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Aihara Y, Ito Y, Takeshita E, Oba M, Yamamoto K, Sumitomo N, Yamamoto H, Baba S, Shimizu-Motohashi Y, Saito T, Komaki H. Prevalence and management of gastrointestinal complications in Duchenne muscular dystrophy: A retrospective cohort study. Brain Dev 2025; 47:104379. [PMID: 40540814 DOI: 10.1016/j.braindev.2025.104379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2024] [Revised: 05/10/2025] [Accepted: 06/02/2025] [Indexed: 06/22/2025]
Abstract
BACKGROUND Gastrointestinal complications in Duchenne muscular dystrophy (DMD) have been understudied, particularly in Asian populations. This study aimed to determine the frequency and clinical characteristics of gastrointestinal complications. METHODS This single-center, retrospective study reviewed medical records of 459 Asian patients with genetically or biopsy-confirmed DMD, aged 1-48 years, from September 1, 2010, to January 1, 2023. RESULTS Constipation was the most common complication, affecting 149 patients (32.5 %), followed by dysphagia in 43 patients (9.4 %). Other conditions included irritable bowel syndrome in 8, gastroesophageal reflux disease in 7, hemorrhoids in 6, acute dilatation of stomach in 4, sigmoid colon volvulus in 2, and pneumatosis cystoides intestinalis in 2. Additionally, 1 case each of appendicitis, esophageal diverticulum, paralytic ileus, aerophagia, anal atresia, malabsorption syndrome, fecal incontinence, inflammatory bowel disease, gastrointestinal bleeding, and rectal prolapse was observed. Treatments for constipation included no intervention in 20 patients (13.4 %), sodium picosulfate hydrate in 62 (41.6 %), magnesium oxide in 59 (39.6 %), and polyethylene glycol 4000 in 20 (13.4 %). Logistic regression analysis showed that body mass index (BMI), age and angiotensin converting enzyme inhibitor use was significantly associated with constipation. CONCLUSIONS This study highlighted constipation as the most frequent gastrointestinal complication in DMD and identified several rare but serious complications, offering key insights into real-world clinical practice.
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Affiliation(s)
- Yu Aihara
- Department of Child Neurology, National Center Hospital, National Center of Neurology and Psychiatry, Kodaira, Tokyo, Japan
| | - Yusuke Ito
- Department of Child Neurology, National Center Hospital, National Center of Neurology and Psychiatry, Kodaira, Tokyo, Japan
| | - Eri Takeshita
- Department of Child Neurology, National Center Hospital, National Center of Neurology and Psychiatry, Kodaira, Tokyo, Japan.
| | - Mari Oba
- Department of Clinical Data Science, Clinical Research & Education Promotion Division, National Center of Neurology and Psychiatry, Kodaira, Japan
| | - Kaoru Yamamoto
- Department of Child Neurology, National Center Hospital, National Center of Neurology and Psychiatry, Kodaira, Tokyo, Japan
| | - Noriko Sumitomo
- Department of Child Neurology, National Center Hospital, National Center of Neurology and Psychiatry, Kodaira, Tokyo, Japan
| | - Hisako Yamamoto
- Department of Child Neurology, National Center Hospital, National Center of Neurology and Psychiatry, Kodaira, Tokyo, Japan
| | - Shimpei Baba
- Department of Child Neurology, National Center Hospital, National Center of Neurology and Psychiatry, Kodaira, Tokyo, Japan
| | - Yuko Shimizu-Motohashi
- Department of Child Neurology, National Center Hospital, National Center of Neurology and Psychiatry, Kodaira, Tokyo, Japan
| | - Takashi Saito
- Department of Child Neurology, National Center Hospital, National Center of Neurology and Psychiatry, Kodaira, Tokyo, Japan
| | - Hirofumi Komaki
- Department of Child Neurology, National Center Hospital, National Center of Neurology and Psychiatry, Kodaira, Tokyo, Japan; Translational Medical Center, National Center of Neurology and Psychiatry, Kodaira, Tokyo, Japan
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2
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Çoşkun N. Comments on the "Risk factors of bowel perforation in neonates with Hirschsprung disease". Pediatr Surg Int 2025; 41:155. [PMID: 40448858 DOI: 10.1007/s00383-025-06055-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/16/2025] [Indexed: 06/02/2025]
Abstract
This letter discusses methodological concerns regarding the diagnosis of pneumatosis intestinalis (PI) as an independent risk factor for bowel perforation in neonates with Hirschsprung's disease (HSCR), as presented in the study by Liu et al. (2025). The author highlights the lack of clear radiological criteria for PI diagnosis, noting that nonspecific findings (e.g., dilated bowel loops) were used without quantitative thresholds or inter-observer validation. The letter emphasizes the need for standardized diagnostic criteria, independent radiological reviews, and histopathological correlation to strengthen the study's reliability. These refinements would enhance the clinical applicability of the findings and support more accurate risk stratification for perforation in HSCR patients.
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Affiliation(s)
- Nurcan Çoşkun
- Department of Pediatric Surgery, Hitit University Erol Olçok Training and Research Hospital, Çorum, Turkey.
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3
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Yön MEE, Ceylan A, Kaya Eİ, Ölçücüoğlu E, Ceran F, Dağdaş S, Özet G. What Happened Suddenly - Acute Abdomen? A Difficult Case of ATRA-Related Pneumatosis Cystoides Intestinalis. Turk J Haematol 2025; 42:150-152. [PMID: 40103785 PMCID: PMC12099487 DOI: 10.4274/tjh.galenos.2025.2025.0020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2025] [Accepted: 03/19/2025] [Indexed: 03/20/2025] Open
Affiliation(s)
| | - Ahmet Ceylan
- Ankara Bilkent City Hospital, Clinic of Hematology, Ankara, Türkiye
| | | | - Esin Ölçücüoğlu
- Ankara Bilkent City Hospital, Clinic of Radiology, Ankara, Türkiye
| | - Funda Ceran
- Ankara Bilkent City Hospital, Clinic of Hematology, Ankara, Türkiye
| | - Simten Dağdaş
- Ankara Bilkent City Hospital, Clinic of Hematology, Ankara, Türkiye
| | - Gülsüm Özet
- Ankara Bilkent City Hospital, Clinic of Hematology, Ankara, Türkiye
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Rigiroli F, Nakhaei M, Karam R, Tabah N, Brook A, Siewert B, Brook OR. Combining clinical and radiological features improves prediction of bowel ischemia in patients with CT findings of pneumatosis intestinalis. Abdom Radiol (NY) 2025:10.1007/s00261-025-04814-1. [PMID: 39873759 DOI: 10.1007/s00261-025-04814-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2024] [Revised: 01/13/2025] [Accepted: 01/17/2025] [Indexed: 01/30/2025]
Abstract
BACKGROUND Pneumatosis intestinalis on CT presents a diagnostic dilemma, because it could reflect bowel ischemia or benign finding. PURPOSE To determine radiological and clinical features that can predict bowel ischemia in patients with pneumatosis intestinalis on CT. MATERIALS AND METHODS Patients with "pneumatosis" in abdominal CT reports performed between 1/1/2002 and 12/31/2018 were retrospectively included. Pneumatosis intestinalis was confirmed by review of images. Radiological features of pneumatosis, laboratory data, clinical signs and symptoms were collected. Pathologic pneumatosis intestinalis (PPI) was defined as presence of ischemic (viable or dead) bowel on surgery or death during admission or within 30 days of discharge due to ischemia. Univariate statistical analysis was used to identify features associated with PPI, followed by multivariate logistic regression models. RESULTS A total of 313 consecutive patients with pneumatosis intestinalis (162 (52%) men, median age 67 years, IQR 55-78 years) were included. Pathologic pneumatosis intestinalis was present in 114/313 (36%) patients. Presence of arterial or venous thrombosis, porto-mesenteric gas, fat stranding, and location in the small bowel were significantly associated with PPI. A combined clinical and radiological model, which included age, WBC, creatinine, abdominal distention, rebound or guarding, shock, presence of porto-mesenteric gas and fat stranding showed an AUC of 0.85 for prediction of PPI, higher than models using clinical (AUC = 0.80, p = 0.005) or radiological factors (AUC = 0.80, p < 0.0001) alone. CONCLUSION Improved prediction of pathological pneumatosis intestinalis can be achieved by a model incorporating both clinical and radiological features (AUC = 0.85)rather than by either clinical (AUC = 0.80) or radiological (AUC = 0.80) features alone.
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5
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Ueda T, Deguchi R, Sano M, Suzuki H. Esophageal pneumatosis and hematomatosis concomitant with achalasia. Endoscopy 2024; 56:E512-E513. [PMID: 38866059 PMCID: PMC11168791 DOI: 10.1055/a-2329-2150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/14/2024]
Affiliation(s)
- Takashi Ueda
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Tokai University School of Medicine, Isehara, Japan
| | - Ryuzo Deguchi
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Tokai University School of Medicine, Isehara, Japan
| | - Masaya Sano
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Tokai University School of Medicine, Isehara, Japan
| | - Hidekazu Suzuki
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Tokai University School of Medicine, Isehara, Japan
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Bezabih NA, Mehammed AH, Gebresilassie MY, Damtie MY, Midekso HD, Gidna EK. A rare case of extensive pneumatosis cystoides intestinalis with intestinal malrotation: Case report. Radiol Case Rep 2024; 19:5100-5104. [PMID: 39253045 PMCID: PMC11381972 DOI: 10.1016/j.radcr.2024.07.145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2024] [Revised: 07/24/2024] [Accepted: 07/25/2024] [Indexed: 09/11/2024] Open
Abstract
Intramural bowel gas (Pneumatosis intestinalis) refers to the radiological or clinical evidence of gas within the wall of the bowel lumen. While intramural gas could be secondary to life-threatening pathologies such as mesenteric ischemia in adults and necrotizing enterocolitis in neonates, it could also occur as a rare benign sub-type called Pneumatosis cystoides intestinalis, which is characterized by multiple gas-filled cysts in the submucosa and/or subserosal of the gastrointestinal tract. Distinguishing between life-threatening Pneumatosis intestinalis and its benign subtypes requires careful clinical and imaging evaluation. This involves identifying additional findings that could indicate potentially concerning causes of Pneumatosis intestinalis. Recognizing these signs is essential for effectively managing the patient because conservative management is preferred for Pneumatosis cystoides intestinalis. In this case study, we describe a patient presenting to our hospital with chronic intermittent abdominal pain persisting for about 2 years, accompanied by episodic vomiting. An abdominal CT scan revealed the presence of multiple air-filled cysts within the wall of the mal-rotated cecal bowel loop, which is abnormally located in the right upper quadrant. Associated with this pneumoperitoneum is seen in the peritoneal cavity. No other significant findings were observed on the scan. To our knowledge, this is the first case of pneumatosis cystoid interstinalis occurring in a mal-rotated gut. We also delve into the potential etiologies and management strategies for Pneumatosis cystoides intestinalis, as well as differentiating signs from the life-threatening intramural gas variant.
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Affiliation(s)
- Natnael Alemu Bezabih
- Addis Ababa University, College of Health Sciences, Department of Radiology, Addis Ababa, Ethiopia
| | - Abdudin Heru Mehammed
- Saint Paul's Hospital Millennium Medical College, Department of Radiology, Addis Ababa, Ethiopia
| | | | - Misganaw Yigletie Damtie
- Saint Paul's Hospital Millennium Medical College, Department of Radiology, Addis Ababa, Ethiopia
| | - Hawi Dida Midekso
- Addis Ababa University, College of Health Sciences, Department of Radiology, Addis Ababa, Ethiopia
| | - Eden Kasay Gidna
- Addis Ababa University, College of Health Sciences, Department of Radiology, Addis Ababa, Ethiopia
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7
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Kagawa H, Furukawa M, Chan EG, Morrell M, Sanchez PG. Pneumatosis Intestinalis and Pneumoperitoneum After Lung Transplantation: Single-Center Experience and Systematic Review. J Transplant 2024; 2024:8867932. [PMID: 39450324 PMCID: PMC11502136 DOI: 10.1155/2024/8867932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 08/09/2024] [Accepted: 08/31/2024] [Indexed: 10/26/2024] Open
Abstract
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).
