Pneumatosis intestinalis and porto-mesenteric venous gas: a multicenter study.

BACKGROUND: Estimating the prognosis of patients with pneumatosis intestinalis (PI) and porto-mesenteric venous gas (PMVG) can be challenging. The purpose of this study was to refine prognostication to improve decision making in daily clinical routine. METHODS: A total of 290 patients with confirmed PI were included in the final analysis. The presence of PMVG and mortality (90d follow-up) were evaluated with regard to the influence of possible risk factors. Furthermore, a linear estimation model was devised combining significant parameters to calculate accuracies for predicting death in patients undergoing surgery by means of a defined operation point (ROC-analysis). RESULTS: Overall, 90d mortality was 55.2% (160/290). In patients with PI only, mortality was 46.5% (78/168) and increased significantly to 67.2% (82/122) in combination with PMVG (median survival: PI: 58d vs. PI and PMVG: 41d; p < 0.001). In the entire patient group, 53.5% (155/290) were treated surgically with a 90d mortality of 58.8% (91/155) in this latter group, while 90d mortality was 51.1% (69/135) in patients treated conservatively. In the patients who survived > 90d treated conservatively (24.9% of the entire collective; 72/290) PMVG/PI was defined as "benign"/reversible. PMVG, COPD, sepsis and a low platelet count were found to correlate with a worse prognosis helping to identify patients who might not profit from surgery, in this context our calculation model reaches accuracies of 97% specificity, 20% sensitivity, 90% PPV and 45% NPV. CONCLUSION: Although PI is associated with high morbidity and mortality, "benign causes" are common. However, in concomitant PMVG, mortality rates increase significantly. Our mathematical model could serve as a decision support tool to identify patients who are least likely to benefit from surgery, and to potentially reduce overtreatment in this subset of patients.

Optimal treatment strategies for hepatic portal venous gas: A retrospective assessment.

BACKGROUND: Hepatic portal venous gas (HPVG) generally indicates poor prognoses in patients with serious intestinal damage. Although surgical removal of the damaged portion is effective, some patients can recover with conservative treatments. AIM: To establish an optimal treatment strategy for HPVG, we attempted to generate computed tomography (CT)-based criteria for determining surgical indication, and explored reliable prognostic factors in non-surgical cases. METHODS: Thirty-four cases of HPVG (patients aged 34-99 years) were included. Necessity for surgery had been determined mainly by CT findings (i.e. free-air, embolism, lack of contrast enhancement of the intestinal wall, and intestinal pneumatosis). The clinical data, including treatment outcomes, were analyzed separately for the surgical cases and non-surgical cases. RESULTS: Laparotomy was performed in eight cases (surgical cases). Seven patients (87.5%) survived but one (12.5%) died. In each case, severe intestinal damage was confirmed during surgery, and the necrotic portion, if present, was removed. Non-occlusive mesenteric ischemia was the most common cause (n = 4). Twenty-six cases were treated conservatively (non-surgical cases). Surgical treatments had been required for twelve but were abandoned because of the patients' poor general conditions. Surprisingly, however, three (25%) of the twelve inoperable patients survived. The remaining 14 of the 26 cases were diagnosed originally as being sufficiently cured by conservative treatments, and only one patient (7%) died. Comparative analyses of the fatal (n = 10) and recovery (n = 16) cases revealed that ascites, peritoneal irritation signs, and shock were significantly more frequent in the fatal cases. The mortality was 90% if two or all of these three clinical findings were detected. CONCLUSION: HPVG related to intestinal necrosis requires surgery, and our CT-based criteria are probably useful to determine the surgical indication. In non-surgical cases, ascites, peritoneal irritation signs and shock were closely associated with poor prognoses, and are applicable as predictors of patients' prognoses.

Gastric pneumatosis: Laboratory and imaging findings associated with mortality in adults.

