Gastric emphysema and pneumatosis intestinalis in two common marmosets with duodenal dilation syndrome.

BACKGROUND: Common marmosets (Callithrix jacchus) are widely used as primate experimental models in biomedical research. Duodenal dilation with chronic vomiting in captive common marmosets is a recently described life-threatening syndrome that is problematic for health control. However, the pathogenesis and cause of death are not fully understood. CASE PRESENTATION: We report two novel necropsy cases in which captive common marmosets were histopathologically diagnosed with gastric emphysema (GE) and pneumatosis intestinalis (PI). Marmoset duodenal dilation syndrome was confirmed in each case by clinical observation of chronic vomiting and by gross necropsy findings showing a dilated, gas-filled and fluid-filled descending duodenum that adhered to the ascending colon. A diagnosis of GE and PI was made on the basis of the bubble-like morphology of the gastric and intestinal mucosa, with histological examination revealing numerous vacuoles diffused throughout the lamina propria mucosae and submucosa. Immunostaining for prospero homeobox 1 and CD31 distinguished gas cysts from blood and lymph vessels. The presence of hepatic portal venous gas in case 1 and possible secondary bacteremia-related septic shock in case 2 were suggested to be acute life-threatening abdominal processes resulting from gastric emphysema and pneumatosis intestinalis. CONCLUSIONS: In both cases, the gross and histopathological findings of gas cysts in the GI tract walls matched the features of human GE and PI. These findings contribute to clarifying the cause of death in captive marmosets that have died of gastrointestinal diseases.

Pneumatosis cystoides intestinalis: A case report.

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.

Machine learning for the prediction of pathologic pneumatosis intestinalis.

BACKGROUND: The radiographic finding of pneumatosis intestinalis can indicate a spectrum of underlying processes ranging from a benign finding to a life-threatening condition. Although radiographic pneumatosis intestinalis is relatively common, there is no validated clinical tool to guide surgical management. METHODS: Using a retrospective cohort of 300 pneumatosis intestinalis cases from a single institution, we developed 3 machine learning models for 2 clinical tasks: (1) the distinction of benign from pathologic pneumatosis intestinalis cases and (2) the determination of patients who would benefit from an operation. The 3 models are (1) an imaging model based on radiomic features extracted from computed tomography scans, (2) a clinical model based on clinical variables, and (3) a combination model using both the imaging and clinical variables. RESULTS: The combination model achieves an area under the curve of 0.91 (confidence interval: 0.87-0.94) for task I and an area under the curve of 0.84 (confidence interval: 0.79-0.88) for task II. The combination model significantly (P < .05) outperforms the imaging model and the clinical model for both tasks. The imaging model achieves an area under the curve of 0.72 (confidence interval: 0.57-0.87) for task I and 0.68 (confidence interval: 0.61-0.74) for task II. The clinical model achieves an area under the curve of 0.87 (confidence interval: 0.83-0.91) for task I and 0.76 (confidence interval: 0.70-0.81) for task II. CONCLUSION: This study suggests that combined radiographic and clinical features can identify pathologic pneumatosis intestinalis and aid in patient selection for surgery. This tool may better inform the surgical decision-making process for patients with pneumatosis intestinalis.

Clinical characteristics of pneumoperitoneum with pneumatosis intestinalis detected using computed tomography: A descriptive study.