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Affiliation(s)
- Hiroshi Kagawa
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
- Division of Cardiothoracic Surgery, Department of Surgery, University of Utah School of Medicine, Salt Lake, Utah, USA
| | - Masashi Furukawa
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Ernest G. Chan
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Matthew Morrell
- Division of Pulmonary, Allergy and Critical Care Medicine, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
- Division of Pulmonary Medicine, Department of Internal Medicine, University of Utah School of Medicine, Salt Lake, Utah, USA
| | - Pablo G. Sanchez
- Department of Cardiothoracic Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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8
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Collins M, Keir I. Presence of pneumatosis intestinalis in a dog with multicentric lymphoma. THE CANADIAN VETERINARY JOURNAL = LA REVUE VETERINAIRE CANADIENNE 2024; 65:1013-1018. [PMID: 39355706 PMCID: PMC11411481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 10/03/2024]
Abstract
A 13-year-old neutered male Lagotto Romagnolo dog had ultrasonographic and computed tomographic findings of pneumatosis intestinalis after presentation to the emergency department because of progressive diarrhea and hyporexia. Further investigations produced a diagnosis of multicentric lymphoma, and treatment with chemotherapy was commenced. Clinical remission of lymphoma was achieved and coincided with resolution of pneumatosis intestinalis on subsequent computed tomographic imaging. Key clinical message: Consider underlying pathology such as neoplasia in cases of pneumatosis intestinalis after excluding surgical emergent causes.
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Affiliation(s)
- Megan Collins
- Small Animal Specialist Hospital Sydney, 1 Richardson Place, North Ryde, NSW 2113, Australia
| | - Iain Keir
- Small Animal Specialist Hospital Sydney, 1 Richardson Place, North Ryde, NSW 2113, Australia
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9
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Klingbeil KD, Zelicha H, Chen Y, Bell DS, Livingston EH. Association of Pneumatosis Intestinalis With Surgical Outcomes and Mortality: A Matched, Retrospective Cohort Study and Literature Review. ANNALS OF SURGERY OPEN 2024; 5:e448. [PMID: 39310369 PMCID: PMC11415091 DOI: 10.1097/as9.0000000000000448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Accepted: 05/01/2024] [Indexed: 09/25/2024] Open
Abstract
Background To determine the clinical importance of pneumatosis intestinalis (PI) on surgical decision-making and patient outcomes. Methods A matched cohort observational study was conducted including all clinical encounters for both ambulatory and inpatient care at UCLA Health between February 15, 2006 and January 31, 2023. Patients were initially identified using encounter diagnostic codes for "other specified diseases of intestine." A radiologic diagnosis of PI was then assessed using natural language processing techniques followed by confirmation using manual chart review. Patients who did not have PI served as a control group. Patient comorbidity was assessed using Elixhauser comorbidity scores. Logistic regression and Cox hazard analyses were used to assess associations between PI and mortality. The main outcome was 90-day all-cause mortality. Secondary outcomes were the proportion of patients undergoing surgery and, of those, how many required bowel resections. Results Of the 16,728 patients identified by diagnostic coding, 315 were confirmed to have a diagnosis of PI. The 90-day mortality rate for all patients with PI was 29%. Surgery was performed for 62 patients (20%), of whom 46 (72%) underwent bowel resection and 16 (28%) underwent abdominal exploration alone. Most patients underwent surgery for peritonitis (37%), bowel obstruction (31%), and/or pneumoperitoneum (23%) in association with PI; whereas only 8% of patients received surgery exclusively for PI. There was no statistically significant association between PI and mortality with logistic regression conditioned on other risk factors for mortality. In contrast, survival analysis of a matched cohort demonstrated a small effect of PI on mortality (hazard ratio = 1.24: 95% confidence interval = 1.16-1.32, P = 0.021). Conclusions Most patients with a diagnosis of PI survive without requiring surgery. Of those who undergo surgery, nearly all have indications for laparotomy exclusive of PI. Mortality in patients who have pneumatosis is strongly associated with comorbid disease, with little to no independent association with PI. Our findings suggest that the presence of PI should not be a primary indication for surgical intervention.
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Affiliation(s)
- Kyle D. Klingbeil
- From the Department of Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA
| | - Hila Zelicha
- From the Department of Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA
| | - Yijun Chen
- From the Department of Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA
| | - Douglas S. Bell
- Department of Medicine, Division of General Internal Medicine, UCLA, Los Angeles, CA
- Informatics Program of the UCLA Clinical and Translational Science Institute (CTSI), UCLA, Los Angeles, CA
| | - Edward H. Livingston
- From the Department of Surgery, UCLA David Geffen School of Medicine, Los Angeles, CA
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10
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Ma O, Day J. Case report: Pneumatosis coli in an anti-TIF1-ɣ-positive dermatomyositis patient. Int J Rheum Dis 2024; 27:e15245. [PMID: 38937988 DOI: 10.1111/1756-185x.15245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2024] [Accepted: 06/18/2024] [Indexed: 06/29/2024]
Affiliation(s)
- Ocean Ma
- Melbourne University, Parkville, Melbourne, Victoria, Australia
| | - Jessica Day
- Melbourne University, Parkville, Melbourne, Victoria, Australia
- Royal Melbourne Hospital, Parkville, Melbourne, Victoria, Australia
- Walter and Eliza Hall Medical Research Institute, Parkville, Melbourne, Victoria, Australia
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11
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Belloch Ripollés V, Muñoz Núñez CF, Fontana Bellorín A, Batista Doménech A, Boukhoubza A, Parra Hernández M, Martí-Bonmatí L. Evaluation of pneumatosis intestinalis as a complication of lung transplantation. RADIOLOGIA 2024; 66:314-325. [PMID: 39089792 DOI: 10.1016/j.rxeng.2023.01.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 01/17/2023] [Indexed: 08/04/2024]
Abstract
INTRODUCTION Pneumatosis intestinalis is a radiological finding characterized by the presence of gas in the bowel wall that is associated with multiple entities. Our aim is to know its incidence in lung transplant patients, its physiopathology and its clinical relevance. METHODS A search of patients with pneumatosis intestinalis was performed in the database of the Lung Transplant Unit of our hospital. The presence of pneumatosis after transplantation was confirmed in all of them and relevant demographic, clinical and imaging variables were collected to evaluate its association and clinical expression, as well as the therapeutic approach after the findings. RESULTS The incidence of pneumatosis intestinalis after lung transplantation in our center was 3.1% (17/546), developing between 9 and 1270 days after transplantation (mean, 198 days; median 68 days). Most of the patients were asymptomatic or with mild symptoms, without any major analytical alterations, and with a cystic and expansive radiological appearance. Pneumoperitoneum was associated in 70% of the patients (12/17). Conservative treatment was chosen in all cases. The mean time to resolution was 389 days. CONCLUSION Pneumatosis intestinalis in lung transplant patients is a rare complication of uncertain origin, which can appear for a very long period of time after transplantation. It has little clinical relevance and can be managed without other diagnostic or therapeutic interventions.
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Affiliation(s)
- V Belloch Ripollés
- Servicio de Radiología, Hospital Universitario y Politécnico La Fe, Valencia, Spain.
| | - C F Muñoz Núñez
- Servicio de Radiología, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - A Fontana Bellorín
- Unidad de Trasplante Pulmonar, Servicio de Cirugía Torácica, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - A Batista Doménech
- Servicio de Radiología, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - A Boukhoubza
- Servicio de Radiología, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - M Parra Hernández
- Servicio de Radiología, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - L Martí-Bonmatí
- Servicio de Radiología, Hospital Universitario y Politécnico La Fe, Valencia, Spain
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12
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Yin X, Yin Y, Zhang B. Pneumatosis cystoides intestinalis secondary to acute appendicitis: A rare clinical condition. Asian J Surg 2024; 47:2700-2701. [PMID: 38553268 DOI: 10.1016/j.asjsur.2024.03.101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2024] [Accepted: 03/06/2024] [Indexed: 06/05/2024] Open
Affiliation(s)
- Xiaonan Yin
- Gastric Cancer Center, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China.
| | - Yuan Yin
- Gastric Cancer Center, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China.
| | - Bo Zhang
- Gastric Cancer Center, Department of General Surgery, West China Hospital, Sichuan University, Chengdu, 610041, Sichuan, China.
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13
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Zolotov E, Quintanilla C, Ahmed N, Sigal A, Shaikh Z, Hosseini DK, Lee R, Omidvari K, Shukla N. Pneumatosis Intestinalis Following Surgical Gastrostomy Tube Placement in a Patient With Glottic Squamous Cell Carcinoma: A Case Report. Cureus 2024; 16:e60918. [PMID: 38910746 PMCID: PMC11193667 DOI: 10.7759/cureus.60918] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/23/2024] [Indexed: 06/25/2024] Open
Abstract
Pneumatosis intestinalis (PI) is a rare medical and post-surgical sequela of multiple different etiologies which can be either benign or life-threatening. Various mechanisms have been proposed to explain the occurrence of PI; however, the pathophysiology is dependent on the suspected cause. The condition is largely categorized into two broad groups: idiopathic PI, which remains relatively uncommon, and secondary PI. The latter often surfaces as a result of a wide array of both gastrointestinal and non-gastrointestinal illnesses. These encompass vascular compromise, bowel mucosal disruption, gastrointestinal dysmotility, as well as infectious and immunological etiologies. Management ranges from conservative medical strategies to emergent surgical intervention. We present the first case to our knowledge of spontaneous PI developing within five days of a surgical gastrostomy tube (SGT) placement in a 79-year-old female with glottic squamous cell carcinoma which unfortunately proved fatal. The purpose of this case report is to highlight a rare fatal complication of a common surgical procedure and the necessity of initiating interdisciplinary management quickly to determine the best treatment course.
