Potential Indicators of Intestinal Necrosis in Portal Venous Gas: A Case Report of an 82-Year-Old Woman on Long-Term Hemodialysis with Ascites and Pneumatosis Coli.

BACKGROUND Several factors have been reported as possible predictors of intestinal necrosis in patients with portal venous gas (PVG). We describe potential indicators of intestinal necrosis in PVG identified by contrasting 3 episodes of PVG in a patient on hemodialysis against previously verified factors. CASE REPORT An 82-year-old woman undergoing hemodialysis was admitted to our hospital thrice for acute abdominal pain. On first admission, she was alert, with a body temperature of 36.3°C, blood pressure (BP) of 125/53 mmHg, pulse rate of 60/min, respiratory rate of 18/min, and 100% oxygen saturation on room air. Computed tomography (CT) revealed PVG, intestinal distension, poor bowel wall enhancement, bubble-like pneumatosis in the intestinal wall, and minimal ascites. PVG caused by intestinal ischemia was diagnosed, and she recovered after bowel rest and hydration. Three months later, she had a second episode of abdominal pain. BP was 115/56 mmHg. CT revealed PVG and a slight accumulation of ascites, without pneumatosis in the intestinal wall. She again recovered after conservative measures. Ten months later, the patient experienced a third episode of abdominal pain, with BP of 107/52 mmHg. CT imaging indicated PVG, considerable ascites, and linear pneumatosis of the intestinal walls. Despite receiving conservative treatment, the patient died. CONCLUSIONS A large accumulation of ascites and linear pneumatosis in the intestinal walls could be potential indicators of intestinal necrosis in patients with PVG caused by intestinal ischemia. As previously reported, hypotension was further confirmed to be a reliable predictor of intestinal necrosis.

Pneumatosis cystoides intestinalis as a rare cause of non-surgical pneumoperitoneum.

Pneumoperitoneum as a finding on imaging examinations is not always a sign of acute abdomen due to gastrointestinal perforation. These findings must be viewed in connection with the clinical condition and personal history of each patient because they may also indicate a non-surgical or spontaneous pneumoperitoneum. This condition is repeatedly described but very often neglected. This paper presents the case report of a patient with non-surgical pneumoperitoneum where, despite proceeding according to the guidelines, no expected intra-abdominal pathology explaining the patient's problems was found.

Pneumatosis coli in preterm neonates: Can they be managed more conservatively to maintain the intestinal milieu?

Necrotising enterocolitis (NEC) is a severe gastrointestinal disease mostly in premature infants due to intestinal necrosis. The aetiology of NEC is multifactorial and includes gut immaturity, intestinal dysbiosis and exaggerated intestinal mucosal reactivity to microbial ligands. Radiographic evidence of pneumatosis intestinalis has been a critical feature for diagnosing NEC Bell stage ≥IIA and recommended treatment includes prolonged antibiotics (7-14 days) while off enteral feeds. Pneumatosis coli (Pcoli), a mild or benign form of NEC, is characterised by pneumatosis limited to the colon in an infant having haematochezia, negative septic screening and no systemic signs. We report two healthy preterm infants with haematochezia and colonic pneumatosis while on breast milk feeds. The sepsis screen was negative. A brief period of antibiotics and gut rest led to the spontaneous resolution of haematochezia and colonic pneumatosis, facilitating early enteral feeds. This case report emphasises the need to differentiate NEC from benign Pcoli.

Multicenter epidemiological survey of pneumatosis intestinalis in Japan.