Pneumoperitoneum has always been considered a surgical emergency as it represents a perforation of the gastrointestinal tract. Although several cases of pneumoperitoneum with pneumatosis intestinalis (PI) have been reported, the characteristics of such cases remain unclear. The current study aimed to clarify the clinical characteristics of pneumoperitoneum cases with PI detected using computed tomography (CT).This descriptive study was conducted at a single center. In a total of 18,513 abdominal CT scans obtained between January 2010 and February 2017, extraluminal free air was detected in 254 examinations of 182 cases. The medical records and CT images of these 182 patients were retrospectively analyzed.Pneumoperitoneum with PI was detected through 23 examinations in 21 cases, and the average age of the patients was 80.1 years. The frequency was 0.12% in all abdominal CT examinations, but 24.7% in the 85 cases with extraluminal free air, excluding iatrogenic air. PI was classified as benign in 20 cases and as life-threatening in 1 case. The majority of cases with benign PI showed good general and local findings and little leukocytosis, while the case with life-threatening PI showed severe conditions. No evidence of bowel wall discontinuity, segmental bowel-wall thickening, perivisceral fat stranding, and abscesses were observed. Ascites were detected less frequently in the cases with PI than in the other pneumoperitoneum cases (P < .01). Pneumoperitoneum and PI occasionally recurred, and PI and/or extraluminal free air generally disappeared quickly.Pneumoperitoneum with PI is a relatively common condition in older patients, and the majority of cases are caused by benign PI. The characteristics of pneumoperitoneum cases with benign PI include well-maintained physical conditions, normal laboratory data, absence of CT findings indicative of peritonitis, and infrequent ascites. In pneumoperitoneum cases with PI, predicting whether the PI is benign or life-threatening is clinically very important, whereas the presence of extraluminal free air is considered to be insignificant.

Radiography and ultrasonography of pneumatosis intestinalis in a cat.

An adult cat was presented for acute history of vomiting and collapse. Radiographs showed the presence of air within small intestinal walls and arborizing gas patterns within the liver, compatible with pneumatosis intestinalis and presumed portal venous gas, respectively. An abdominal ultrasound the following day was suggestive of gas within the intestinal wall, however, gas within the hepatic vasculature, parenchyma, or biliary tree was not evident. Due to progressive clinical deterioration of the patient, the owners elected humane euthanasia. Necropsy revealed severe necrotizing hemorrhagic enterotyphlocolitis secondary to Clostridium difficile toxin.

Pneumatosis cystoides intestinalis: a case report and literature review.

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

Portal vein gas and pneumatosis intestinalis: A case of intestinal necrosis caused by acute organophosphorus pesticide poisoning?

Acute organophosphorus pesticide poisoning (AOPP) is fairly common in rural areas of Asia. The symptoms of AOPP are mainly caused by acetylcholine accumulation. According to the clinical characteristics, AOPP symptoms can fall into the following three categories: muscarinic, nicotinic, and central. Death from fatal poisoning is caused by respiratory paralysis, and neurological complications are common. However, no case of intestinal necrosis caused by AOPP has been reported. Hepatic portal vein gas and pneumatosis intestinalis are considered typical and early imaging manifestations of intestinal necrosis. In this article, we describe a very rare case of computed tomography imaging-proven intestinal necrosis caused by AOPP.

Pneumatosis intestinalis: cost paid for rheumatoid arthritis treatment.

A 75-year-old woman with rheumatoid arthritis on rituximab presented with a 1-week history of constipation and abdominal distension. Subsequent workup showed presence of air in the bowel wall without perforation initially. Due to positive blood cultures, worsening leucocytosis and high suspicion for perforation, an exploratory laparotomy was performed revealing necrotic bowel, walled off perforation and abscess. Patient underwent right hemicolectomy with diversion loop ileostomy. Clinicians must recognise that monoclonal antibodies like rituximab can mask signs of inflammation and therefore should maintain a high index of suspicion for intestinal perforation when evaluating patients with minimal symptoms and pneumatosis intestinalis.

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

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

Pneumatosis intestinalis and pneumoretroperitoneum post steroid use in a patient with superior mesenteric artery syndrome.