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Affiliation(s)
- Eli Zolotov
- Internal Medicine, Hackensack University Medical Center, Hackensack, USA
| | - Caden Quintanilla
- Internal Medicine, Hackensack University Medical Center, Hackensack, USA
| | - Noreen Ahmed
- Internal Medicine, Hackensack University Medical Center, Hackensack, USA
| | - Anat Sigal
- Pediatrics, Hackensack University Medical Center, Hackensack, USA
| | - Zahf Shaikh
- Gastroenterology, Hackensack University Medical Center, Hackensack, USA
| | - Davood K Hosseini
- Gastroenterology, Hackensack University Medical Center, Hackensack, USA
| | - Robert Lee
- Critical Care, Hackensack University Medical Center, Hackensack, USA
| | - Karan Omidvari
- Critical Care, Hackensack University Medical Center, Hackensack, USA
| | - Nilesh Shukla
- Gastroenterology, Hackensack University Medical Center, Hackensack, USA
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14
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Aihara Y, Takeshita E, Chiba E, Yamamoto K, Shimizu-Motohashi Y, Sato N, Ariga H, Komaki H. Pneumatosis Cystoides Intestinalis in Muscular Dystrophy and Congenital Myopathies: A Report of Five Cases. Cureus 2024; 16:e61188. [PMID: 38933611 PMCID: PMC11208106 DOI: 10.7759/cureus.61188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/26/2024] [Indexed: 06/28/2024] Open
Abstract
Pneumatosis cystoides intestinalis (PCI) is a rare disease wherein air accumulates in the intestinal subserosa and submucosa, causing multiple gaseous cysts within the gastrointestinal wall. While PCI has various known risk factors, reports identifying muscular diseases as a factor are scarce. The aim of this study is to elucidate the clinical characteristics of PCI in muscle disease. We present a case series of five cases, including two cases of Duchenne muscular dystrophy (DMD) and three cases of rare congenital myopathies. All cases are of male patients, with poor intestinal peristalsis and constipation, who underwent tube feeding and mechanical ventilation via tracheostomy. They had no signs of severe complications, such as intestinal necrosis, and all of them improved with conservative treatment. Case 1 is a 23-year-old man with DMD who developed cardiopulmonary arrest at the age of 20 years. Pulmonary hemorrhage occurred three months before the incidental detection of PCI in the ascending colon, which resolved with conservative oxygen treatment. Case 2 is a 25-year-old man with DMD who progressed to immobility necessitating tracheostomy at the age of 20 years. He experienced persistent abdominal pain and nausea, and PCI was detected in the cecum and ascending colon. He showed near-complete resolution of PCI after three months of conservative treatment. Case 3 is a six-year-old boy with reducing body myopathy. Constipation was diagnosed at four years of age. He experienced intermittent bloody stools, leading to the incidental detection of PCI at six years of age. After two months of conservative treatment, the PCI resolved with no subsequent recurrence. Case 4 is a 33-year-old man with infantile severe myotubular myopathy. He required mechanical ventilation immediately after birth and later underwent tracheostomy and tube feeding due to complications. At the age of 27 years, PCI was incidentally detected on abdominal CT. He had episodes of remission and worsening for a few years; however, PCI completely resolved after three years. Case 5 is a 27-year-old man with nemaline myopathy. At the age of 14 years, he had persistent bloody stools. After lower gastrointestinal endoscopy, he was diagnosed with PCI with numerous rectal cysts. PCI required no specific therapeutic intervention. There was spontaneous resolution of PCI and bloody stools. Given that PCI lacks specific symptoms and cases with muscular diseases often experience abdominal issues, many cases are liable to be overlooked or misdiagnosed. Cases with muscular diseases complaining of persistent abdominal symptoms should undergo radiographic imaging to rule out PCI.
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Affiliation(s)
- Yu Aihara
- Department of Child Neurology, National Center Hospital, National Center of Neurology and Psychiatry, Tokyo, JPN
| | - Eri Takeshita
- Department of Child Neurology, National Center Hospital, National Center of Neurology and Psychiatry, Tokyo, JPN
| | - Emiko Chiba
- Department of Radiology, National Center Hospital, National Center of Neurology and Psychiatry, Tokyo, JPN
| | - Kaoru Yamamoto
- Department of Child Neurology, National Center Hospital, National Center of Neurology and Psychiatry, Tokyo, JPN
| | - Yuko Shimizu-Motohashi
- Department of Child Neurology, National Center Hospital, National Center of Neurology and Psychiatry, Tokyo, JPN
| | - Noriko Sato
- Department of Radiology, National Center Hospital, National Center of Neurology and Psychiatry, Tokyo, JPN
| | - Hajime Ariga
- Department of General Internal Medicine, National Center Hospital, National Center of Neurology and Psychiatry, Tokyo, JPN
| | - Hirofumi Komaki
- Department of Child Neurology, National Center Hospital, National Center of Neurology and Psychiatry, Tokyo, JPN
- Translational Medical Center, National Center of Neurology and Psychiatry, Tokyo, JPN
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15
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Rey Chaves CE, Fonseca JF, Ballen N, Bravo A, Becerra Sarmiento L, Parra Blanco FG, Peña Carvajalino LF, Azula Uribe MC. An unusual case of small bowel volvulus due to pneumatosis cystoides intestinalis: Case report and literature review. Int J Surg Case Rep 2024; 116:109328. [PMID: 38320416 PMCID: PMC10850951 DOI: 10.1016/j.ijscr.2024.109328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 01/27/2024] [Accepted: 01/29/2024] [Indexed: 02/08/2024] Open
Abstract
INTRODUCTION AND IMPORTANCE Pneumatosis cystoides intestinalis (PCI) is an uncommon condition characterized by intramural gas accumulation in the intestinal submucosa. Idiopathic or secondary is presented with non-specific clinical signs; in some cases, diagnosis is incidental. Its acute presentation is uncommon, and surgical management could be performed in selected cases. CASE PRESENTATION We present the case of an 85-year-old woman with 3 days of abdominal pain, 6 months of weight loss, and abdominal distension after meals. Abdominal computed tomography evidenced PCI at the small intestine with changes due to intestinal ischemia and internal mesenteric hernia. Intestinal resection and lateral-lateral mechanical anastomosis were performed with no complications after 90 days of follow-up. CLINICAL DISCUSSION PCI is an infrequent and benign condition; pathophysiology is, to date, poorly understood. Idiopathic or secondary to other gastrointestinal pathologies are described. The final diagnosis is performed with histopathological analysis. Nevertheless, in some cases, the benign nature could be presented as an acute abdomen, and surgical management should be in the physician's armamentarium. CONCLUSION PCI is an uncommon and benign entity. Nevertheless, in some cases, it could be presented as an acute abdomen. The surgical approach is appropriate, safe, and feasible.
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Affiliation(s)
- Carlos Eduardo Rey Chaves
- Estudiante de posgrado Cirugía General, Pontificia Universidad Javeriana, Facultad de Medicina. Bogotá, Colombia.
| | - Juan Fernando Fonseca
- Estudiante de posgrado Cirugía General, Pontificia Universidad Javeriana, Facultad de Medicina. Bogotá, Colombia
| | - Natalia Ballen
- Estudiante de posgrado Cirugía General, Pontificia Universidad Javeriana, Facultad de Medicina. Bogotá, Colombia
| | - Andrés Bravo
- Estudiante de posgrado Cirugía General, Pontificia Universidad Javeriana, Facultad de Medicina. Bogotá, Colombia
| | | | | | - Laura Felisa Peña Carvajalino
- Patologa, Pontificia Universidad Javeriana, Facultad de Medicina, Hospital Universitario San Ignacio, Bogotá, Colombia
| | - Maria Camila Azula Uribe
- Cirugía General, Pontificia Universidad Javeriana, Facultad de Medicina, Hospital Universitario San Ignacio, Bogotá, Colombia
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16
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Ichimata S, Hata Y, Yoshida K, Tanaka R, Nishida N. Sudden unexpected death of a young adult due to subarachnoid hemorrhage associated with polyarteritis nodosa: Clinicopathological appearance and literature review. Cardiovasc Pathol 2024; 69:107602. [PMID: 38072093 DOI: 10.1016/j.carpath.2023.107602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Revised: 11/21/2023] [Accepted: 12/05/2023] [Indexed: 12/30/2023] Open
Abstract
A 28-year-old male was found dead in his bedroom. There were no anomalies in his birth and medical history, and there was no family history of sudden unexpected death (SUD). Autopsy showed subarachnoid hemorrhage (SAH) with basilar top inflammatory pseudoaneurysm rupture accompanied by fibrinoid necrosis in the aneurysm wall. Active and healed arteritides in small- to medium-sized arteries were identified in the brain, heart, and systemic connective tissue, which was consistent with polyarteritis nodosa (PAN). Furthermore, pneumatosis cystoides intestinalis was observed in the ascending colon. Hepatitis B virus infection and antineutrophil nuclear antibodies were negative. Genetic investigation using whole-exome sequencing showed no mutations among autoinflammatory-related genes, including UBA1, MEFV, and ADA2. SAH due to rupture of a pseudoaneurysm formed by PAN was considered as the cause of death in the present case. Although myocardial ischemia linked to coronary arteritis is a recognized trigger for SUD in PAN, our study showed that rupture of inflammatory pseudoaneurysm in the cerebral artery can also cause SUD in younger subjects with PAN, even if prodromal symptoms are not evident before death.
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Affiliation(s)
- Shojiro Ichimata
- Department of Legal Medicine, Faculty of Medicine, University of Toyama, Toyama, Japan
| | - Yukiko Hata
- Department of Legal Medicine, Faculty of Medicine, University of Toyama, Toyama, Japan
| | - Koji Yoshida
- Department of Legal Medicine, Faculty of Medicine, University of Toyama, Toyama, Japan
| | - Ryo Tanaka
- Department of Neurology, Toyama University Hospital, Toyama, Japan
| | - Naoki Nishida
- Department of Legal Medicine, Faculty of Medicine, University of Toyama, Toyama, Japan.
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17
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Calenda CD, Toohey CR, Levy M, Bhardwaj A, Ubhi J, Sharma A, Abou Rizk F. Pneumatosis Intestinalis, Pneumoperitoneum, Pneumoretroperitoneum, Pneumomediastinum, and Pneumobilia After Pembrolizumab Therapy: A Case Report. Cureus 2024; 16:e55972. [PMID: 38601394 PMCID: PMC11004849 DOI: 10.7759/cureus.55972] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Accepted: 03/10/2024] [Indexed: 04/12/2024] Open
Abstract
Immune checkpoint inhibitors (ICIs) are becoming increasingly popular in treating cancers resistant to traditional chemotherapy. While ICIs have shown promise in treating cancer, the class of drugs also comes with certain risks, such as the development of pneumatosis intestinalis (PI) in rare cases. Pembrolizumab, an ICI that inhibits programmed cell death protein 1 (PD-1), has, in some rare instances, caused PI. Patients with ICI-induced PI may also present with pneumoperitoneum, pneumoretroperitoneum, pneumomediastinum, and pneumobilia. In the current report, we describe the presentation and management of a 50-year-old female with initial complaints of diffuse abdominal pain, constipation, abdominal distension, nausea, and decreased urine output approximately six months after beginning pembrolizumab and two months after the most recent dose of pembrolizumab. Subsequent CT imaging revealed massive PI with pneumoperitoneum, pneumoretroperitoneum, pneumomediastinum, and pneumobilia suspected to be secondary to pembrolizumab. Here, we discuss the possible mechanisms of ICI-induced PI and evaluate the management of patients presenting with PI and pneumoperitoneum.
