and a long history of smoking who had been taking 1–2 tablets of Nimesulide per day for a long time without doctor’s prescription; the intake of NSAIDs was not controlled on an outpatient basis. The reason for hospitalization was sharp pain in the epigastrium; the plain abdominal radiography in the emergency room revealed free gas below both domes of the diaphragm, and ultrasound examination of the abdominal cavity showed a level of inhomogeneous free fluid detected in all sloping areas and pneumatosis intestinalis. In this regard, the patient was urgently hospitalized to the department of surgery, where surgical intervention was performed, including upper-middle laparotomy, abdominoscopy, suture repair of the perforated gastric ulcer, and sanitation and drainage of the abdominal cavity. Conclusion. This clinical case draws attention to the problem of NSAID gastropathy in clinical practice. The task of a clinician is to prevent the development of NSAID-induced gastropathy, identify patients with risk factors for NSAID gastropathy at the earliest possible time, and carry out preventive and therapeutic measures. Patient management at the outpatient stage according to the clinical recommendations could have prevented the development of gastrointestinal bleeding associated with NSAID gastropathy.

Low-risk pneumatosis intestinalis in the pediatric surgical population.

Pneumatosis intestinalis (PI, presence of air in bowel wall) develops in a variety of settings and due to a variety of insults which is then characterized by varying severity and clinical course. Anecdotally, many of these cases are benign with few clinical sequelae; however, we lack evidence-based guidelines to help guide management of such lower-risk cases. We aimed to describe the clinical entity of low-risk PI, characterize the population of children who develop this form of PI, determine if management approach or clinical outcomes differed depending on the managing physician's field of practice, and finally determine if a shortened course of NPO and antibiotics was safe in the population of children with low-risk PI. We performed a retrospective review of all children over age 1year treated at Children's Hospital Colorado (CHCO), between 2009 and 2019 with a diagnosis of PI who did not also have a diagnosis of cancer or history of bone marrow transplant (BMT). Data including demographic variables, clinical course, and outcomes were obtained from the electronic medical record. Low-risk criteria included no need for ICU admission, vasopressor use, or urgent surgical intervention. Ninety-one children were treated for their first episode of PI during the study period, 72 of whom met our low-risk criteria. Among the low-risk group, rates of complications including hemodynamic decompensation during treatment, PI recurrence, Clostridium difficile colitis, and death did not differ between those who received 3days or less of antibiotics and those who received more than 3days of antibiotics. Outcomes also did not differ between children cared for by surgeons or pediatricians. Here, we define low-risk PI as that which occurs in children over age 1 who do not have a prior diagnosis of cancer or prior BMT and who do not require ICU admission, vasopressor administration, or urgent surgical intervention. It is likely safe to treat these children with only 3days of antibiotic therapy and NPO. Level III.

Pneumatosis intestinalis as a manifestation of chronic intestinal volvulus: case report

The pneumatosis cystoides intestinalis (PCI) is a rare disease characterized by presence of gaseous cysts containing nitrogen, hydrogen and carbon dioxide in the intestinal wall that can be idiopathic or associated with other diseases. There are 5 theories about the pathophysiology: mechanic (obstruction), immunosuppression (atrophy of Peyer's patches), bacterial (Clostridium spp.), pulmonary (chronic pulmonary disease) and chemical (exposure to trichloroethylene). The aim of this paper is to present a clinical case of a patient with rheumatic comorbidity admitted to the emergency service and diagnosed with acute abdomen secondary to intestinal volvulus associated with pneumatosis intestinalis.

Pneumatosis Cystoides Intestinalis with Fatal Air Embolism after Minor Blunt Abdominal Trauma in a 6-Year-Old Girl Undergoing Hematopoietic Stem Cell Trasplant: Case Report and Review of Literature.

Pneumatosis Cystoides Intestinalis with Fatal Air Embolism after Minor Blunt Abdominal Trauma in a 6-Year-Old Girl Undergoing Hematopoietic Stem Cell Trasplant: Case Report and Review of Literature.