BACKGROUND: Pneumatosis intestinalis (PI) is a rare condition characterized by gas collection in the intestinal wall. We aimed to determine the etiology and affected segments associated with complications, treatment, and outcome. METHODS: We conducted a multicenter epidemiological survey using a standardized data collection sheet in Japan. Complicating PI was defined as strangulation or bowel necrosis, bowel obstruction, adynamic ileus, sepsis, shock, and massive gastrointestinal bleeding requiring blood transfusion. RESULTS: We enrolled 167 patients from 48 facilities. Multivariate analysis revealed that older age (adjusted OR, 1.05 and 95% confidence intervals [CI], 1.02-1.09, P = 0.0053) and chronic kidney disease (adjusted OR, 13.19 and 95% CI 1.04-167.62, P = 0.0468) were independent predictors of the small-bowel-involved type. Complicating PI was associated with the small-bowel-involved combined type (adjusted OR, 27.02 and 95% CI 4.80-152.01, P = 0.0002), the small-bowel-only type (adjusted OR, 3.94 and 95% CI 1.02-15.27, P = 0.0472), and symptomatic PI (adjusted OR, 16.24 and 95% CI 1.82-145.24, P = 0.0126). Oxygen therapy was performed in patients with a past history of bowel obstruction (adjusted OR, 13.77 and 95% CI 1.31-144.56, P = 0.0288) and surgery was performed in patients with complicating PI (adjusted OR, 8.93 and 95% CI 1.10-72.78, P = 0.0408). Antihypertensives (adjusted OR, 12.28 and 95% CI 1.07-140.79, P = 0.0439) and complicating PI (adjusted OR, 11.77 and 95% CI 1.053-131.526; P = 0.0453) were associated with exacerbation of PI. The complicating PI was the only indicator of death (adjusted OR, 14.40 and 95% CI 1.09-189.48, P = 0.0425). DISCUSSION: Small-bowel-involved type and symptomatic PI were associated with complications which were indicators of poor prognosis.

[Pneumatosis cystoides intestinalis in lung transplant recipients: three cases report and literature review].

Objective: To report the clinical characteristics and treatment courses of pneumatosis cystoides intestinalis(PCI) after lung transplantation(LT). Methods: We included all cases of PCI after LT from March 2017 to June 2021 in China-Japan Friendship Hospital. In addition to our cases, we searched literatures published in Chinese and English languages using China National Knowledge Infrastructure (CNKI), Wanfang Data and PubMed/MEDLINE with the search terms"pneumatosis intestinalis"and"lung transplantation". The clinical characteristics and treatment courses of all cases were summarized and analyzed. Results: Three cases of PCI occurred after LT in this study, with an incidence of 0.804% (3/373). Thirteen related literatures were retrieved, with 51 cases enrolled. The median age of the 54 patients was 55.4 years (22-79 years), with 33 males and 21 females. 64.81% (35/54) of the 54 patients underwent LT for interstitial lung disease and 90.74% (49/54) underwent bilateral LT. Twenty-two cases(40.7%) were asymptomatic when PCI occurred. Thirty-eight cases (38/54,70.37%)had involvement of ascending colon, and 35 cases(35/54,64.81%)had involvement of transverse colon. Forty-three cases(43/54, 79.63%) were treated conservatively. The average interval between transplantation and PCI was 210 (5-2 495) days. Conclusion: PCI is a rare complication after lung transplantation, most often occurring in the colon. Most patients were asymptomatic and could improve by conservative treatments.

Pneumatosis intestinalis after thoracic organ transplantation in children: A case series and review of the literature.

Pneumatosis intestinalis (PI) is a rare complication after thoracic organ transplantation. There are several theories for explaining the pathophysiology of this disease. In this paper, we highlight three cases of PI in a single pediatric center, one after lung transplantation and two after heart transplantation. Although the presentations differed, all cases improved with non-surgical therapies. There are not many articles in the pediatric literature about post-transplantation PI, and there are still many questions regarding the incidence, etiology, and treatment for this disease.

Gastric Pneumatosis with Portal Venous Gas can be Treated Non-operatively: A Retrospective Multi-institutional Study.