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Affiliation(s)
- Charles D Calenda
- Medicine, College of Osteopathic Medicine, University of New England, Biddeford, USA
| | - Cameron R Toohey
- Medicine, College of Osteopathic Medicine, University of New England, Biddeford, USA
| | - Madeline Levy
- Medicine, College of Osteopathic Medicine, University of New England, Biddeford, USA
| | - AyJy Bhardwaj
- General Surgery, Concord Hospital - Laconia, Laconia, USA
| | - Jaspreet Ubhi
- Internal Medicine, Concord Hospital - Laconia, Laconia, USA
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18
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Sperling G, Shatila M, Varatharajalu K, Lu Y, Altan M, Zhou Y, Zhao D, De Toni EN, Török HP, Schneider BJ, Khan A, Thomas AS, Zhang HC, Shafi MA, Wang Y. Pneumatosis intestinalis in cancer patients who received immune checkpoint inhibitors. J Cancer Res Clin Oncol 2023; 149:17597-17605. [PMID: 37917197 DOI: 10.1007/s00432-023-05461-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2023] [Accepted: 10/05/2023] [Indexed: 11/04/2023]
Abstract
PURPOSE Immune checkpoint inhibitor (ICI) therapy may give rise to immune-related adverse events (irAEs). Pneumatosis intestinalis (PI), or gas within the bowel wall, has very rarely been observed following ICI therapy, and its clinical significance is unclear. We described the clinical characteristics and outcomes of PI as a possible irAE in cancer patients. METHODS We retrospectively identified 12 adult cancer patients with radiologic evidence of PI within 1 year after ICI exposure during January 2010-January 2023. Clinical characteristics, treatment, and outcomes were evaluated. RESULTS The median age of our sample was 64 years. The most common cancer types were thoracic/head & neck and gastrointestinal. Eleven patients (92%) received anti-PD-1/L1 monotherapy, while 1 patient (8%) received a combination of anti-PD-1/L1 and anti-CTLA-4. PI occurred a median of 7 months after the first ICI dose. Half the patients (50%) were asymptomatic on diagnosis, and the most common presenting symptom was abdominal pain (42%). Six patients experienced complications, namely pneumoperitoneum (n = 6, 50%) and microperforation (n = 1, 8%), identified on imaging. Nine patients were treated with antibiotics and 3 patients were monitored conservatively. Nine patients (75%) resumed cancer treatment after PI. CONCLUSION PI may develop as an irAE. While half of cases were incidental radiologic findings, management with antibiotics as well as hospitalization for observation may still be appropriate. The decision to restart cancer therapy and possibly resume ICI therapy remains to be elucidated. Further large-scale studies may be warranted to clarify the association between PI and ICI therapy.
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Affiliation(s)
- Gabriel Sperling
- School of Medicine, University of Texas Medical Branch, Galveston, TX, USA
| | - Malek Shatila
- Department of Gastroenterology, Hepatology, and Nutrition, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Unit 1466, Houston, TX, 77030, USA
| | - Krishnavathan Varatharajalu
- Department of Gastroenterology, Hepatology, and Nutrition, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Unit 1466, Houston, TX, 77030, USA
| | - Yang Lu
- Department of Nuclear Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Mehmet Altan
- Department of Thoracic/Head and Neck Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Yan Zhou
- Department of Hospital Medicine, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Dan Zhao
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Enrico N De Toni
- Department of Medicine II, University Hospital, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Helga-Paula Török
- Department of Medicine II, University Hospital, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Bryan J Schneider
- Department of Thoracic Medical Oncology, The University of Michigan, Ann Arbor, MI, USA
| | - Anam Khan
- Department of Gastroenterology, Hepatology, and Nutrition, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Unit 1466, Houston, TX, 77030, USA
| | - Anusha S Thomas
- Department of Gastroenterology, Hepatology, and Nutrition, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Unit 1466, Houston, TX, 77030, USA
| | - Hao Chi Zhang
- Department of Gastroenterology, Hepatology, and Nutrition, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Unit 1466, Houston, TX, 77030, USA
| | - Mehnaz A Shafi
- Department of Gastroenterology, Hepatology, and Nutrition, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Unit 1466, Houston, TX, 77030, USA
| | - Yinghong Wang
- Department of Gastroenterology, Hepatology, and Nutrition, The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Unit 1466, Houston, TX, 77030, USA.
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19
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Erdem S, Patel SV, Patel D, Patel S, Patel S, Chaudhary AJ. Understanding the Nuances of Hepatic Portal Venous Gas in Pneumatosis Intestinalis: An Indication of Bowel Ischemia? Cureus 2023; 15:e45330. [PMID: 37849594 PMCID: PMC10577153 DOI: 10.7759/cureus.45330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/15/2023] [Indexed: 10/19/2023] Open
Abstract
Pneumatosis intestinalis (PI) is a relatively rare gastrointestinal finding that has a wide variety of causes - ranging from benign to life-threatening. It is described as the pathological presence of gas within the bowel wall with multiple hypotheses emerging as to the likely mechanism. An important indicator of a life-threatening source of PI is the presence of gas within the hepatic portal vein, referred to as hepatic portal venous gas (HPVG). While non-specific for isolated PI, HPVG has been reported in PI patients to be associated with bowel ischemia and is thereby considered an indication for emergent management. Herein we report a case involving an atypical presentation of altered mental status in which the patient was found to have PI with contemporaneous HPVG. These findings have been reported to have a high mortality rate. Our patient rapidly deteriorated during their hospital course, expiring shortly after being deemed a poor surgical candidate due to their severe co-morbidity burden. Through this case, we review evidence supporting the management of patients with PI and concurrent HPVG from an extensive review of available literature. While PI is a non-specific finding and commonly a source of diagnostic confusion, a better understanding of its natural course and potentially unorthodox sequela may afford more directed and crucial care for critically ill patients, in which time is often a precious commodity.
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Affiliation(s)
- Saliha Erdem
- Internal Medicine, Wayne State University School of Medicine, Detroit, USA
| | - Suraj V Patel
- Internal Medicine, Ross University School of Medicine, Miramar, USA
| | - Dhruvil Patel
- Internal Medicine, Wayne State University School of Medicine, Detroit, USA
| | - Shivam Patel
- Biomedical Sciences, University of South Florida, Tampa, USA
| | - Shlok Patel
- Pharmaceutical Science, University of Michigan, Ann Arbor, USA
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20
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Mehl L, Schmidt C, Weidner U, Lock G. Sonographically Detected Hepatic Portal Venous Gas - Prevalence, Causes, and Clinical Implications. ULTRASCHALL IN DER MEDIZIN (STUTTGART, GERMANY : 1980) 2023; 44:408-413. [PMID: 35483869 DOI: 10.1055/a-1797-9986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
PURPOSE Hepatic portal venous gas (HPVG) is a rare clinical finding, often caused by a severe underlying disease. In the literature as well as in clinical practice, HPVG is considered "signum malum" with a poor prognosis and bowel ischemia as the most common cause. Most studies are based on the results of computed tomography (CT) examinations. The aim of this retrospective study is to report on the prevalence, causes, and clinical course of HPVG in a monocentric cohort of abdominal ultrasound (US) investigations. MATERIALS AND METHODS The US database of an academic teaching hospital was searched with specific keywords (timespan 01/2000 to 12/2020). Reports, pictures, and clinical data of all cases with HPVG were re-evaluated. RESULTS Out of 134 804 US examinations, 8 HPVG cases were identified. There was a wide variety of underlying diseases, with mesenteric ischemia being seen in only 2 cases. 5 patients were discharged in stable condition, with 4 of them having undergone surgical treatment. 2 patients who had rejected further measures died, and one was lost to follow-up. DISCUSSION HPVG is a rare phenomenon in clinical US. However, ultrasonographic prevalence is comparable to the prevalence in CT studies. Underlying diseases are mostly severe, and in nearly all cases an underlying cause can be found by thorough investigation. In some cases, US may even be superior to CT scans for the detection of HPVG. Despite its rarity, every sonographer should know the typical sonographic presentation of HPVG, and appropriate images should be included in US teaching modules.
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Affiliation(s)
- Lisa Mehl
- Internal Medicine, Albertinen Hospital, Hamburg, Germany
| | | | - Ulrike Weidner
- Institute for Radiology, Albertinen Hospital, Hamburg, Germany
| | - Guntram Lock
- Internal Medicine, Albertinen Hospital, Hamburg, Germany
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21
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Hiyama T, Hasegawa A, Komatsu S, Kikuchi A, Maezawa R, Kurasawa K. Pneumatosis intestinalis in a patient with anti-synthetase syndrome. Oxf Med Case Reports 2023; 2023:omad068. [PMID: 37484559 PMCID: PMC10359063 DOI: 10.1093/omcr/omad068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 05/10/2023] [Accepted: 05/29/2023] [Indexed: 07/25/2023] Open
Affiliation(s)
- Tomoka Hiyama
- Department of Rheumatology, Dokkyo Medical University, Mibu, Tochigi, Japan
| | - Anna Hasegawa
- Department of Rheumatology, Dokkyo Medical University, Mibu, Tochigi, Japan
| | - Sara Komatsu
- Department of Rheumatology, Dokkyo Medical University, Mibu, Tochigi, Japan
| | - Azusa Kikuchi
- Department of Rheumatology, Dokkyo Medical University, Mibu, Tochigi, Japan
| | - Reika Maezawa
- Department of Rheumatology, Dokkyo Medical University, Mibu, Tochigi, Japan
| | - Kazuhiro Kurasawa
- Correspondence address. Department of Rheumatology, Dokkyo Medical University, Kita-Kobayashi 880, Mibu, 321-0293 Tochigi, Japan. Tel: +81-282-87-2496; Fax: +81-282-86-7566; E-mail:
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22
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Tropeano G, Di Grezia M, Puccioni C, Bianchi V, Pepe G, Fico V, Altieri G, Brisinda G. The spectrum of pneumatosis intestinalis in the adult. A surgical dilemma. World J Gastrointest Surg 2023; 15:553-565. [PMID: 37206077 PMCID: PMC10190725 DOI: 10.4240/wjgs.v15.i4.553] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 02/10/2023] [Accepted: 03/21/2023] [Indexed: 04/22/2023] Open
Abstract
Pneumatosis intestinalis (PI) is a striking radiological diagnosis. Formerly a rare diagnostic finding, it is becoming more frequently diagnosed due to the wider availability and improvement of computed tomography scan imaging. Once associated only with poor outcome, its clinical and prognostic significance nowadays has to be cross-referenced to the nature of the underlying condition. Multiple mechanisms of pathogenesis have been debated and multiple causes have been detected during the years. All this contributes to creating a broad range of clinical and radiological presentations. The management of patients presenting PI is related to the determining cause if it is identified. Otherwise, in particular if an association with portal venous gas and/or pneumoperitoneum is present, the eventual decision between surgery and non-operative management is challenging, even for stable patients, since this clinical condition is traditionally associated to intestinal ischemia and consequently to pending clinical collapse if not treated. Considering the wide variety of origin and outcomes, PI still remains for surgeons a demanding clinical entity. The manuscript is an updated narrative review and gives some suggestions that may help make the decisional process easier, identifying patients who can benefit from surgical intervention and those who can benefit from non-operative management avoiding unnecessary procedures.
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Affiliation(s)
- Giuseppe Tropeano
- Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome 00168, Italy
| | - Marta Di Grezia
- Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome 00168, Italy
| | - Caterina Puccioni
- Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome 00168, Italy
| | - Valentina Bianchi
- Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome 00168, Italy
| | - Gilda Pepe
- Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome 00168, Italy
| | - Valeria Fico
- Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome 00168, Italy
| | - Gaia Altieri
- Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome 00168, Italy
| | - Giuseppe Brisinda
- Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome 00168, Italy
- Department of Surgery, Università Cattolica del Sacro Cuore, Rome 00168, Italy
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23
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Wang C, Zhang Y. Acarbose associated pneumatosis cystoides intestinalis: A case report. Int J Diabetes Dev Ctries 2023. [DOI: 10.1007/s13410-023-01191-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/01/2023] Open
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Miller B, Taj S, Pannu VS, Tavakolian K, Joseph L, Hossain MA. Ominous Sign of Pneumatosis Intestinalis With Portal Venous Gas. Cureus 2023; 15:e35605. [PMID: 37007392 PMCID: PMC10063244 DOI: 10.7759/cureus.35605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/26/2023] [Indexed: 03/06/2023] Open
Abstract
The presence of gas and free air in the extraluminal space of the intestines is known as pneumatosis intestinalis (PI). There are many different causes of this finding, including gastrointestinal, pulmonary, autoimmune, and many more. It is often difficult to differentiate the etiology and clinical importance of the radiographic evidence on pneumatosis intestinalis due to the unclear pathophysiology causing the disease. To complicate things further, the ominous sign of portal venous gas poses the question of whether surgical intervention is needed. We report two cases both with clinical and radiographic evidence of secondary pneumatosis intestinalis with an associated sinister finding of portal venous gas. The cases differ by urgent surgical intervention versus observation before surgery. In this case series, we emphasize the importance of recognizing the radiographic finding and stress the need for further research to standardize a plan of care, including indications for surgery. We encourage more cases like this to be reported to aid in diagnosing and treating this condition early on with the aim of improving the mortality associated with it.