AIM: To describe laboratory and imaging findings associated with mortality in patients with gastric pneumatosis. MATERIALS AND METHODS: Institution review board approval was obtained for this retrospective study. Using radiology report databases, all patients with "gastric pneumatosis" or "emphysematous gastritis" in their CT reports were identified from two institutions during 12 or 9 year periods. Clinical parameters and laboratory values [lactic acid, white blood cell (WBC) count, and serum creatinine] were obtained from medical records and images were reviewed in consensus by two readers. Bivariate associations between continuous variables were tested by Mann-Whitney tests. Fisher's exact test was used to evaluate bivariate associations between categorical variables. RESULTS: Of the 24 patients identified, there were five (21%) deaths. Median serum lactic acid and creatinine levels were significantly higher in patients who died compared to surviving patients [median (interquartile range, IQR): 1.95 (1.45-4.15) versus 1.5 (1.3-2.6), p = 0.001; 1.2 (1-2.8) versus 1 (0.8-1.4), p = 0.005, respectively). There was no significant difference in WBC levels between the groups. Coexistent small bowel pneumatosis and colonic pneumatosis were significantly more common in patients who died compared to surviving patients (80% versus 0%, p < 0.001; 40% versus 0%, p = 0.04, respectively). There was no significant difference for portal or mesenteric venous gas, free intraperitoneal gas, or dilated bowel. CONCLUSIONS: When the imaging finding of gastric pneumatosis was associated with elevated serum lactic acid, elevated serum creatinine, or concomitant small bowel or colonic pneumatosis, an association with mortality was observed. These findings suggest that more aggressive treatment may be warranted in patients with these laboratory or imaging abnormalities.

MELD predicts mortality in conservatively managed pneumatosis intestinalis in cirrhotics.

Pneumatosis intestinalis (PI) is a radiologic finding associated with multiple conditions and a high mortality rate (33-40%, 1-3). The current literature addressing PI is limited to an unselected population. This is the first study addressing the management of PI in cirrhotics, a population in which surgical intervention is particularly risky. While nonoperative management is acceptable in the general population, it is unknown whether the same is true when managing patients with underlying cirrhosis. We retrospectively identified cases of PI found on computed tomography (CT) scans performed on cirrhotics from 2004 to 2011. Chart review included comorbidities, hospital course, serum lactate levels, APACHE scores and MELD scores. Nine cirrhotics with PI were identified. Eight were managed conservatively. One patient with MELD score of 18 underwent exploration and died. In total, six patients died. The mean MELD score in patients who died was higher than in those who survived (28 vs. 14). Mortality was 100% in cirrhotic patients with PI whose MELD was greater than 16. Mean lactate levels (33 mg/dL vs. 21 mg/dL) and mean APACHE scores (28 vs. 15) were also higher in those who died. Serum bicarbonate levels and white blood cell counts were not consistently elevated. Our results suggest that the MELD score is an important predictor of mortality in cirrhotics with PI. Serum lactate and APACHE scores are also important markers. Larger studies are required to determine whether there is a role for operative management in cirrhotic patients with a MELD lower than 16.

Incidence, risk factors, and outcome of pneumatosis intestinalis in pediatric stem cell transplant recipients.

BACKGROUND: Pneumatosis Intestinalis (PI) is a rare complication following hematopoietic stem cell transplant (HSCT). We sought to assess the incidence, risk factors, and outcome associated with PI. PROCEDURE: We retrospectively reviewed the incidence of PI among 178 patients who underwent allogeneic HSCT between September 1999 and February 2010. RESULTS: Eighteen of 178 children (10.1%) who received allogeneic HSCT developed PI at a median of 94 days (range, 11-1169) after transplant. All patients presented with either abdominal pain or distention, and half of the patients had free air on radiographs. Patients who developed PI had a significantly higher proportion of acute (83% vs. 44%, P = 0.002) and chronic graft versus host disease (GVHD; 56% vs. 18%, P < 0.001). Only 39% of patients with PI had GVHD involving the gasterointestinal track. All patients were managed conservatively without surgery. Transplant related mortality (TRM) was significantly higher in patients who developed PI compared to those who did not (OR 4.3, 95% CI: 1.3-13.1; P = 0.007), but no deaths were attributable to PI. CONCLUSIONS: We conclude that PI is a common complication associated with treatment of GVHD after HSCT, and patients who develop PI experience higher TRM. Patients who develop PI should be managed medically.

Computed tomographic diagnosis of pneumatosis intestinalis: clinical measures predictive of the need for surgical intervention.