BACKGROUND: Gastric pneumatosis (GP) is a rare radiologic finding with an unpredictable prognosis. The aim of this study was to identify mortality risk factors from patients presenting with GP on computed tomography (CT), and to develop a model which would allow us to predict which patients would benefit most from operative management. METHODS: Between 2010 and 2020, all CT-scan reports in four tertiary centers were searched for the following terms: "gastric pneumatosis," "intramural gastric air" or "emphysematous gastritis." The retrieved CT scans were reviewed by a senior surgeon and a senior radiologist. Relevant clinical and laboratory data for these patients were extracted from the institutions' medical records. RESULTS: Among 58 patients with GP, portal venous gas and bowel ischemia were present on CT scan in 52 (90%) and 17 patients (29%), respectively. The 30-day mortality rate was 31%. Univariate analysis identified the following variables as predictive of mortality at the time of the diagnosis of GP: abdominal guarding, hemodynamic instability, arterial lactate level >2 mmol/l, and the absence of gastric dilatation. Multivariable analysis identified the following variables as independent predictors of mortality: arterial lactate level (OR: 1.39, 95% CI: 1.07-1.79) and the absence of gastric dilatation (OR: 0.07, 95% CI: 0.01-0.79). None of the patients presenting with a baseline lactate rate<2 mmol/l died within 30 days following diagnosis, and no more than 17 patients out of 58 had bowel ischemia (29%). CONCLUSIONS: GP could be managed non-operatively, even in the presence of portal venous gas. However, patients with arterial lactate level>2 mmol/l, or the absence of gastric dilation should be surgically explored due to a non-negligible risk of mortality.

Intestinal pneumatosis: a rare and misdiagnosed entity.

Intestinal pneumatosis is a rare entity, usually found incidentally, and in most cases asymptomatic. We present the case of an 84-year-old man who underwent colonoscopy for adenomatous polyps surveillance and presented typical endoscopic images of intestinal pneumatosis. Some of the most important aspects of the disease are highlighted and even if the endoscopic image is quite impressive, conservative management is the treatment of choice.

Successful Non-Operative Management of Extensive Pneumatosis Cystoides Intestinalis Due to Graft Versus Host Disease.

Graft versus host disease is a serious complication of allogenic stem cell transplants and can manifest with gastrointestinal complications including pneumatosis cystoides intestinali (PCI). A 43-year-old male with a history of acute myeloid leukemia presented to the hospital with abdominal pain and sepsis. The patient was intubated and admitted to the ICU. His CT scan demonstrated extensive colonic pneumatosis. He was high risk for laparotomy so was treated non-operatively. He improved and his abdominal exam remained benign. With aggressive resuscitation, close monitoring, and antibiotics, the patient was able to avoid major abdominal surgery. pneumatosis cystoides intestinali is a concerning finding that often leads to surgical interventions. Concurrent sepsis, gut ischemia, and frank perforation often lead to surgical intervention. In patients with high surgical risk and lack of critical bowel findings, non-operative management can be successful.

Pneumatosis intestinalis in the pediatric oncology population: An 11-year retrospective review at Memorial Sloan Kettering Cancer Center.

BACKGROUND: Pneumatosis intestinalis (PI) is characterized by the presence of intramural gas in the gastrointestinal (GI) tract. The overall aim of this study was to review risk factors and outcome of pediatric oncology patients at our institution who developed PI. PROCEDURE: Patients diagnosed with PI between 2007 and 2018 were identified from ICD-10 coding of radiology reports at Memorial Sloan Kettering Kids, a tertiary pediatric oncology center. Outcomes of interest were (a) resolution and time to resolution of PI, (b) surgical intervention within 2 weeks of diagnosis of PI, or (c) death secondary to PI. To capture the resolution of PI, we defined the "time to recovery (TTR)" as the time elapsed between date of PI diagnosis and the date of recovery. RESULTS: Forty-two patients were identified. Within 30 days of diagnosis of PI, three patients had surgical intervention for PI (7%) and two patients died (5%) due to non-PI causes. Median TTR of PI was 4.5 days (95% CI: 3-7 days). In univariable and multivariable analyses, only steroid use in the prior 30 days was significantly associated with a faster TTR of PI (HR = 2.27 [95% CI: 1.17-4.41], p = .02). CONCLUSIONS: This is the largest case series of patients with PI in the pediatric oncology population, which reveals significantly lower surgical and mortality rates than other published PI series. For the majority of patients, conservative medical management is indicated. A prospective study is warranted to define diagnosis and management guidelines for PI in the pediatric oncology population in a cooperative group setting.

