Current approaches to the management of pneumatosis intestinalis: an American Pediatric Surgical Association membership survey.

PURPOSE: Pneumatosis intestinalis (PI) remains difficult to treat as it can lead to a broad range of clinical sequalae and there are little published data available to guide management. Our aim was to evaluate how pediatric surgeons currently manage children with PI, how treatment varies based on etiology, and to identify opportunities to optimize current PI management strategies. METHODS: We administered a web-based survey of practicing pediatric surgeons in the United States and Canada. The survey was distributed to all members of the American Pediatric Surgical Association. RESULTS: Of 1508 distributed surveys, 333 responses were received (22% response rate); 174 were complete and included in analysis (12% analyzed). For all scenarios, respondents recommended treatment for PI include a median 7 days of bowel rest and 7 days antibiotics. Only 41% reported their approach to PI management was optimal. Ways to optimize care include treatment based on etiology (83%), decreased number of repeat images (64%), shorter NPO course (49%), and shorter antibiotic course (47%). CONCLUSION: Pediatric surgeons manage PI similarly regardless of etiology but most report this is suboptimal. Future work is needed to prospectively evaluate management protocols that consider etiology.

Extensa neumatosis colónica ¿Manejo conservador o tratamiento quirúrgico? / No disponible

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Pneumatosis intestinalis in COVID-19.

INTRODUCTION: COVID-19 is a respiratory illness due to novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), described in December 2019 in Wuhan (China) and rapidly evolved into a pandemic. Gastrointestinal (GI) tract can also be involved. CASE PRESENTATION: A 44-year-old man was hospitalised for COVID-19-associated pneumonia. A rapid recovery of respiratory and general symptoms was observed after 1 week of treatment with lopinavir/ritonavir plus hydroxychloroquine and broad-spectrum antibiotics (piperacillin-tazobactam plus teicoplanin). No GI symptoms were reported during hospitalisation, but a lung contrast-enhancement CT (CE-CT) excluding thromboembolism showed, as collateral finding, intraperitoneal free bubbles not present on a previous CT examination; the subsequent abdominal CE-CT described pneumatosis intestinalis (PI) involving the caecum and the right colon. Ciprofloxacin plus metronidazole was started, and the 2-week follow-up CT showed the complete resolution of PI. DISCUSSION: The pathogenesis of PI is poorly understood. PI involving the caecum and right colon has been described for HIV and Cytomegalovirus infections, but, to our best knowledge, never before in COVID-19. We hypothesise a multifactorial aetiopathogenesis for PI, with a possible role of the bowel wall damage and microbiota impairment due to SARS-CoV-2 infection, and we suggest a conservative management in the absence of symptoms.

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.

Gastric and intestinal pneumatosis / Neumatosis gástrica e intestinal

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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.

A Case of Recurrent Pneumoperitoneum and Pneumatosis Intestinalis After Bilateral Lung Transplant.

We report a case of a 60-year-old male patient with recurrent episodes of free gas in the peritoneal and the retroperitoneal cavities as well as pneumatosis intestinalis 3 months after bilateral lung transplant. Interestingly, despite staged laparotomy within the scope of the first episode, no cause for free gas could be found. In a second episode of symptomatically pneumatosis, a conservative treatment with metro_nidazole was performed successfully. Despite several case reports on patients with pneumatosis intestinalis after lung transplant, an effective treatment strategy has not yet been proposed.

Gefitinib successfully administered in a lung cancer patient with leptomeningeal carcinomatosis after erlotinib-induced pneumatosis intestinalis.

BACKGROUND: Pneumatosis intestinalis (PI) is a rare complication of chemotherapy, characterized by multiple gas accumulations within the bowel wall. CASE PRESENTATION: A 71-year-old woman with epidermal growth factor receptor (EGFR) mutation-positive lung adenocarcinoma was admitted to our hospital because of reduced consciousness. She was diagnosed as having leptomeningeal carcinomatosis (LM) using lumbar puncture. Because she could not swallow a tablet, erlotinib was administered via a feeding tube. Her state of consciousness gradually improved, but she experienced diarrhea several times a day. After 3 weeks of erlotinib therapy, PI occurred. Erlotinib was discontinued and PI was resolved after treatment with conservative therapies. Erlotinib was re-administrated and PI occurred again. After improvement of erlotinib-induced PI, gefitinib was administered by a feeding tube and the patient did not experience PI or diarrhea. The patient survived 8 months from the diagnosis of LM. CONCLUSION: PI is one of the side effects of erlotinib, and consecutive therapies are useful for the treatment of PI. In this patient, gefitinib was successfully administered after erlotinib-induced PI.