Comparing two different Protocols in Withholding Feeds around time of Packed Red Cell Transfusion and Occurrence of TANEC (Transfusion Associated Necrotizing Enterocolitis) in Preterm Neonates

Background: Necrotizing enterocolitis (NEC) is a gastrointestinal disease characterized by pneumatosis intestinalis, pneumoperitoneum, or intestinal necrosis accompanied by signs or symptoms of shock. Our study aims to determine incidence of occurrence of NEC in preterm neonates after red blood cell transfusion with different feeding protocols and to assess the value of withholding feeds around the pRBCs transfusion in decreasing the incidence of transfusion associated necrotizing enterocolitis (TANEC). Methods: The study was done on 90 preterms who received packed red blood cells (pRBCs) during their admission in the neonatal intensive care unit (NICU). Theywere divided in two groups according to different feeding protocols; Group (A): 45 preterms where only one feed was withheld during pRBCs transfusion and Group (B): 45 preterms where feeds were withheld 4 hours before till 4 hours after pRBCs transfusion. Results: The incidence of transfusion related NEC (positive TANEC) in preterm neonates and other complications of prematurity such as (intracranial hemorrhage (ICH), bronchopulmonary dysplasia (BPD), patent ductus arteriosus (PDA), retinopathy of prematurity (ROP) and pneumothorax in group (A) were relatively higher than those of group (B). Conclusion: The modulation of feeding protocol and necessity of keeping nothing per oral (NPO) before, during and after blood transfusion. Significant risk factors for NEC occurrence are feeding preterm before and after pRBCS transfusion, low birth weight, low gestational age, low APGAR score.

Necrotizing Enterocolitis Complicating Severe RSV Bronchiolitis in PICU Settings.

This retrospective study aims to analyze the baseline characteristics and factors associated with poor outcomes in patients with necrotizing enterocolitis (NEC) complicating respiratory syncytial virus (RSV) infection. Using the Virtual Pediatric Systems data registry, patients under 2 years admitted to the pediatric intensive care unit (PICU) were screened. Patients with documented RSV infection and NEC, intestinal perforation, noninfectious gastroenteritis/colitis, or pneumatosis intestinalis occurring around the timing of RSV bronchiolitis diagnosis were included. Out of the screened patients, 41 were analyzed. Most patients (93%) were aged 30 days to 2 years, one-third had baseline anatomical cardiac defects, and 20% history of prematurity. Median PICU length of stay was 11.7 days. Seven patients died before hospital discharge. While not statistically significant, nonsurvivors tended to exhibit higher PRISM-3 scores, more acidemia, and lower systolic blood pressure. These findings emphasize the need for cautious assessment of gastrointestinal symptoms in critically ill patients with RSV infection.

The Challenge of Pneumatosis Intestinalis: A Contemporary Systematic Review.

Pneumatosis intestinalis is a radiological finding with incompletely understood pathogenesis. To date, there are no protocols to guide surgical intervention. A systematic review of literature, according to PRISMA criteria, was performed. Medline and PubMed were consulted to identify articles reporting on the items "emergency surgery, pneumatosis coli, and pneumatosis intestinalis" from January 2010 up to March 2022. This study has not been registered in relevant databases. A total of 1673 patients were included. The average age was 67.1 ± 17.6 years. The etiology was unknown in 802 (47.9%) patients. Hemodynamic instability (246/1673-14.7% of the patients) was associated with bowel ischemia, necrosis, or perforation (p = 0.019). Conservative management was performed in 824 (49.2%) patients. Surgery was performed 619 (36.9%) times, especially in unstable patients with bowel ischemia signs, lactate levels greater than 2 mmol/L, and PVG (p = 0.0026). In 155 cases, surgery was performed without pathological findings. Many variables should be considered in the approach to patients with pneumatosis intestinalis. The challenge facing the surgeons is in truly identifying those who really would benefit and need surgical intervention. The watch and wait policy as a first step seems reasonable, reserving surgery only for patients who are unstable or with high suspicion of bowel ischemia, necrosis, or perforation.

Outcomes of patients with pneumatosis intestinalis and/or portal venous gas: a study of factors associated with survival and surgical intervention.