Pneumatosis intestinalis in children beyond the neonatal period: is it always benign?

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.

Management of pneumatosis cystoides intestinalis with pneumoperitoneum: 5-years systematic review

Introduction: Pneumatosis cystoides intestinalis (PCI) is a rare condition characterized by gas-filled cysts in the intestinal wall. Although rare, it may also involve other regions, such as the mesentery. PCI is classified as primary or secondary and is associated with multiple predisposing factors. It may be associated with either a benign condition or a potentially fatal condition, such as mesenteric ischemia. The objective of this study was to review the medical literature on the rare benign presentations of PCI, excluding cases associated with intestinal ischemia.Methods: We conducted a systematic literature review according to the PRISMA statement. We searched PubMed and LILACS databases for articles published between January 2015 and December 2020 using the following Medical Subject Headings: "pneumatosis cystoides intestinalis" and "pneumoperitoneum," "pneumatosis intestinalis," and "pneumoperitoneum" or "mesenteric pneumatosis."Results: We included 51 articles comprising 58 patients with PCI and pneumoperitoneum. Most patients were men, and mean patient age was 64.9 years. We identified an idiopathic etiology in 29.31% of cases, and the most common predisposing factor was immune dysfunction (29.31%). A total of 24.13% of patients were asymptomatic. The most commons symptoms were abdominal pain (43.10%), nausea and vomiting (41.37%), and abdominal distention (37.93%). Diagnostic surgery was conducted in 26 patients (44.82%). Only 1 patient underwent surgical treatment.Conclusions: PCI is a clinical condition that may have a benign etiology and not require surgery. Treatment of the benign etiology is conservative. Thus, life-threatening conditions should be excluded in all cases.

A rare case of pneumatosis cystoides intestinalis with bowel perforation and secondary sepsis.

MATERIALS AND METHODS: We present here the case of an 83 y.o. male with intestinal perforation from pneumatosis cystoides intestinalis and consequent sepsis. RESULTS: The patient underwent urgency intestinal resection in our institute, with complete restitution ad integrum Discussion: Pneumatosis cystoides intestinalis is a rare affection, which can be categorized as primary (15%) or idiopathic( 85%). The clinical appearance can be very variable from patient to patient, since it can be completely asymptomatic or start with life-threatening clinical presentation of bowel perforation and sepsis. There are various theories about the formation of the gas bubbles trough the intestinal wall. The mechanical theory assumes that the gas, tearing trough the intestinal wall seeps trough it. The bacterial theory assumes that antibiotic treatment, such as with metronidazole, allows the creation of gas by microbiological elements like Clostridium Perfringens or Clostridium Difficile. The pulmonary theory, instead, assumes that air released from ruptured alveoli gets into the mediastinum and retro peritoneum, reaching the intestinal tract. The treatment is conservative most of the times, except for the cases of intestinal perforation and sepsis. CONCLUSIONS: Despite of the long history of the disease, with the first description in 1783, little is known nowadays about PCI, due to the rarity of symptomatic disease. Further studies are needed to better evaluate the aetiology of the condition, and the prognostic criteria, which may be very important for clinical decisions about conservative or surgical treatment. KEY WORDS: Diagnosis, Pneumatosis cystoides intestinalis, Peritonitis, Therapy.

Gastric Pneumatosis in a Critically Ill Pediatric Burn Patient: Case Report and Overview of Risk Factors, Diagnosis, and Management.

Pneumatosis intestinalis and gastric pneumatosis are rare, but potentially morbid conditions in the burn-injured patient. They present a pediatric patient with severe scald injuries and isolated gastric pneumatosis who was successfully treated with a multidisciplinary approach and nonoperative management.

