Presence Of Pneumatosis Intestinalis Research Articles

Prognostic factors in patients with acute mesenteric ischemia – a novel tool for determining patient outcomes

Abstract Objective Acute mesenteric ischemia (MI) is a devastating disease with poor prognosis. Due to the multitude of underlying factors and broad clinical presentation, prediction of outcomes remains poor. Here, we aimed to identify factors governing survival in MI and develop a novel prognostic tool. Methods The present study is a monocentric retrospective analysis of patients with suspected MI undergoing imaging between January 2014 and December 2019. Primary endpoint was identification of factors influencing survival in patients undergoing surgery for confirmed MI, secondary endpoint was the development of a predictive nomogram to aid in determination of patient prognosis. Results 539 patients underwent CT imaging for suspected MI, 216 of which had radiological indication of MI and 137 of those had subsequently confirmed MI. Factors associated with confirmed ischemia were increasing age, nausea/vomiting, history of peripheral arterial disease and presence of pneumatosis intestinalis and dilated bowel loops. 125 patients underwent surgery, 58 of which survived, and 67 died (median 9 days after diagnosis, IQR: 22). Baseline characteristics, including time from diagnosis to surgery were not different among patients, and outcomes were not affected by the presence of a surgical senior consultant or daytime of the operation. A minimally invasive approach was attempted more often in survivors (25.9% vs. 10.4%, p=0.024), however, in all but 1 patient (1.7%) conversion to open surgery was performed following detection of ischemia. Increasing age and ASA score, type 2 diabetes, decreased haemoglobin and pH, increased creatinine, radiological atherosclerosis, vascular occlusion (versus non-occlusive MI) and affection of the colon (compared to small bowel ischemia only) were independently associated with impaired survival. Based on a multivariate model, we developed a nomogram for survival prediction, which showed adequate power upon internal validation (C-index = 0.738, Figure 1). Conclusion Acute MI remains a condition with high mortality. Here, we identified factors affecting survival after MI, namely colonic involvement, vascular co-morbidities and increasing age. Minimally invasive surgical approaches have not yet gained widespread acceptance in treatment of confirmed MI. Our novel nomogram might prove helpful in outcome prediction of patients with MI.

Differentiation of food protein-induced enterocolitis syndrome and necrotizing enterocolitis in neonates by abdominal sonography

ObjectivesTo summarize and differentiate abdominal ultrasound findings of necrotizing enterocolitis and food protein-induced enterocolitis syndrome. MethodsFrom January 2017 to December 2018, the abdominal ultrasound results of 304 cases diagnosed necrotizing enterocolitis or food protein-induced enterocolitis syndrome were retrospectively analyzed. The presence of pneumatosis intestinalis, portal venous gas, bowel wall thickening, intestinal motility, focal fluid collections and hypoechoic change of gallbladder wall were calculated, and the results were compared and analyzed. ResultsPneumatosis intestinalis, portal venous gas, bowel wall thickening, intestinal motility weakened/absent, focal fluid collections and hypoechoic change of gallbladder wall can be found in both necrotizing enterocolitis and food protein-induced enterocolitis syndrome infants. However, in infants with necrotizing enterocolitis, intestinal motility was weakened/absent in whole abdomen, and in food protein-induced enterocolitis syndrome, it only involved isolated segment of bowel. The positive rates of above signs in necrotizing enterocolitis infants were significantly higher than those in food protein-induced enterocolitis syndrome (p<0.01). Moreover, it was observed that the rate of weakened intestinal motility besides the lesion segment of bowel in necrotizing enterocolitis infants was 100%, and in food protein-induced enterocolitis syndrome infants, it was 0%, which is supposed to be a main sign for identification. ConclusionIn the early stage, abdominal ultrasound can be used to differentiate necrotizing enterocolitis and food protein-induced enterocolitis syndrome.

Feeding Jejunostomy-Associated Small Bowel Necrosis After Elective Esophago-Gastric Resection