This study investigated the incidence of, and mortality and management outcomes following, pneumatosis intestinalis and/or portal venous gas on computed tomography. A retrospective study of patients identified with pneumatosis intestinalis and/or portal venous gas on computed tomography at a quaternary centre (2013-2021) was performed. Data relating to clinical presentation (including quick sequential organ failure assessment score), co-morbidities (Charlson Comorbidity Index), biochemical data (including peak lactate level), and radiological findings, were obtained. Factors associated with these were assessed by logistic regression. From 16 428 scans, 107 (0.65%) demonstrated pneumatosis intestinalis and/or portal venous gas (mean 65.2 years [SD 15.2]; 60 [56%] male). Overall, 37 patients (35%) had both findings present. Thirty-three deaths (31%) were recorded. Fifty-four patients (51%) underwent surgery. Death was associated with quick sequential organ failure assessment score (score 1: OR 5.71, 95% CI 1.31-24.87; score 2: OR 10.00, 95% CI 1.94-51.54), Charlson Comorbidity Index ≥5 (OR 2.86, 95% CI 1.19-6.84), peak lactate ≥2.6 mmol/L (OR 14.53, 95% CI 4.39-48.14), and concomitant pneumatosis intestinalis and portal venous gas (OR 8.25, 95% CI 3.04-22.38). The presence of free peritoneal fluid (OR 3.23, 95% CI 1.44-7.28) or perforated viscus (OR 5.10, 95% CI 1.05-24.85) were the only predictors for surgery. Pneumatosis intestinalis and portal venous gas are rare findings. Despite traditionally portending a poor prognosis, mortality occurred in only one-third of patients. There were clear indicators of mortality viz. sepsis severity, comorbidities, and concomitant pneumatosis intestinalis and portal venous gas. Factors predicting surgery warrant further investigation.

Pneumatosis Intestinalis and Pneumoperitoneum After Lung Transplantation: Single-Center Experience and Systematic Review.

Background: Pneumatosis intestinalis (PI) and pneumoperitoneum are some of the complications after lung transplantation (LT). But only limited reports are published. The purpose of this study is to review our experience and perform a systematic review to discuss the possible causes, risk factors, and management. Methods: We reviewed the characteristics, management, and outcome of the patients who developed PI or pneumoperitoneum after LT in our institution from 2013 to 2022. We also performed a systematic review to discuss the management and outcome. Results: PI and pneumoperitoneum were found in 15 out of 729 patients (2.06%) in our institution. We also found 50 patients in the systematic review. Tracheostomy was performed in 40% and gastrointestinal procedures were performed in 55.6%. Laparotomy was performed in 23.4%. A total of 44.6% of patients had benign physical exams or no symptoms. Rejection was seen in 42.9%. A total of 28.6% of patients died during follow-up periods. Conclusions: This report has the largest number of patients so far with PI and pneumoperitoneum after LT. These conditions have a high rejection and high mortality rate. Mechanical ventilation, tracheostomy, gastrointestinal procedure, CMV infection, Clostridium difficile (C. difficile) infection, and immunosuppression can be the risk factors, and the management includes laparotomy or conservative management. It is generally recommended to proceed with laparotomy if patients have portal venous gas, elevated white blood cell count, elevated lactic acid level, decreased bicarbonate level, elevated amylase level, metabolic acidosis, abdominal tenderness, or abdominal distension. Otherwise, most of the patients recover with conservative management with nil per os (NPO), metronidazole, ganciclovir, antibiotics, high-flow oxygen, and holding mycophenolate mofetil (MMF).

Pneumatosis cystoides intestinalis: a case report and literature review

Pneumatosis cystoides was first described by Du Vernay in 1783. This is a fairly rare disease with nonspecific symptoms and CT data on pneumoperitoneum. The authors present pneumatosis intestinalis in a patient with systemic connective tissue disorder. Free gas in abdominal cavity and dilated intestinal loops were an indication for emergency surgery with subsequent resection of intestine due to signs of ischemic damage. A review of clinical cases allows us to conclude that pneumoperitoneum requires careful differential diagnosis. Free gas in abdominal cavity in patients with cystic pneumatosis is an indication for emergency surgery only in case of complicated course of disease.