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Belloch Ripollés V, Muñoz Núñez C, Fontana Bellorín A, Batista Doménech A, Boukhoubza A, Parra Hernández M, Martí-Bonmatí L. Valoración de la neumatosis intestinal como complicación del trasplante pulmonar. RADIOLOGIA 2023. [DOI: 10.1016/j.rx.2023.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023]
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Kyaw NK, Abubakar M, Shekhda KM, Tageldeen R, Afifi W, Halliru FM, Ibrahim YW. Man with Acute Abdomen. Oman Med J 2023; 38:e473. [PMID: 36825247 PMCID: PMC9941422 DOI: 10.5001/omj.2023.09] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 09/25/2021] [Indexed: 11/03/2022] Open
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Pswarayi R, Sanders CJ. Pneumatosis cystoides intestinalis: A complicated case presentation. Ann Med Surg (Lond) 2022; 82:104514. [PMID: 36268340 PMCID: PMC9577395 DOI: 10.1016/j.amsu.2022.104514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 08/21/2022] [Accepted: 08/21/2022] [Indexed: 10/27/2022] Open
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Chihab M, Qadabashi K, Abbas H, Attar M, Aljaber A, Alabd M, Ayoub K. Acute abdomen with gastric volvulus revealing an underlying pneumatosis cystoides intestinalis: a case report. BMC Surg 2022; 22:267. [PMID: 35820895 PMCID: PMC9277939 DOI: 10.1186/s12893-022-01717-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 07/06/2022] [Indexed: 11/28/2022] Open
Abstract
Background Pneumatosis intestinalis is an abnormal presence of free air outside the lumen of the intestines in many shapes. It is classified based on its etiology to primary or secondary, it affects adults as well as infants and can involve any part of the GI tract. Case presentation We report a case of a 55-year-old man with a past medical history of a surgically repaired perforated duodenal ulcer who presented with an acute abdominal pain, Flatulence and constipation. On examination of the abdomen; severe distension, tenderness and tympanicity on percussion were noted. An erect CXR was performed and showed bilateral sub-diaphragmatic air levels. We performed an abdominal Paracentesis under the right subcostal margin which led to evacuation of large amounts of air. Next, an investigational laparotomy showed that the reason was a gastric volvulus associated with an anterior and posterior gastric wall lacerations. The suitable surgical repair approach was taken, but another lesion was detected incidentally. A pneumatosis cystoides intestinalis (PCI) was extended along large length of the intestines in many shapes and without any symptoms or signs. Conclusions Pneumatosis cystoides intestinalis has been reported continuously in relation to peptic ulcer disease (PUD). We aim to report a new association of a gastric volvulus and PCI secondary to pyloric stenosis caused by a duodenal ulcer; which we believe can aid in the diagnosing of dangerous complications, of a rare disease.
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Affiliation(s)
- Mtanyous Chihab
- Department of Internal Medicine, Aleppo University Hospital, University of Aleppo, Aleppo, Syria
| | - Khaled Qadabashi
- Department of Internal Medicine, Aleppo University Hospital, University of Aleppo, Aleppo, Syria.
| | - Huda Abbas
- Faculty of Medicine, University of Aleppo, Aleppo, Syria
| | - Maysam Attar
- Faculty of Medicine, University of Aleppo, Aleppo, Syria
| | - Ahmad Aljaber
- Department of General Surgery, Aleppo University Hospital, University of Aleppo, Aleppo, Syria
| | - Maden Alabd
- Department of General Surgery, Aleppo University Hospital, University of Aleppo, Aleppo, Syria
| | - Kusay Ayoub
- Department of General Surgery, Aleppo University Hospital, University of Aleppo, Aleppo, Syria
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Sumbal R, Ali Baig MM, Sumbal A. Predictors of Mortality in Acute Mesenteric Ischemia: A Systematic Review and Meta-Analysis. J Surg Res 2022; 275:72-86. [DOI: 10.1016/j.jss.2022.01.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2021] [Revised: 12/24/2021] [Accepted: 01/27/2022] [Indexed: 12/12/2022]
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Lassandro G, Picchi SG, Romano F, Sica G, Lieto R, Bocchini G, Guarino S, Lassandro F. Intestinal pneumatosis: differential diagnosis. Abdom Radiol (NY) 2022; 47:1529-1540. [PMID: 32737548 DOI: 10.1007/s00261-020-02639-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 06/21/2020] [Accepted: 07/04/2020] [Indexed: 01/04/2023]
Abstract
Intestinal pneumatosis (IP) is an infrequent radiological sign defined as pathological gas infiltration into the bowel wall. It may be associated to different underlying clinical conditions-inflammatory bowel diseases, malignancies, chemotherapy, infections, immune deficiency status, trauma, intestinal ischemia, and necrosis-that are often related to emergency state and require a prompt diagnosis. All the imaging techniques, especially abdominal radiography and Computed Tomography, could detect the presence of IP and discern the forms related to emergency conditions. The differential diagnosis is essential to start an immediate clinical or surgical management and treatment. The aim of this article is to review the radiological features of IP in different illnesses, with particular attention to differential diagnosis.
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Affiliation(s)
- Giulia Lassandro
- Department of Advanced Biomedical Sciences, Federico II University, Naples, Italy
| | | | | | - Giacomo Sica
- Department of Radiology, Monaldi Hospital, Naples, Italy
| | - Roberta Lieto
- Department of Radiology, Monaldi Hospital, Naples, Italy
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Abramov A, Luks VL, De Bie F, Hwang R, Allukian M, Nace GW. Pneumatosis intestinalis in children beyond the neonatal period: is it always benign? Pediatr Surg Int 2022; 38:399-407. [PMID: 34837497 DOI: 10.1007/s00383-021-05048-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/20/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE The significance and management of pediatric pneumatosis intestinalis (PI) remains poorly defined. We sought to add clarity in children beyond the neonatal period. METHODS Pediatric patients 3 months-18 years admitted to a quaternary children's hospital with a diagnosis of PI were included in this retrospective study. Pathologic PI was defined as irreversible, transmural intestinal ischemia. RESULTS 167 children were identified with PI. Of these children, 155 (92.8%) had benign PI and 12 (7.2%) developed pathologic PI. The most common underlying diagnosis for pathologic PI was global developmental delay (75%), although we identified a spectrum of underlying diagnoses at risk for PI. Physical exam notable for abdominal distension (p = 0.023) or guarding (p = 0.028), and imaging with portal venous gas (p < 0.001) or bowel distension (p = 0.001) were significantly associated with pathologic PI. Only 6.6% of all children underwent an operation. For those undergoing non-surgical management of benign PI, 75% of children received antibiotics and average duration of bowel rest was 6.8 days. CONCLUSIONS PI in children is primarily a benign phenomenon and often does not warrant surgical intervention. Bowel rest and antibiotics are therapeutic strategies frequently used in the treatment of this finding.
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Affiliation(s)
- Alexey Abramov
- Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Valerie L Luks
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Felix De Bie
- Division of Pediatric General, Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Rosa Hwang
- Division of Pediatric General, Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Myron Allukian
- Division of Pediatric General, Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Gary W Nace
- Division of Pediatric General, Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA.
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Wessling J, Schreyer A, Grenacher L, Juchems M, Ringe K. [Incidental and "leave me alone" findings of the GI tract-part 2 : Intestinal wall and mesentery]. Radiologe 2022; 62:167-178. [PMID: 35088094 DOI: 10.1007/s00117-021-00964-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/21/2021] [Indexed: 11/25/2022]
Abstract
Due to the widespread use of computed tomography (CT) and magnetic resonance imaging (MRI) asymptomatic incidental findings of the gastrointestinal (GI) tract are increasingly being recognized. Incidental findings are frequently not part of the primary inquiry from referring physicians but it is obligatory to make a diagnosis and to stipulate the need for further clarification. A multitude of incidental findings in the intestinal lumen, in the intestinal wall and in the adjacent mesentery or subperitoneal space are shown in CT and MRI of the GI tract. The last part of the two-part review addresses the gastrointestinal incidental findings in the intestinal wall and the adjacent sections. Extramural incidental findings occur as mesenteric inflammation, tumors and cysts. Many of the findings can be classified as benign and as "leave me alone lesions" do not necessitate any further clarification but in contrast others need a definitive clarification. The most important incidental findings in the GI tract are systematically classified, illustrated and evaluated with respect to the clinical relevance, depending on the localization (e.g. stomach, small and large intestines).
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Affiliation(s)
- J Wessling
- Zentrum für Radiologie und Neuroradiologie, Clemenshospital, Raphaelsklinik, EVK Münster, Düesbergweg 24, 48153, Münster, Deutschland.
| | - A Schreyer
- Institut für Diagnostische und Interventionelle Radiologie, Universitätsklinikum der Medizinischen Hochschule Brandenburg, Hochstr. 29, 14770, Brandenburg, Deutschland
| | - L Grenacher
- Conradia Radiologie München, Augustenstr. 115, 80798, München, Deutschland
| | - M Juchems
- Diagnostische und Interventionelle Radiologie, Klinikum Konstanz, Mainaustr. 35, 78464, Konstanz, Deutschland
| | - K Ringe
- Institut für Diagnostische und Interventionelle Radiologie, Medizinische Hochschule Hannover, Carl-Neuberg-Str. 1, 30625, Hannover, Deutschland
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Zhang Q, Niu X, Wang C, He Q, Xiang J. Pneumatosis cystoides intestinalis: A case report. Medicine (Baltimore) 2022; 101:e28588. [PMID: 35060523 PMCID: PMC8772708 DOI: 10.1097/md.0000000000028588] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 12/27/2021] [Indexed: 01/05/2023] Open
Abstract
RATIONALE Pneumatosis cystoides intestinalis (PCI) is a rare condition characterized by multiple gas-filled cysts in the intestinal wall, and can be caused by many conditions. PATIENT CONCERNS We reported a-69-year-old man with a long history of chronic obstructive pulmonary disease was admitted to the gastroenterology department because of alternating bowel movement and intermittent bloody stool. DIAGNOSES Colonoscopy revealed multiple nodular protuberances covered with normal-looking mucosa in the ascending and proximal transverse colon. Abdominal computed tomography scan and endoscopic ultrasound revealed multiple gas-filled cystic lesions in the submucosa. The diagnosis of PCI was confirmed by cyst collapse after puncturing with a fine needle. INTERVENTIONS AND OUTCOMES Considering that the patient had no peritonitis or other complications, conservative approaches, including oxygen inhalation and oral probiotics, were used. The patient was transferred to the anorectal department after 5days of clinical observation in good condition to further treat hemorrhoids. LESSONS PCI is a rare condition that may be secondary to many other diseases. Because of its atypical clinical manifestations, it can be misdiagnosed as other diseases, such as polyps, inflammatory bowel disease, and even cancer. The diagnosis of PCI depends on computed tomography, colonoscopy, and endoscopic ultrasonography. Fine-needle aspiration may be helpful in the diagnosis and treatment of PCI.