OBJECTIVE: To determine which clinical, laboratory, and radiographic parameters predict positive operative findings in patients with pneumatosis intestinalis on computed tomography (CT). DESIGN: Retrospective record review. SETTING: Tertiary care hospital and affiliated community hospital. PATIENTS: One hundred fifty consecutive patients diagnosed as having pneumatosis intestinalis on CT. MAIN OUTCOME MEASURES: Presence or absence of abdominal pathological findings at laparotomy and mortality rates. RESULTS: Of the 150 patients studied, 54 (36%) were managed nonoperatively, 72 (48%) were managed operatively, and 24 (16%) were considered unsalvageable and given comfort measures only. Sixty patients (47%) improved with nonoperative management or had negative intraoperative findings. In the nonoperative group, 50 (93%) improved (n = 50) and 3 (5%) crossed over to surgery. One patient (2%) died. In the operative group, 63 patients (87%) had operative findings requiring intervention and 9 (13%) had negative results on exploration. Twenty-one patients (28%) died. Univariate analysis identified numerous predictors of positive intraoperative findings, including history of coronary artery disease, tachycardia, tachypnea, hypotension, peritonitis, abdominal distention, and lactic acidemia. The significant radiographic findings included dilated loops of bowel, portal venous gas, and atherosclerosis on CT. On multivariate analysis, only abdominal distention (odds ratio = 13.19; P = .001), peritonitis (odds ratio = 9.35; P = .007), and lactic acidemia (odds ratio = 2.29; P = .02) were predictive of positive intraoperative findings. CONCLUSIONS: Many patients with pneumatosis intestinalis on CT can be successfully treated nonoperatively. In determining a management strategy, abnormal physical examination findings were more predictive of the need for surgical intervention than laboratory values or radiographic findings.

Pneumatosis intestinalis in patients with severe thermal injury.

Severe thermal injury is associated with pronounced changes in intestinal physiology, which may cause ischemia, infarction, and pneumatosis intestinalis (PI). PI is a pathologic condition defined as infiltration of gas into the gastrointestinal tract wall. Historically, PI prompted urgent surgery, yet some surgeons "watch and wait" to avoid the risks of a negative laparotomy. The authors reviewed experience with PI at a single burn center. They retrospectively identified burn center intensive care unit patients with radiographic or pathologic evidence of PI. Data included demographics, injury severity score, TBSA burned, operative findings, length of stay, and mortality. From January 2003 through August 2009, 1129 patients were admitted to the authors' burn center intensive care unit. Fifteen had PI. Twelve had radiographic evidence of PI, and 10 had PI associated with intestinal infarction. Nonsurvivors had lower base deficits (P = .02), higher lactate levels (P = .05), and required vasopressor support (P = .02) within 24 hours of developing PI. Massive intestinal infarction (P = .004) and open abdomens (P = .004) were more common among nonsurvivors. PI can be identified by radiologic or pathologic findings. The authors' experience with PI among patients with burn injury revealed a high mortality rate. Because of the association of bowel ischemia with PI, exploratory laparotomy should be strongly considered in patients with burn injury with radiographic evidence of PI.

Management algorithm for pneumatosis intestinalis and portal venous gas: treatment and outcome of 88 consecutive cases.

BACKGROUND: Pneumatosis intestinalis (PI) and portal venous gas (PVG) historically mandated laparotomy due to the high mortality rate associated with mesenteric ischemia. Computed tomography (CT) can identify PI/PVG in patients with ischemic emergencies and benign idiopathic conditions. METHODS: A consecutive series of patients with PI or PVG was reviewed from a single institution over 5 years. Eighty-eight cases of PI/PVG were studied: 74 initial patients (year 1-4) were used to generate a treatment algorithm and fourteen additional cases were used to test the algorithm. RESULTS: PI and PVG were associated with three major clinical subgroups: mechanical causes (n=29), acute mesenteric ischemia (n=29), and benign idiopathic (n=26); four were unclassifiable. Patients with acute mesenteric ischemia were associated with abdominal pain (p=0.01), elevated lactate (>or=3.0 mg/dL; p=0.006), small bowel PI (p=0.04), and calculated vascular disease score (p<0.0005). The three subgroups could be distinguished using the generated algorithm with a sensitivity of 89%, specificity of 100%, and positive predictive value of 100%. CONCLUSIONS: With greater sensitivity of modern CT scans, PI and PVG are being detected in patients with a wide range of surgical and non-surgical conditions. This clinical algorithm can identify subgroups to direct surgical intervention for acute ischemic insults and prevent non-therapeutic laparotomies for benign idiopathic PI and PVG.

Pneumatosis intestinalis in adults: management, surgical indications, and risk factors for mortality.