BackgroundFeeding jejunostomy has increasingly become a standard adjunctive procedure during major esophago-gastric resections. They provide nutritional support during the post-operative period as required. However, significant early complications have been reported, most notably small bowel necrosis. Literature reports have been restricted to case reports or series. This study aims to determine the frequency of this complication in a cohort of patients undergoing esophago-gastric resection, and identify any difference in the risk of this complication between patients undergoing esophagectomy and gastrectomy. MethodsConsecutive patients who had esophago-gastric resections for malignancy and who had a feeding jejunostomy placed were identified from a prospectively maintained database at Leicester Royal Infirmary during the years 2009–2015. Case notes were reviewed to extract information relating to demographics, presenting features and clinical outcome. ResultsThe study included 360 patients, 285 of which had esophagectomy and 75 had gastrectomy. There were no small bowel complications among esophagectomy patients (0%), while six patients who had total gastrectomy developed small bowel ischemia or necrosis (8%), p = 0.05, in spite of an identical feeding regimen. Every patient that developed the complication underwent surgery with five out six having resection of the infarcted segment and double-barrel stoma formation. A 6–8-week period of parenteral nutrition was required before stoma reversal. One patient had leucocytosis on the day of diagnosis. The other five patients showed no derangements in biochemical or clinical parameters in the preceding 48 h. Five of the six patients survived. ConclusionsSmall bowel necrosis and perforation is a life-threatening complication of feeding jejunostomy. In our cohort, it happened exclusively in total gastrectomy patients. Antecedent signs were lacking. The condition requires prompt attention with earlier use of CT scanning and a return to the operating room. The presence of pneumatosis intestinalis on CT scan should prompt surgical intervention that improves survival.

Pneumoperitoneum in the Setting of Pneumatosis Intestinalis in Children: Is Surgery Always Indicated?

Aim Pneumatosis intestinalis (PI) is a condition in which multiple gas-filled cysts form within the wall of the gastrointestinal tract in either the subserosa or submucosa. The presence of pneumoperitoneum in the presence of PI can present a therapeutic dilemma. The aim of our study was to review our experience and management of this condition. Methods A single-center retrospective study of consecutive children (> 1 year) presenting with a pneumoperitoneum and evidence of PI (2009-2015). Demographics, case notes, microbiology, and imaging were reviewed. Results Seven patients were identified (four males; age range 5-14 years). Four children had global developmental delay and were percutaneous endoscopic gastrostomy or jejunostomy fed, one was immunocompromised (acute lymphoblastic leukemia). The others had encephalitis and eosinophilic gastroenteritis. One patient proceeded to an exploratory laparotomy; no perforation was identified, pneumatosis of the colon was observed, and a loop ileostomy was formed. The remaining six were managed conservatively and made nil by mouth with intravenous antibiotics commenced. Five of the six had a computed tomography (CT) scan which revealed PI and free air with no other worrying signs. One died from nongastrointestinal causes, while the remaining five had feeds reintroduced uneventfully. Conclusion Free air in the setting of PI may represent rupture of the gas cysts and not always transmural perforation. Surgery may not always be indicated and conservative management may suffice. A CT scan can be useful for excluding other intra-abdominal pathological findings and continued clinical assessment is essential.

Three Cases of Preterm Infants Showing Pneumatosis Intestinalis without Progression to Typical Necrotizing Enterocolitis

Necrotizing enterocolitis (NEC) is a major gastrointestinal disorder in premature infants associated with high morbidity and mortality rates. When NEC is clinically suspected, radiological and laboratory studies should be performed to confirm the diagnosis and to aid in the management of patients. As the clinical manifestations of NEC are usually nonspecific, diagnoses are often made using abdominal radiographic findings, such as pneumatosis intestinalis. Clinicians typically consider the presence of pneumatosis intestinalis on radiographs as the definite evidence of stage II NEC. Here, we report 3 cases of preterm infants who had radiographic findings of pneumatosis intestinalis but did not have any other associated laboratory and clinical evidence of NEC, except bloody stools. The infants’ systemic manifestations were mild or absent, and all of them completely recovered within 2–3 days, as demonstrated by the resolution of pneumatosis intestinalis on abdominal radiographs. The combination of hematochezia and intestinal pneumatosis in preterm infants strongly suggests the diagnosis of NEC. In our cases, there was no laboratory evidence of inflammation or platelet consumption, and the clinical course was benign without any sings of surgical abdomen. Additionally, our patients had barium-induced colitis or milk protein allergy, which are other possible causes of pneumatosis intestinalis. Because pneumatosis intestinalis can result from causes other than NEC, it is important to consider clinical, laboratory, and radiological findings to confirm the diagnosis of NEC.

Pneumatosis intestinalis versus pseudo-pneumatosis: review of CT findings and differentiation

Pneumatosis intestinalis is defined as the presence of gas within the wall of the gastrointestinal tract. Originally described on plain abdominal radiographs, it is an imaging sign rather than a specific diagnosis and it is associated with both benign and life-threatening clinical conditions. The most common life-threatening cause of pneumatosis intestinalis is bowel ischaemia. Computed tomography (CT) is usually requested to detect underlying disease. The presence of pneumatosis intestinalis often leads physicians to make a diagnosis of serious disease. However, an erroneous diagnosis of pneumatosis intestinalis may be made (i.e. pseudo-pneumatosis) when intraluminal beads of gas are trapped within or between faeces and adjacent mucosal folds. The purpose of this pictorial essay is to review and describe the CT imaging findings of pneumatosis and pseudo-pneumatosis intestinalis and to discuss key discriminatory imaging features.