Intestinal cystic pneumatosis: A case report

Intestinal cystic pneumatosis: A case report

Yield of abdominal radiographs in children with suspected intussusception; rate of pneumoperitoneum and other abdominal pathology

ObjectivesUltrasound is the criterion standard imaging modality for the diagnosis of intussusception. However, to our knowledge the utility of abdominal radiographs to concurrently screen for pneumoperitoneum or other abdominal pathology that could have a similar presentation has not been studied. Our institutional protocol requires the performance of AP supine and left lateral decubitus views of the abdomen prior to ultrasound evaluation for intussusception, providing an opportunity to examine the yield of abdominal radiographs in this setting.Our primary objective was to determine the rate of pneumoperitoneum on screening abdominal radiographs in children undergoing evaluation for intussusception. Our secondary objective was to determine the rate that other clinically significant pathology is found on these screening abdominal radiographs. MethodsWe performed a retrospective chart review of all patients under 6 years of age who had any imaging ordered in our large urban pediatric emergency department to evaluate for suspected intussusception during the calendar years 2018–2020. Results1115 patient encounters met our inclusion criteria. Among 1090 who had screening abdominal radiographs, 82 (8%) had findings concerning for intussusception. Of those not concerning for intussusception, 635 (58%) were read as normal, 263 (24%) showed moderate to large stool burden, 107 (10%) showed generalized bowel distention, and 22 (2%) showed abnormal gastric distention. Individually the remainder of all other findings compromised <1% of encounters and included radiopaque foreign body (8), intraabdominal calcification (4), pneumonia/effusion (3), pneumatosis intestinalis, abdominal mass (2), diaphragmatic hernia (1), rib fracture (1), appendicolith (1), feeding tube malposition (1), and bowel wall thickening (1). In one encounter the patient had a bowel perforation with pneumoperitoneum present secondary to ingestion of multiple magnets. ConclusionsOur study indicates that radiograph-detected pneumoperitoneum is rare in children with suspected intussusception. Constipation is the most common abnormal finding on screening radiographs. Other findings occur in approximately 15% of total cases, some of which require further workup.

Status Epilepticus Complicated by Pneumatosis Intestinalis.

Status Epilepticus Complicated by Pneumatosis Intestinalis.

Presence of Portomesenteric Venous Gas and Pneumatosis Intestinalis in Nonocclusive Mesenteric Ischemia as a Complication of Transrectal Ultrasound-Guided Prostate Biopsy

ABSTRACT A 58-year-old man with a history of mechanical aortic valve replacement, on anticoagulation with warfarin, presented to the emergency department with hematochezia 1 day after undergoing transrectal ultrasound-guided prostate biopsy. On presentation, he was found to have hemorrhagic shock. Fluid resuscitation, packed red blood cell transfusion, and empiric antibiotic therapy were initiated, and the patient was admitted to an intensive care unit. Abdominal-pelvic computed tomography demonstrated portomesenteric venous gas and pneumatosis intestinalis. Colonoscopy showed ischemic ulcers at the ascending colon and stigmata of recent bleeding at the site of biopsy in the rectum, which was treated endoscopically. The patient was discharged after continued improvement during hospitalization. On follow-up, the patient continued to be symptom-free, and a repeat colonoscopy demonstrated healing colonic ulcers.

Nailfold capillary dropout precedes the presentation of pneumatosis intestinalis and micro-perforation in juvenile dermatomyositis

Juvenile dermatomyositis (JDM) is a rare autoimmune disease characterized by chronic inflammation of the skin and muscle vasculature. Loss of nailfold capillary end row loops (ERL) is associated with disease activity. We now present the first report of serious gastrointestinal (GI) events in two JDM patients, both preceded by a precipitous drop in their ERL, which contributes to the consideration of JDM as a member of the vasculitis group of myopathies. These cases demonstrate that the sudden and significant loss of ERL density appears to be a novel and reliable indicator of severe systemic microangiopathy, including gastrointestinal vasculopathy, in selected children with JDM.

Northern State Medical University; Arkhangelsk Regional Children’s Clinical Hospital named after P. G. Vyzhletsov

Intestinal cystous pneumatosis is a rare pathology in pediatric practice, accompanied by a nonspecific clinical picture, which greatly complicates the diagnosis. The literature describes isolated cases of the development of this condition in oncohematological patients of childhood. Intestinal cystous pneumatosis in them can be complicated by life-threatening conditions, and therefore the choice of the correct tactics for managing these patients significantly affects survival. This article describes 2 clinical cases when cystic pneumatosis of the intestine developed during the treatment of an oncological disease.