BACKGROUND: Pneumatosis intestinalis (PI) is an unusual finding that can exist in a benign setting but can indicate ischemic bowel and the need for surgical intervention. We present a series of cases of PI in adults to illustrate factors associated with death and surgical intervention. METHODS: We reviewed the radiology database of the Mount Sinai Medical Center for cases of PI between 1996-2006 in adult patients. Chi-square and multivariable logistic regression analyses were used to identify factors significant for surgery and death. RESULTS: Forty patients developed PI over a 10-year span. The overall in-hospital mortality rate was 20%, and the surgical rate was 35%. Factors independently associated with surgical management on multivariable analysis were age >or= 60 years (p = 0.03), the presence of emesis (p = 0.01), and a WBC > 12 c/mm3 (p = 0.03). Pre-existing sepsis was independently associated with mortality (p = 0.03) while controlling for surgery. CONCLUSION: Patients with the concomitant presence of PI, a WBC > 12 c/mm3, and/or emesis in the >60-year-old age group were most likely to have surgical intervention, whereas PI patients with sepsis had the highest risk for death. A management algorithm is proposed, but further research will be needed to determine which patients with PI may benefit most from surgery.

Serum lactic acid determines the outcomes of CT diagnosis of pneumatosis of the gastrointestinal tract.

Computed tomography (CT) diagnosis of pneumatosis involving the gastrointestinal tract can represent a broad range of clinical entities from a benign process to ischemic bowel. The purpose of this study is to define the significance and outcome of pneumatosis intestinalis (PI). All CT scans from 5/93 to 12/01 with the finding of PI were reviewed. Eighty-six CT scans had the finding of PI, with the colon being the most frequent location (51%), followed by small bowel (36%) and gastric (9%). Forty per cent of patients underwent surgery, with an overall mortality rate of 42 per cent and a surgical mortality rate of 47 per cent. Univariate analysis demonstrated significant correlation between serum lactic acid (LA) > 2.0 mmol/L [odds ratio (OR) = 23.4; 95% confidence interval (C.I.), 7.21-75.92] and serum creatinine > 1.5 mg/dL (OR = 3.05; 95% C.I., 1.25-7.42) with mortality. Age was suggestive but not a significant risk factor for mortality (P = 0.09). Multivariate analysis found serum LA > 2.0 (OR = 30.37; 95% C.I., 7.31-126.2) to be the only significant predictor of mortality. CT diagnosis of PI is associated with significant in-hospital mortality, especially in the elderly. Serum LA level > 2.0 mmol/L at time of diagnosis is associated with a greater than 80 per cent mortality. Surgical consultation is necessary to determine which patients need urgent surgical intervention.

Neumatosis quística intestinal en síndrome de Crest

Presentamos un caso de neumatosis quística intestinal (NQI) en una paciente de 64 años con diagnóstico de Síndrome de Crest. Esta complicación simulaba un abdomen agudo por perforación de vícera hueca. Las radiografías del abdomen evidenciaron neumoperitoneo y neumatosis quística intestinal. Se le practicó laparotomía y se encontro neumatosis quística intestinal, diagnóstico confirmado con patología.

[Intestinal pneumatosis in pediatrics. Report of 72 cases]. / Neumatósis intestinal en pediatría.

We analyzed 72 cases of pneumatosis intestinalis at the Hospital Infantil de México during a 32 years period. We found the higehst incidence in children under 6 months of age. In the new-born period, the entity is associated with necrotizing entrocolitis and in the older children group, this alteration is associated with gastroenteritis. The diagnosis was made by radiology in 93% of the cases and in 7%, it was made at the surgical event. We propose 3 mechanisms in the pathophysiology of the entity having all of them disruption of the integrity of the intestinal mucosa and higher pressure of the intraluminal gas. The mortality rate was high because we included cases from the initiation of the hospital's activities (1943). The conclusion is: 1) The prognosis is based on an early diagnosis. 2) It is imperative to take proper care of the complication. 3) It is also very important to give a rest for variable period of time to the injured intestine with parenteral feeding and eventually, elemental feeding.

[Intestinal pneumatosis. Analysis of 30 cured cases]. / Neumatósis intestinal: Análisis de 30 casos que curaron.

The study included 30 patients with gastroenteritis and pneumatosis intestinalis, seen at the pediatric hospital of the IMSS, who followed a satisfactory course. Complications and associated diseases were found in these patients to be less severe than in other patients who died. Lethality in this type of patients (33%) is analyzed together with the clinical records in 33 cases of death from gastroenteritis and pneumatosis intestinalis during the period from January 1974 to April 1975. It was found that the period of hospital stay was shorter than in the group that recovered; that complications leading to death were severe and of acute evolution among which, bronchopneumonia, septic shock, intestinal infarct and others, predominated. Decrease in lethality may be considered to lie in an earlier diagnosis together with prevention and treatment of pneumatosis intestinalis and its complications.