Pneumatosis Intestinalis: A Rare Manifestation of Acute Appendicitis

Pneumatosis intestinalis (PI), the presence of gas within the bowel wall, is a rare condition. To our knowledge, only two cases of PI secondary to acute appendicitis have been reported in the literature. We present a new case of a 46-year-old man who complained of abdominal pain and progressive abdominal distension for 4 days and oliguria for 1 day. In the Emergency Department, his abdomen was markedly distended and showed peritoneal signs. Preoperative blood culture grew Bacteroides fragilis. Abdominal computed tomography scan revealed marked bowel distension, bubble-like intramural gas scattered in the proximal small bowel, and localized fluid accumulation in the right lower quadrant of the abdomen. Small bowel ischemia was interpreted preoperatively. Emergency laparotomy revealed that the appendix was gangrenous and perforated, with local abscess formation but no bowel infarction. Hence, only appendectomy was performed, with subsequent uneventful patient recovery. The presence of PI may not always be an ominous sign; rather, it depends on the severity of any underlying diseases.

Postoperative neonatal necrotizing enterocolitis

Neonatal necrotizing enterocolitis (NEC) classically occurs in stressed premature newborns within the first ten days of life. Although it has been sporadically described in other settings, it has not been frequently cited as a postoperative complication. This paper presents eleven surgical infants whose postoperative course was complicated by the development of NEC. During the last 5 yr, 11 newborns (mean 2.4 kg.) have been treated for postoperative NEC. Each of these had undergone a major operation within the first week of life. Diagnoses included gastroschisis (7), omphalocele (1), jejunal atresia (1), aganglionosis (1), and malrotation with duodenal web (1). The mean age at onset of symptoms was 36 days (range 5–136 days) and an average of 29 days postoperatively (range 5–120 days). NEC was documented in each case by the presence of pneumatosis intestinalis or surgical and/or autopsy specimen. Four infants responded to medical therapy. Seven required operation, three of whom had involvement of the entire midgut. Five of the eleven neonates (46%) died of overwhelming sepsis. Of the remaining six, two require T.P.N. for survival (15 and 16 months old) and two additional require frequent hospitalization for diarrhea (morbidity 67%). NEC resulted in substantial morbidity and mortality in these surgical neonates. It occurred late in the postoperative period and pursued a virulent course. In only three infants could etiologic factors be identified. Two occurred after attempts at closure of abdominal wall defects and the third suffered hypoxia prior to the onset of symptoms. In each of these, NEC became apparent early postoperatively (Avg. 7th postoperative day). In the remaining eight, however, contributing factors could not be identified and onset of symptoms occurred late (Avg. 39th postoperative day). The preponderance of abdominal wall defects suggests a possible increased susceptibility in these infants. NEC should be included in the differential diagnosis of gastrointestinal symptoms in postoperative neonates. Neonatal necrotizing enterocolitis (NEC) classically occurs in stressed premature newborns within the first ten days of life. Although it has been sporadically described in other settings, it has not been frequently cited as a postoperative complication. This paper presents eleven surgical infants whose postoperative course was complicated by the development of NEC. During the last 5 yr, 11 newborns (mean 2.4 kg.) have been treated for postoperative NEC. Each of these had undergone a major operation within the first week of life. Diagnoses included gastroschisis (7), omphalocele (1), jejunal atresia (1), aganglionosis (1), and malrotation with duodenal web (1). The mean age at onset of symptoms was 36 days (range 5–136 days) and an average of 29 days postoperatively (range 5–120 days). NEC was documented in each case by the presence of pneumatosis intestinalis or surgical and/or autopsy specimen. Four infants responded to medical therapy. Seven required operation, three of whom had involvement of the entire midgut. Five of the eleven neonates (46%) died of overwhelming sepsis. Of the remaining six, two require T.P.N. for survival (15 and 16 months old) and two additional require frequent hospitalization for diarrhea (morbidity 67%). NEC resulted in substantial morbidity and mortality in these surgical neonates. It occurred late in the postoperative period and pursued a virulent course. In only three infants could etiologic factors be identified. Two occurred after attempts at closure of abdominal wall defects and the third suffered hypoxia prior to the onset of symptoms. In each of these, NEC became apparent early postoperatively (Avg. 7th postoperative day). In the remaining eight, however, contributing factors could not be identified and onset of symptoms occurred late (Avg. 39th postoperative day). The preponderance of abdominal wall defects suggests a possible increased susceptibility in these infants. NEC should be included in the differential diagnosis of gastrointestinal symptoms in postoperative neonates.