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Affiliation(s)
- Qiuyu Zhang
- Department of Gastroenterology, Affiliated Hospital & Clinical Medical College of Chengdu University, Chengdu, Sichuan, China
| | - Xiangke Niu
- Department of Radiology, Affiliated Hospital & Clinical Medical College of Chengdu University, Chengdu, Sichuan, China
| | - Cong Wang
- Department of Gastroenterology, Affiliated Hospital & Clinical Medical College of Chengdu University, Chengdu, Sichuan, China
| | - Qiang He
- Department of Gastroenterology, Affiliated Hospital & Clinical Medical College of Chengdu University, Chengdu, Sichuan, China
| | - Junying Xiang
- Department of Gastroenterology, Affiliated Hospital & Clinical Medical College of Chengdu University, Chengdu, Sichuan, China
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Ito N, Masuda T, Yamaguchi K, Sakamoto S, Horimasu Y, Nakashima T, Miyamoto S, Iwamoto H, Fujitaka K, Hamada H, Hattori N. Pneumatosis Intestinalis following Radiation Esophagitis during Chemoradiotherapy for Lung Cancer: A Case Report. Case Rep Oncol 2021; 14:1454-1459. [PMID: 34899236 PMCID: PMC8613634 DOI: 10.1159/000518315] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Accepted: 07/05/2021] [Indexed: 11/19/2022] Open
Abstract
Pneumatosis intestinalis (PI) is a rare disease that forms emphysema lesions under the mucosa and serosa of the gastrointestinal tract. We present the first case of PI following radiation-induced esophagitis during chemoradiotherapy (CRT) for lung cancer. A 74-year-old man with severe chronic obstructive pulmonary disease (COPD) was treated with CRT for lung cancer. During the treatment, he presented with vomiting and abdominal distention. CT showed pneumatosis from the esophagus to the small intestine. Severe radiation-induced esophagitis was observed, and gastrointestinal endoscopy revealed a circumferential esophageal ulcer. From these observations, this case was diagnosed as PI following severe esophagitis. A nasogastric tube was inserted, and conservative treatment with fasting, fluid replacement, and antibiotic was performed. Four days after the onset of PI, CT showed marked improvement of the pneumatosis. When CRT is performed for lung cancer patients, we should not only consider esophagitis but also PI. The presence of COPD may be considered a specific factor for the development of severe esophagitis and the consequent PI in this case.
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Affiliation(s)
- Noriaki Ito
- Department of Respiratory Medicine, Hiroshima University Hospital, Hiroshima, Japan
| | - Takeshi Masuda
- Department of Respiratory Medicine, Hiroshima University Hospital, Hiroshima, Japan
| | - Kakuhiro Yamaguchi
- Department of Respiratory Medicine, Hiroshima University Hospital, Hiroshima, Japan
| | - Shinjiro Sakamoto
- Department of Respiratory Medicine, Hiroshima University Hospital, Hiroshima, Japan
| | - Yasushi Horimasu
- Department of Respiratory Medicine, Hiroshima University Hospital, Hiroshima, Japan
| | - Taku Nakashima
- Department of Respiratory Medicine, Hiroshima University Hospital, Hiroshima, Japan
| | - Shintaro Miyamoto
- Department of Respiratory Medicine, Hiroshima University Hospital, Hiroshima, Japan
| | - Hiroshi Iwamoto
- Department of Molecular and Internal Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Kazunori Fujitaka
- Department of Molecular and Internal Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Hironobu Hamada
- Department of Physical Analysis and Therapeutic Sciences, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Noboru Hattori
- Department of Molecular and Internal Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
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Van Den Bosch J, Broos P, Vijgen G. Is surgical exploration necessary in asymptomatic intestinal pneumatosis after lung transplantation? BMJ Case Rep 2021; 14:e243955. [PMID: 34772675 PMCID: PMC8593612 DOI: 10.1136/bcr-2021-243955] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/29/2021] [Indexed: 11/03/2022] Open
Abstract
Pneumatosis intestinalis is described as gas within the bowel wall and can be a sign of bowel ischaemia with a pending perforation. The described patient presented with the incidental diagnosis of pneumatosis intestinalis with free intraperitoneal gas on CT scan. His medical history included a successful lung transplantation. We here describe the clinical decision-making and evaluate our case with previous cases in the literature.
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Affiliation(s)
| | - Pieter Broos
- Surgery, Zuyderland Medical Centre Heerlen, Heerlen, Netherlands
| | - Guy Vijgen
- Surgery, Zuyderland Medical Centre Heerlen, Heerlen, Netherlands
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36
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Wallace G, Rosen N, Towbin AJ, Jodele S, Myers KC, Davies SM, Flannery A, Gurria JP. Pneumatosis intestinalis after hematopoietic stem cell transplantation: When not doing anything is good enough. J Pediatr Surg 2021; 56:2073-2077. [PMID: 33455803 DOI: 10.1016/j.jpedsurg.2020.12.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2020] [Revised: 12/19/2020] [Accepted: 12/28/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND/PURPOSE Pneumatosis intestinalis (PI) has been reported in hematopoietic stem cell transplant recipients (HSCT) since 1980s and at present there is no uniform consensus of the significance and management of this condition. METHODS We retrospectively reviewed medical records of 990 consecutive pediatric HSCT recipients and examined data for clinical PI presentation, management and outcomes RESULTS: PI was identified in 53 patients (5.4%), mainly allogeneic HSCT recipients receiving systemic steroids. Abdominal X-ray was the main diagnostic modality. Forty-seven patients (89%) were evaluated because of clinical concerns and others were identified as incidental findings. Pneumoperitoneum was reported in 15 patients (28%). None of these patients had signs of acute abdomen. The majority of patients (43/53, 81%) had no targeted clinical intervention for PI and resolved PI in a median of 15 days (IQR 3-61). Surgery consult was only requested for 7/53 (13%) patients, three of whom had evidence of pneumoperitoneum. None of these patients required any surgical interventions. CONCLUSIONS Pneumatosis intestinalis commonly occurs in HSCT recipient receiving steroids, but unlike with NEC, PI rarely poses clinical risk after transplant. The majority of HSCT recipients with PI require only close monitoring without interventions. Surgical evaluation should be based on clinical symptoms and not PI presence alone.
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Affiliation(s)
- Gregory Wallace
- Division of Bone Marrow Transplant and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; University of Cincinnati, Cincinnati, OH, USA.
| | - Nelson Rosen
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center Cincinnati, OH, USA; University of Cincinnati, Cincinnati, OH, USA
| | - Alexander J Towbin
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; University of Cincinnati, Cincinnati, OH, USA
| | - Sonata Jodele
- Division of Bone Marrow Transplant and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; University of Cincinnati, Cincinnati, OH, USA
| | - Kasiani C Myers
- Division of Bone Marrow Transplant and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; University of Cincinnati, Cincinnati, OH, USA
| | - Stella M Davies
- Division of Bone Marrow Transplant and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; University of Cincinnati, Cincinnati, OH, USA
| | - Amanda Flannery
- Division of Bone Marrow Transplant and Immune Deficiency, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; University of Cincinnati, Cincinnati, OH, USA
| | - Juan P Gurria
- Surgical Critical Care / Pediatric Surgery, Phoenix Children's Hospital / Mayo Clinic, Phoenix, AZ, USA
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Miratashi Yazdi SA, Chinisaz F, Mohammadi L, Najjari K, Zabihi Mahmoudabadi H. Intestinal volvulus secondary to pneumatosis intestinalis: A case report. Int J Surg Case Rep 2021; 88:106515. [PMID: 34695667 PMCID: PMC8554248 DOI: 10.1016/j.ijscr.2021.106515] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 10/09/2021] [Accepted: 10/13/2021] [Indexed: 10/26/2022] Open
Abstract
INTRODUCTION AND IMPORTANCE Pneumatosis intestinalis (PI) is a rare but important medical condition that is defined as a collection of individual gas cysts in the submucosa and subserosa of the intestine. PI can be primary or secondary; however, this condition is secondary to underlying diseases most of the time. CASE PRESENTATION This article presents a 30-year-old man as a case report complaining of generalized abdominal pain and several episodes of non-bilious bloodless vomiting. The patient was admitted to the surgical service department for further investigation, and his abdominal CT scan revealed PI. CLINICAL DISCUSSION The patient underwent emergency laparotomy surgery due to progressive abdominal pain and peritonitis. The involved segment of the small intestine was resected, and ileo-ileal anastomosis was performed. The patient was discharged from the hospital after a week, stable, and in good medical condition. CONCLUSION This article intends to emphasize that although most of the patients with PI are asymptomatic or show unspecific symptoms, surgeons must take into account rare but lethal complications of PI such as intestinal volvulus. Early recognition of such complications is so crucial and can be life-saving.
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Affiliation(s)
| | - Fatemeh Chinisaz
- Students' Scientific Research Center, Tehran University of Medical Sciences, Tehran, Iran
| | - Lida Mohammadi
- Department of Surgery, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Khosrow Najjari
- Department of Surgery, Sina Hospital, Tehran University of Medical Sciences, Tehran, Iran
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De Groot Ta A, Farrell M, Dillman JR, Trout AT. Clinical Predictors and Outcomes for Recurrent Pneumatosis Intestinalis in Children: A Case Control Study. J Pediatr Gastroenterol Nutr 2021; 73:e87-e93. [PMID: 34183613 PMCID: PMC11097597 DOI: 10.1097/mpg.0000000000003216] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
INTRODUCTION Pneumatosis intestinalis (PI) is air collections within the wall of the intestine that can be associated with life threatening conditions. Recurrent episodes of PI have been reported; however, little is known about risks for recurrent disease. This study aims to identify predictors of recurrent PI and evaluate long-term outcomes in patients with recurrent PI. METHODS This retrospective case-control study evaluated patients, ages 6 months to 18 years, with imaging evidence of PI over a 30-month period. Images were analyzed by consensus to confirm PI. Recurrent PI was defined as new findings of PI after resolution by imaging and/or at least 1-month interval between episodes of PI. Univariate and multivariable analyses were performed using logistic regression, with significance set to P < 0.05. RESULTS Forty-six children were included. Recurrent PI occurred in 17 (37%) patients, with a total of 39 episodes. Predictors of recurrent PI all related to the segment of bowel involved with small bowel PI predictive of recurrent PI (odds ratio [OR] 1.6; 95% confidence interval [CI] 1.01, 2.4) and colonic PI protective (OR 0.6; 95% CI 0.4, 0.87) after adjusting for age. Predictors for surgical intervention included cerebral palsy (OR 17; 95% CI 1.7, 167) and PI involving small bowel (OR 19; 95% 3.1, 114). CONCLUSION Location of PI is predictive of recurrence. Clinical outcomes were similar between groups with single episode and recurrent PI.
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Affiliation(s)
- Allison De Groot Ta
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Michael Farrell
- Division of Gastroenterology, Hepatology and Nutrition, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Jonathan R. Dillman
- Department of Radiology, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
- Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH
| | - Andrew T. Trout
- Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
- Department of Radiology, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH
- Department of Radiology, University of Cincinnati College of Medicine, Cincinnati, OH
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Duan G, Qi M, Guo Q, Song Z. Primary amyloidosis involving the gastrointestinal tract, mesentery and omentum: A case report. Exp Ther Med 2021; 22:1145. [PMID: 34504590 PMCID: PMC8393627 DOI: 10.3892/etm.2021.10579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2020] [Accepted: 09/11/2020] [Indexed: 11/05/2022] Open
Abstract
Amyloidosis, a systemic disease characterized by the deposition of misfolded protein, is difficult to rapidly diagnose due to its wide range of symptoms. The present study reported on a case of primary amyloidosis (AL) with involvement of the gastrointestinal tract, mesentery and omentum in a 66-year-old male presenting with recurrent diarrhoea and abdominal distension. Oesophagogastroduodenoscopy and enteroscopy revealed multiple gastric ulcers and multiple protuberant lesions in the colon. Laparotomy indicated multiple nodules in the mesentery of the small intestine. Contrast-enhanced CT revealed dilation of the small bowel with pneumatosis intestinalis and positive Congo red staining of gastric mucosa and mesentery biopsy specimens confirmed amyloid deposition. Therefore, the patient was diagnosed with AL. In this case, the clinical manifestation of mesentery amyloidosis was multiple nodules and extensive peritoneal adhesions, which, to the best of our knowledge, has not been reported by any previous study.