Unraveling the Clinical Spectrum: A Case Study of Classic and Aplasia-Related Paroxysmal Nocturnal Hemoglobinuria

Introduction: Paroxysmal nocturnal hemoglobinuria (PNH) is a rare nonmalignant clonal disorder of hematopoietic stem cells characterized by a phosphatidylinositol glycan protein A (PIGA) gene mutation. This mutation results in the deficiency of glycosylphosphatidylinositol (GPI)-anchored proteins, CD55 and CD59, on the cell surface, rendering red blood cells (RBC) susceptible to complement-mediated destruction. This leads to hemolytic anemia, thromboses, and bone marrow failure. Here we describe two cases of PNH presenting to a tertiary care center. Case 1 A 29-year-old male with a history of polysubstance use presented to the Emergency Department with a 2-day history of progressively worsening left lower quadrant abdominal pain. CT abdomen pelvis showed multiple renal infarcts and findings suggestive of pneumatosis intestinalis. A complete blood count (CBC) revealed pancytopenia with a leukocyte count (WBC) of 3 x 10 9/L, hemoglobin (Hb) of 94 g/L, and platelet count (Plt) of 48 x 10 9/L. Lactate dehydrogenase (LDH) was elevated (900 IU/L), haptoglobin level was low ( &amp;lt;8mg/dL), and direct antiglobulin test (DAT) was negative. Urine was positive for hemosiderin, and flow cytometry showed RBCs (6.7%), granulocytes (97.97%), and monocytes (89.02%) with PNH phenotype. Bone marrow biopsy (BMB) was negative for dysplasia and fibrosis with normal hematopoiesis but showed increased erythroid precursors. Enoxaparin was started for thromboses and levofloxacin for neutropenia. Treatment for PNH was initiated with a loading dose of ravulizumab and meningococcal vaccination. The patient was lost to follow-up after receiving the first maintenance dose. Case 2 An 81-year-old female with a medical history of hypertension and coronary artery disease was hospitalized for gradually worsening shortness of breath and fatigue ongoing for 2 months. She reported easy bruising but denied a history of obvious bleeding from any orifice. Physical exam was significant for petechial rash in her lower extremities. Labs revealed pancytopenia (WBC 1.44 x 10 9/L, Hb 68 g/L, Plt 8 x 10 9/L), low reticulocyte count, LDH of 276 IU/L, and negative DAT. BMB showed marked aplasia, and she became transfusion dependent. Subsequently, flow cytometry revealed PNH phenotype in 1.45% of RBCs, 54% granulocytes, and 54% monocytes. Eculizumab therapy was started for the diagnosis of PNH. However, her transfusion requirements did not decrease. She developed iron overload and showed positive conversion on DAT. Darbepoetin alfa and romiplostim were added. Her Hb stabilized at &amp;gt;70g/L in 3 years, following which she only required romiplostim to maintain Plt &amp;gt;20,000 ( Graph 1). After 5 years, she opted to discontinue all treatment. She is being followed up regularly and has since remained stable. Discussion The two cases above are reflective of how PNH can present in different ways, ranging from the classic triad of symptoms to those with subclinical findings associated with other underlying conditions, such as aplastic anemia or myelodysplastic syndrome. The introduction of complement inhibitors completely changed the natural history of PNH, as patients' median survival shifted from 15-20 years to align with age-matched controls. Indications for treatment include severe anemia, thrombosis, or PNH symptoms like dyspnea, fatigue, and painful paroxysms. Currently, eculizumab and ravulizumab are the only FDA-approved drugs for PNH treatment. Ravulizumab is non-inferior to eculizumab, with the added advantage of less frequent dosing (every 8 weeks versus 2 weeks). Regular monitoring for hemolysis is warranted with treatment. Many patients require long-term therapy, which continues to be a significant challenge, even with the spaced dosing of ravulizumab. Eculizumab protects from terminal complement-mediated damage preventing intravascular hemolysis. However, these cells are still deficient in CD55, making them vulnerable to opsonization by C3 and premature removal in the spleen. As a result, &amp;gt;50% of PNH patients receiving treatment show positive conversion on DAT, as seen in case 2. Heparin is preferred in acute thrombotic states. Most hematologists recommend anticoagulation till a few months after starting complement inhibition.