[Diagnosis and treatment of pneumatosis cystoides intestinalis].

Pneumatosis cystoides intestinalis (PCI) is a rare disease, which is characterized by the accumulation of gas cysts located in the submucosa or subserosa of the gastrointestinal tract. It can occur in the whole or part of the gastrointestinal tract from the esophagus to the rectum, but clinically the main involved sites are the colon and small intestine. PCI can also appear in other sites such as mesentery, the greater omentum and the hepatogastric ligament. In recent years, with the renewal of imaging method, the detection rate of PCI has been on the rise. Most patients with PCI have no obvious symptoms or only non-specific symptoms of the digestive tract like abdominal distension, abdominal pain, diarrhea, hematochezia, etc. The atypical clinical symptoms of PCI can easily lead to missed diagnosis or misdiagnosis. A small amount of patients would have complications like peritonitis and even perforation of the digestive tract. The therapeutic principle for these patients is different from that for patients with acute abdomen. The prognosis of PCI depends on its severity and comorbidities. In this article, a literature review would be conducted on the epidemiological characteristics, etiology and pathogenesis, clinical manifestations, diagnosis and treatment of PCI, which might help clinical doctors with diagnosis and treatment of the disease.

Mesenteric ischemia with pneumatosis intestinalis and portal vein gas associated with enteral nutrition: a series of three patients.

Enteral nutrition is usually associated with a low risk of intestinal complications. We report three non-critically ill patients who received enteral nutrition and developed mesenteric ischemia with pneumatosis intestinalis and hepatic portal vein gas. These findings are often considered to be indications for emergency surgery. In these three patients, prompt cessation of enteral nutrition avoided progression to intestinal necrosis obviating the need for intestinal resection, although one patient underwent surgical exploration. Follow-up computed tomography scan showed resolution of the radiologic findings, and all patients started enteral nutrition again without complications. All patients had comorbidities associated with atherosclerosis, which may have led to a mismatch between oxygen delivery and demand in the bowel, resulting in ischemia. To the best of our knowledge, this is the first report of successful management of mesenteric ischemia related to enteral nutrition in non-critically ill patients without resection. If the cause of mesenteric ischemia such as enteral nutrition, can be eliminated quickly, non-resectional and possibly nonoperative management can be a reasonable management option, with close follow-up and readiness for resection.

Extensive colonic pneumatosis. Conservative or Surgical approach?

Intestinal pneumatosis is a radiologic finding that consists of the presence of air in the intestinal wall. The etiology is extensive and can range from a benign entity to one that compromises the patients´ life. It is important to know and recognize the differences between them as the surgical management will depend on it. We report the case of an 82-year-old male diagnosed with a metastatic castration resistant prostate carcinoma, under chemotherapy with disease progression in treatment with high doses of intravenous morphics. The patient reported abdominal distension with constipation and no vomiting in the emergency department and a distended and tympanic abdomen, without generalized peritonitis was identified during physical examination. A blood analysis showed lactate levels of 0.9 mmol/L and a PCR of 4.2 mg/L without leukocytosis. An extensive colonic pneumatosis with minimum pneumoperitoneum without free fluid was confirmed by a computed tomography (CT) scan (Fig 1). A conservative approach with intravenous antibiotic and clinical surveillance was decided due to the fact that the patient was clinically stable without generalized peritonitis nor pathological findings in the supplementary blood tests. The clinical evolution was uneventful and the patient was discharged from hospital De la Serna et al. opted for a conservative approach for a patient with stage IV lung adenocarcinoma under chemotherapy treatment, who presented asymptomatic intestinal pneumatosis and subsequently made a full recovery. We also believe that the use of some chemotherapeutic agents may cause an increase in the permeability of the intestinal capillaries, allowing air to flow into the intestinal walls. Thus, resulting in this radiologic image, which is more a radiological finding than a disease. We think that a conservative initial attitude should be recommended in hemodynamically stable cases, without peritonitis and non-pathological blood analysis.