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Affiliation(s)
- Guihua Duan
- Department of Gastroenterology, The First People's Hospital of Yunnan Province, The Affiliated Hospital of Kunming University of Science and Technology, Kunming, Yunnan 650032, P.R. China
| | - Min Qi
- Department of Radiology, The Third People's Hospital of Kunming City, The Sixth Affiliated Hospital of Dali University, Kunming, Yunnan 650041, P.R. China
| | - Qiang Guo
- Department of Gastroenterology, The First People's Hospital of Yunnan Province, The Affiliated Hospital of Kunming University of Science and Technology, Kunming, Yunnan 650032, P.R. China
| | - Zhengji Song
- Department of Gastroenterology, The First People's Hospital of Yunnan Province, The Affiliated Hospital of Kunming University of Science and Technology, Kunming, Yunnan 650032, P.R. China
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Uchiyama AAT, Lopes MDSM, Vana MNM, Peixoto RD. Clostridium difficile Infection Leading to Intestinal Pneumatosis in a Patient with a Recent Diagnosis of Pancreatic Cancer Local Recurrence: A Case Report and Literature Review. Case Rep Oncol 2021; 14:1111-1117. [PMID: 34413741 PMCID: PMC8339445 DOI: 10.1159/000513003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 11/05/2020] [Indexed: 11/19/2022] Open
Abstract
Clostridium difficile infection (CDI) causing pneumatosis intestinalis (PI) is a rare event, described mostly in immunocompromised patients. We present the case of a 65-year-old female diagnosed with adenocarcinoma of the pancreas who underwent a duodenopancreatectomy with lymphadenectomy and adjuvant gemcitabine and capecitabine. Four months after the end of chemotherapy, she experienced abdominal pain and intermittent diarrhea which became aggravated within 6 months. CT scans revealed diffuse intestinal pneumatosis and recurrence of ductal adenocarcinoma. We hypothesize that local pancreatic cancer recurrence may lead to gastrointestinal dysmotility with consequent increased risk for CDI. The patient had almost complete resolution of PI during the CDI treatment, thus we believe that the CDI was directly responsible for PI in this case.
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Pirola L, Palermo A, Mulinacci G, Ratti L, Fichera M, Invernizzi P, Viganò C, Massironi S. Acute mesenteric ischemia and small bowel imaging findings in COVID-19: A comprehensive review of the literature. World J Gastrointest Surg 2021; 13:702-716. [PMID: 34354803 PMCID: PMC8316849 DOI: 10.4240/wjgs.v13.i7.702] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 04/12/2021] [Accepted: 07/02/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Coronavirus disease 2019 (COVID-19), an infectious condition caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), has rapidly spread worldwide since its first description in Wuhan in December 2019. Even though respiratory manifestations are the most prevalent and responsible for disease morbidity and mortality, extrapulmonary involvement has progressively gained relevance. In particular, gastrointestinal (GI) signs and symptoms, reported in up to two-thirds of patients with COVID-19, might represent the first and, in some cases, the only disease presentation. Their presence has been associated in some studies with an increased risk of a severe disease course. Proposed pathogenic mechanisms explaining GI tract involvement are either direct viral access to intestinal cells via angiotensin-converting enzyme 2 or indirect damage of the intestinal wall through mesenteric ischemia induced by the hypercoagulable state associated with COVID-19 infection. Although not typical of SARS-CoV-2 infection, several small bowel manifestations have been described in infected patients who underwent any form of abdominal imaging. The radiological findings were mainly reported in patients with abdominal symptoms, among which abdominal pain was the most common. AIM To discuss small bowel radiological manifestations of SARS-CoV-2 infection in abdominal imaging studies. METHODS Bibliographical searches were performed in PubMed, using the following keywords: "COVID-19" AND "imaging" AND "gastrointestinal" OR "abdominal" OR "small bowel". RESULTS Of 62 patients with described radiologic small bowel alterations, mesenteric ischemia was diagnosed in 31 cases (50%), small bowel wall thickening in 10 cases (16%), pneumatosis in nine cases (15%), intussusception in eight cases (13%), pneumoperitoneum in two cases (3%) and paralytic ileus in two cases (3%). We also reported mesenteric adipose tissue hypertrophy and lymph nodes enlargement in a young woman. CONCLUSION So far it is difficult to establish whether these manifestations are the direct consequence of SARS-CoV-2 infection or collateral findings in infected patients, but their recognition would be pivotal to set a closer follow-up and to reduce missed diagnoses.
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Affiliation(s)
- Lorena Pirola
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, Monza 20900, Italy
- European Reference Network on Hepatological Diseases, San Gerardo Hospital, Monza 20900, Italy
| | - Andrea Palermo
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, Monza 20900, Italy
- European Reference Network on Hepatological Diseases, San Gerardo Hospital, Monza 20900, Italy
| | - Giacomo Mulinacci
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, Monza 20900, Italy
- European Reference Network on Hepatological Diseases, San Gerardo Hospital, Monza 20900, Italy
| | - Laura Ratti
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, Monza 20900, Italy
- European Reference Network on Hepatological Diseases, San Gerardo Hospital, Monza 20900, Italy
| | - Maria Fichera
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, Monza 20900, Italy
- European Reference Network on Hepatological Diseases, San Gerardo Hospital, Monza 20900, Italy
| | - Pietro Invernizzi
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, Monza 20900, Italy
- European Reference Network on Hepatological Diseases, San Gerardo Hospital, Monza 20900, Italy
| | - Chiara Viganò
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, Monza 20900, Italy
- European Reference Network on Hepatological Diseases, San Gerardo Hospital, Monza 20900, Italy
| | - Sara Massironi
- Division of Gastroenterology and Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, Monza 20900, Italy
- European Reference Network on Hepatological Diseases, San Gerardo Hospital, Monza 20900, Italy
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Nunomiya K, Inoue S, Sato K, Igarashi A, Yamauchi K, Abe Y, Watanabe M. Pneumatosis Intestinalis in Lung Cancer Induced Twice by Different Drugs: Bevacizumab and Pemetrexed. Intern Med 2021; 60:2109-2113. [PMID: 33551401 PMCID: PMC8313921 DOI: 10.2169/internalmedicine.5564-20] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
A 72-year-old man diagnosed with stage 4 lung adenocarcinoma developed asymptomatic pneumatosis intestinalis while undergoing treatment with first-line chemotherapy, which included carboplatin, paclitaxel, and bevacizumab (BEV). He was treated conservatively. The pneumatosis recurred while the patient was undergoing treatment with the third-line chemotherapy, which included pemetrexed (PEM). His condition resolved after 4 weeks of supportive therapy. To our knowledge, this is the first case in which pneumatosis intestinalis was induced twice by two drugs in a patient with lung cancer. BEV and PEM are often administered to patients with lung cancer; thus, it should be noted that pneumatosis intestinalis may occur as an adverse event in patients treated with these drugs.
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Affiliation(s)
- Keiko Nunomiya
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University Faculty of Medicine, Japan
| | - Sumito Inoue
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University Faculty of Medicine, Japan
| | - Kento Sato
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University Faculty of Medicine, Japan
| | - Akira Igarashi
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University Faculty of Medicine, Japan
| | - Keiko Yamauchi
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University Faculty of Medicine, Japan
| | - Yuki Abe
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University Faculty of Medicine, Japan
| | - Masafumi Watanabe
- Department of Cardiology, Pulmonology, and Nephrology, Yamagata University Faculty of Medicine, Japan
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Pneumatosis intestinalis and spontaneous perforation associated with drug toxicity in oncologic patients: a case series. Acta Gastroenterol Belg 2021; 84:497-499. [PMID: 34599575 DOI: 10.51821/84.3.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Pneumatosis Intestinalis (PI) is a rare radiological finding defined as the presence of extra-luminal gas within the intestinal wall. Several anti-tumor drugs can induce a damage of the gastrointestinal walls as an adverse effect, causing loss of mucosal integrity and endoluminal gas diffusion, responsible for PI development. We retrospectively analyzed 8 cases of PI detected through radiological imaging in oncologic patients undergoing various therapeutic regimens: five patients were receiving chemotherapy, two molecular targeted therapy (MTT) and one immunotherapy. Three patients were asymptomatic and pneumatosis was incidentally detected at routinary follow-up CT and then treated conservatively. Five patients presented acute abdomen symptoms and in these cases bowel perforation was the cause of death. Our experience confirms PI and perforation as rare complications of drug toxicity, especially in oncologic patients treated with combinations of different anticancer drugs and documented the second reported case of PI associated with atezolizumab and alectinib single administration.
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Hines JJ, Mikhitarian MA, Patel R, Choy A. Spectrum and Relevance of Incidental Bowel Findings on Computed Tomography. Radiol Clin North Am 2021; 59:647-660. [PMID: 34053611 DOI: 10.1016/j.rcl.2021.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
A wide spectrum of incidental bowel findings can be seen on CT, including but not limited to, pneumatosis intestinalis, diverticular disease, non-obstructive bowel dilatation, transient small bowel intussusception, and submucosal fat. Radiologists should be aware that such findings are almost always benign and of little clinical significance in the absence of associated symptoms. Conversely, vigilance must be maintained when evaluating the bowel, because malignant neoplasms occasionally come to clinical attention as incidental imaging findings. When suspicious incidental bowel wall thickening is detected, the radiologist can alert the clinical team to the finding prior to the patient becoming symptomatic, potentially leading to definitive management at an early, more curable stage.
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Affiliation(s)
- John J Hines
- Donald and Barbara Zucker School of Medicine at Hofstra/ Northwell, Department of Radiology, Huntington Hospital, Northwell Health, 270 Park Avenue, Huntington, NY 11743, USA.
| | - Mark A Mikhitarian
- Department of Radiology, Northwell Health, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, North Shore University Hospital, 300 Community Drive, Manhasset, NY 11030, USA
| | - Ritesh Patel
- Department of Radiology, Northwell Health, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, North Shore University Hospital, 300 Community Drive, Manhasset, NY 11030, USA
| | - Andy Choy
- Department of Radiology, Northwell Health, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, North Shore University Hospital, 300 Community Drive, Manhasset, NY 11030, USA
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Miyara SJ, Becker LB, Guevara S, Kirsch C, Metz CN, Shoaib M, Grodstein E, Nair VV, Jandovitz N, McCann-Molmenti A, Hayashida K, Takegawa R, Shinozaki K, Yagi T, Aoki T, Nishikimi M, Choudhary RC, Cho YM, Zanos S, Zafeiropoulos S, Hoffman HB, Watt S, Lumermann CM, Aronsohn J, Shore-Lesserson L, Molmenti EP. Pneumatosis Intestinalis in the Setting of COVID-19: A Single Center Case Series From New York. Front Med (Lausanne) 2021; 8:638075. [PMID: 34150792 PMCID: PMC8212022 DOI: 10.3389/fmed.2021.638075] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Accepted: 03/08/2021] [Indexed: 12/18/2022] Open
Abstract
This case series reviews four critically ill patients infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) [coronavirus disease 2019 (COVID-19)] suffering from pneumatosis intestinalis (PI) during their hospital admission. All patients received the biological agent tocilizumab (TCZ), an interleukin (IL)-6 antagonist, as an experimental treatment for COVID-19 before developing PI. COVID-19 and TCZ have been independently linked to PI risk, yet the cause of this relationship is unknown and under speculation. PI is a rare condition, defined as the presence of gas in the intestinal wall, and although its pathogenesis is poorly understood, intestinal ischemia is one of its causative agents. Based on COVID-19's association with vasculopathic and ischemic insults, and IL-6's protective role in intestinal epithelial ischemia-reperfusion injury, an adverse synergistic association of COVID-19 and TCZ can be proposed in the setting of PI. To our knowledge, this is the first published, single center, case series of pneumatosis intestinalis in COVID-19 patients who received tocilizumab therapy.