Pneumatosis intestinalis (PI) refers to the presence of gas within the wall of the small or large intestine. PI can be both asymptomatic and life-threatening. The patient was a 50-year-old man with previous cervical spine abscess and osteomyelitis post debridement 4 years ago, with a heroin abuse history. He presented with abdominal distension ongoing for 4 days and vomiting for 3 times with fluid content. Abdominal computed tomography revealed pneumatosis with pneumoretroperitoneum. A surgeon was contacted and antibiotic treatment was started. The patient was kept on nothing per os and intravenous fluid supply. A drainage tube was inserted into retroperitoneum space on the same day. Tracing back his history, our patient was discharged from the hospital recently with a diagnosis of superior mesenteric artery dyndrome (SMAS), hypersensitivity pneumonitis, and asbestosis with soft tissue pleural plaques and calcified pleural plaques. During the hospitalization period, hydrocortisone dexamethasone and methylprednisolone were prescribed for hypersensitivity pneumonitis. Steroid use and SMAS maybe the cause of PI. Finally, he was discharged 5 days later with a nasojejunal and drainage tubes and was arranged for OPD follow-up. PI can be asymptomatic or life-threatening, and patient management varies based on the clinical condition. Although in this case PI was found in the emergency department, a patient's past history of underlying disease and medication should be reviewed to find the most possible etiology.

Intestinal necrosis cannot be neglected in a patient with hepatic portal vein gas combined with appendicitis: a rare case report and literature review.

BACKGROUND: Hepatic portal vein gas (HPVG) is a rare acute abdomen, which is not an independent disease. Meanwhile, HPVG combined with appendicitis has been rarely reported. We found only a similar report by looking for literature, but no intestinal necrosis occurred. We report a patient with HPVG, appendicitis and intestinal necrosis was reported in the current study. The patient was given frequent monitoring and had been conducted operation in time. CASE PRESENTATION: An 86-year-old female with appendicitis complicated by HPVG was reported in the present study. Abdominal examination revealed rebound tenderness at the McBurney's point. Moreover, abdominal computed tomography (CT) revealed gas in portal and mesenteric veins in addition to appendicitis. An emergency operation was planned on the appendix. However, the patient refused surgical treatment. Therefore, conservative treatment of antibiotics and frequent imaging observation was conducted for this patient. Although imaging results suggested disappeared gas in intra- and extra-hepatic portal veins, the small intestine was dilated, after conservative treatment of antibiotics. In addition, signs of diffused peritonitis could also be observed and an exploratory laparotomy was performed. Intra-operative findings had confirmed suppurated appendix, mesenteric ischemia and small intestinal necrosis. CONCLUSIONS: Frequent monitoring benefits us in observing the progress of intestinal diseases. When there exist other possible causes of HPVG such as infection, it is not easy for us to ignore the possibility of intestinal necrosis.

Predictors of prognosis in children with portal venous gas detected by ultrasound.

AIMS: To evaluate ultrasound findings in order to determine potential predictors of prognosis in pediatric patients with portal venous gas (PVG) detected by ultrasound. MATERIALS AND METHODS: Thirty-nine children were included and divided into two groups: benign PVG (n=24) and life-threatening PVG (n=15; 6 surgical interventions and 9 deaths). Possible predictors, i.e., the location of PVG in the liver, the distribution of intestinal pneumatosis, ascites and free air were compared between the two groups. RESULTS: A significant difference was noted between the two groups in terms of the distribution of intestinal pneumatosis (limited to the large bowel, benign vs life-threatening = 60.9% (14/23):21.4% (3/14), p=0.040), the absence of ascites (benign vs life-threatening = 79.1% (19/24):40.0% (6/15), p=0.019) and patient age (benign vs life-threatening = 52.5±65.3 months vs 19.7±44.0 months, p=0.019). No significant difference was observed in the location of PVG in the liver, the presence of free air, and sex between the two groups. CONCLUSIONS: In pediatric patients with PVG, including various ages and underlying diseases, intestinal pneumatosis limited to the large bowel and absence of ascites were predictors of a benign prognosis. However, despite the presence of these predictors, some patients with PVG required surgical intervention, therebysuggesting that the cause of PVG, such as necrotizing enterocolitis, volvulus, or pancreatitis, must be also carefully evaluated.