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Affiliation(s)
- Santiago J. Miyara
- Elmezzi Graduate School of Molecular Medicine, Manhasset, NY, United States
- Feinstein Institutes for Medical Research, Manhasset, NY, United States
| | - Lance B. Becker
- Elmezzi Graduate School of Molecular Medicine, Manhasset, NY, United States
- Feinstein Institutes for Medical Research, Manhasset, NY, United States
- Department of Surgery, North Shore University Hospital, Manhasset, NY, United States
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY, United States
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
| | - Sara Guevara
- Department of Surgery, North Shore University Hospital, Manhasset, NY, United States
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY, United States
| | - Claudia Kirsch
- Department of Radiology, North Shore University Hospital, Manhasset, NY, United States
| | - Christine N. Metz
- Elmezzi Graduate School of Molecular Medicine, Manhasset, NY, United States
- Feinstein Institutes for Medical Research, Manhasset, NY, United States
| | - Muhammad Shoaib
- Feinstein Institutes for Medical Research, Manhasset, NY, United States
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY, United States
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
| | - Elliot Grodstein
- Department of Surgery, North Shore University Hospital, Manhasset, NY, United States
| | - Vinay V. Nair
- Department of Medicine, North Shore University Hospital, Manhasset, NY, United States
| | - Nicholas Jandovitz
- Department of Surgery, North Shore University Hospital, Manhasset, NY, United States
- Department of Pharmacy, North Shore University Hospital, Manhasset, NY, United States
| | | | - Kei Hayashida
- Feinstein Institutes for Medical Research, Manhasset, NY, United States
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY, United States
| | - Ryosuke Takegawa
- Feinstein Institutes for Medical Research, Manhasset, NY, United States
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY, United States
| | - Koichiro Shinozaki
- Feinstein Institutes for Medical Research, Manhasset, NY, United States
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY, United States
| | - Tsukasa Yagi
- Feinstein Institutes for Medical Research, Manhasset, NY, United States
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY, United States
| | - Tomoaki Aoki
- Feinstein Institutes for Medical Research, Manhasset, NY, United States
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY, United States
| | - Mitsuaki Nishikimi
- Feinstein Institutes for Medical Research, Manhasset, NY, United States
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY, United States
| | - Rishabh C. Choudhary
- Feinstein Institutes for Medical Research, Manhasset, NY, United States
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY, United States
| | - Young Min Cho
- Department of Surgery, North Shore University Hospital, Manhasset, NY, United States
| | - Stavros Zanos
- Elmezzi Graduate School of Molecular Medicine, Manhasset, NY, United States
- Feinstein Institutes for Medical Research, Manhasset, NY, United States
| | - Stefanos Zafeiropoulos
- Elmezzi Graduate School of Molecular Medicine, Manhasset, NY, United States
- Feinstein Institutes for Medical Research, Manhasset, NY, United States
| | - Hannah B. Hoffman
- Department of Surgery, North Shore University Hospital, Manhasset, NY, United States
| | - Stacey Watt
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, United States
| | - Claudio M. Lumermann
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
- Department of Anesthesiology, North Shore University Hospital, Manhasset, NY, United States
| | - Judith Aronsohn
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
- Department of Anesthesiology, North Shore University Hospital, Manhasset, NY, United States
| | - Linda Shore-Lesserson
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
- Department of Anesthesiology, North Shore University Hospital, Manhasset, NY, United States
| | - Ernesto P. Molmenti
- Department of Surgery, North Shore University Hospital, Manhasset, NY, United States
- Department of Emergency Medicine, North Shore University Hospital, Manhasset, NY, United States
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, United States
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Esposito AA, Zannoni S, Castoldi L, Giannitto C, Avola E, Casiraghi E, Catalano O, Carrafiello G. 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. Emerg Radiol 2021; 28:911-919. [PMID: 34021845 DOI: 10.1007/s10140-021-01932-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Accepted: 04/07/2021] [Indexed: 01/04/2023]
Abstract
PURPOSE 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. METHODS 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. RESULTS 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%). CONCLUSION 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.
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Affiliation(s)
- Andrea Alessandro Esposito
- Department of Radiology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Sforza 35, 20122, Milan, Italy.
| | - Stefania Zannoni
- Post-Graduate School in Radiodiagnostics, Università Degli Studi Di Milano, Via Festa del Perdono 7, 20122, Milan, Italy
| | - Laura Castoldi
- Department of Surgical Emergency, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Sforza 35, 20122, Milan, Italy
| | - Caterina Giannitto
- Department of Radiology, Istituto Clinico Humanitas, Via Manzoni 56, 20089, Rozzano, MI, Italy
| | - Emanuele Avola
- Post-Graduate School in Radiodiagnostics, Università Degli Studi Di Milano, Via Festa del Perdono 7, 20122, Milan, Italy
| | - Elena Casiraghi
- Department of Computer Science, University of Milan, Via Celoria 18, 20133, Milan, Italy
| | - Onofrio Catalano
- Department of Radiology, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA
| | - Gianpaolo Carrafiello
- Department of Radiology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Via Sforza 35, 20122, Milan, Italy
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Zaki-Metias KM, Zarour CC, Mian A, Vempala M, Ogunde B, Al-Hameed M, Bhatti ZS. Asymptomatic pneumoperitoneum in the setting of pneumatosis intestinalis: a benign entity or surgical emergency? Clin Imaging 2021; 76:104-108. [PMID: 33582616 DOI: 10.1016/j.clinimag.2021.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 01/31/2021] [Accepted: 02/08/2021] [Indexed: 11/29/2022]
Abstract
Pneumatosis intestinalis is a potential cause of asymptomatic pneumoperitoneum without peritonitis. The disease can be managed conservatively and presents a clinical scenario where pneumoperitoneum does not necessitate surgical management. This case illustrates the importance of acknowledging the condition and its variable presentation, allowing for increased awareness and avoidance of invasive procedures when not indicated.
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Affiliation(s)
- Kaitlin M Zaki-Metias
- Department of Radiology, St. Joseph Mercy Oakland Hospital, Pontiac, MI, United States.
| | - Christopher C Zarour
- Department of Radiology, St. Joseph Mercy Oakland Hospital, Pontiac, MI, United States
| | - Arooj Mian
- Windsor University School of Medicine, Cayon, Saint Kitts and Nevis
| | | | - Barakat Ogunde
- Department of Radiology, St. Joseph Mercy Oakland Hospital, Pontiac, MI, United States
| | - Mohammed Al-Hameed
- Department of Radiology, St. Joseph Mercy Oakland Hospital, Pontiac, MI, United States
| | - Zeeshaan S Bhatti
- Department of Radiology, St. Joseph Mercy Oakland Hospital, Pontiac, MI, United States; Huron Valley Radiology, Ypsilanti, MI, United States
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48
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Łaski D, Biernat K, Kaska Ł. Pneumatosis Intestinalis Due to COVID-19 Infection in Kidney Transplant Recipient: A Case Report. Transplant Proc 2021; 53:1215-1218. [PMID: 33678444 PMCID: PMC8054270 DOI: 10.1016/j.transproceed.2021.01.039] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2021] [Accepted: 01/25/2021] [Indexed: 01/15/2023]
Abstract
BACKGROUND Pneumatosis intestinalis (PI) is a rare condition usually occurring among adults who have undergone solid organ transplant and are taking steroid therapy. The coronavirus disease 2019 (COVID-19) virus uses angiotensin-converting enzyme 2 in gastrointestinal epithelium as a receptor for entry process. Due to the steroid intake, the COVID-19 virus is present in the patient's gastrointestinal tract for extended period of time. It may therefore increase the possibility of PI in such patients. It is usually asymptomatic, with a clinical spectrum ranging from indolent to life-threatening. Unfortunately, there are no algorithms concerning diagnosis and treatment of PI. AIM OF STUDY The aim of this study is to highlight the problem of PI induced by COVID-19, especially in high-risk groups such as solid organs recipients. CONCLUSION On the basis of the presented case of a severe course of COVID-19-induced PI, we conclude that laparotomy with bowel resection can be a feasible and a safe option for treatment.
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Affiliation(s)
- D Łaski
- General, Endocrine and Transplant Surgery Department, Medical University Gdańsk, Gdańsk, Poland.
| | - K Biernat
- General, Endocrine and Transplant Surgery Department, Medical University Gdańsk, Gdańsk, Poland
| | - Ł Kaska
- General, Endocrine and Transplant Surgery Department, Medical University Gdańsk, Gdańsk, Poland
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Shetty DS, Naik LP, Amarapurkar AD. Bubbly bowel: A life-threatening condition. INDIAN J PATHOL MICR 2021; 63:325-326. [PMID: 32317547 DOI: 10.4103/ijpm.ijpm_474_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Affiliation(s)
- Divya S Shetty
- Department of Pathology, Lokmanya Tilak Municipal Medical College and Sion Hospital, Mumbai, Maharashtra, India
| | - Leena P Naik
- Department of Pathology, Lokmanya Tilak Municipal Medical College and Sion Hospital, Mumbai, Maharashtra, India
| | - Anjali D Amarapurkar
- Department of Pathology, Lokmanya Tilak Municipal Medical College and Sion Hospital, Mumbai, Maharashtra, India
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50
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Contini G, Bertocchini A, Carta R, Merli P, Inserra A, Bagolan P, Morini F. Case Report: Massive Intestinal Pneumatosis and Pneumoretroperitoneum Following Hematopoietic Stem Cell Transplantation in a 2-Year-Old Child. Front Pediatr 2021; 9:700736. [PMID: 34956969 PMCID: PMC8693778 DOI: 10.3389/fped.2021.700736] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2021] [Accepted: 11/11/2021] [Indexed: 11/13/2022] Open
Abstract
A 2-year-old boy with severe combined immunodeficiency (SCID) developed intestinal graft-versus-host disease (GVHD) after hematopoietic stem cell transplantation (HSCT), associated with massive intestinal pneumatosis (IP), pneumoretroperitoneum (PRP), and pneumomediastinum. His fair clinical conditions allowed conservative management, with progressive normalization of imaging findings. The patient did not require surgery and is alive and in good clinical conditions at follow-up. In children with GVHD-related IP but good clinical conditions and no signs of peritonitis, IP is not a mandatory indication for surgery, despite its potentially striking imaging features. Conservative management, with intestinal rest, decompression, and antibiotics, often allows regression of the clinical picture.
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Affiliation(s)
- Giorgia Contini
- Medical and Surgical Department of the Fetus, Neonate and Infant, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Arianna Bertocchini
- Department of Pediatric Surgery, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Roberto Carta
- Department of Pediatric Hematology and Oncology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Pietro Merli
- Department of Pediatric Hematology and Oncology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Alessandro Inserra
- Department of Pediatric Surgery, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Pietro Bagolan
- Medical and Surgical Department of the Fetus, Neonate and Infant, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Francesco Morini
- Medical and Surgical Department of the Fetus, Neonate and Infant, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
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