Four Cases of Pneumatosis Cystoides Intestinalis Complicated by Connective Tissue Diseases.

Pneumatosis cystoides intestinalis (PCI) is a rare disease that involves the presence of gas in the intestinal wall. Connective tissue disease (CTD) is a major cause of secondary PCI. In addition to the nature of CTDs, the use of prednisolone and some immunosuppressants, and the presence of complicating diseases such as diabetes mellitus, constipation and pulmonary diseases are involved in the development of PCI. This report describes four cases of PCI with different CTDs (granulomatosis with polyangiitis, rheumatoid arthritis, dermatomyositis, and overlap syndrome) and discusses the background of each patient and common risk factors for the occurrence of PCI.

Enteritis with pneumatosis intestinalis following rotavirus immunisation in an infant with short bowel syndrome.

Rotavirus vaccines now form part of the national immunisation schedule in many countries. Contraindications to its use are few but do not currently include infants with short bowel syndrome (SBS). We present a nearly 3-month-old boy with SBS who developed enteritis with pneumatosis intestinalis following administration of the Rotarix vaccine.

Pneumatosis coli in a domestic ferret (Mustela putorius furo).

A 4-year-old spayed female ferret was presented with acute diarrhea and partial anorexia. Pneumatosis coli and segmental enteropathy were identified by ultrasonography and radiography. Fecal culture did not identify any pathogenic bacteria. Medical management of concurrent diseases and antibiotic therapy resulted in resolution of clinical signs and pneumatosis coli.

Pneumatose chez un furet domestique(Mustela putorius furo). Un furet femelle stérilisé âgé de 4 ans a été présenté avec une diarrhée aiguë et de l'anorexie partielle. Une pneumatose et une entéropathie segmentaire ont été identifiés par échographie et radiographie. Une culture fécale n'a pas permis de mettre en évidence une bactérie pathogène. La gestion médicale de maladies concomitantes et d'une thérapie antibiotique ont produit une résolution des signes cliniques et de pneumatose.(Traduit par Isabelle Vallières).

Intestinal Pneumatosis Associated with Tuberculosis after Allogeneic Hematopoietic Stem Cell Transplantation.

Pneumatosis intestinalis (PI), defined as intestinal intra- and extramural gas accumulation, is a rare radiographic finding in conditions of intestinal wall damage of varied etiology. Here, we report on a 56-year-old female with multiple myeloma who presented with undulating fever, fluctuating abdominal symptoms, and a distended abdomen 5 months after allogeneic hematopoietic stem cell transplantation (HSCT). Abdominal X-ray and CT scan documented PI with gas accumulation both in the intestinal and colonic bowel walls. Concurrently, thoracic CT revealed mediastinal and bihilar lymphadenopathy associated with bilateral pleural effusions. Microscopy of bronchoalveolar lavage fluid (BALF) revealed acid-fast bacilli, which were identified as Mycobacterium tuberculosis. Tuberculostatic treatment resulted in timely clinical improvement, a complete clearance of the radiological and clinical findings of PI, and the control of the tuberculosis (Tbc), determined by multiple negative BALF results. Taken together, PI occurred as the initial symptom of Tbc in an allogeneic stem cell recipient, achieving complete recovery by tuberculostatic treatment only.

Segmental pneumatosis cystoides coli: computed tomography-facilitated diagnosis

Background: Intestinal pneumatosis is a rare entity of unclear etiopathogenesis characterized by the presence of gaseous cystic or linear collections within the intestinal wall. Intestinal pneumatosis may be primary and idiopathic in origin or, more frequently, it accompanies various clinical conditions. Rarely, the development of intestinal pneumatosis is attributed to the pharmacotherapy with different drugs. Case report: This is a case report of cystic pneumatosis limited to the large intestine with predominant clinical presentation of chronic watery diarrhea in a 64-year-old man suffering from diabetes mellitus treated with metformin and acarbose. The patient had been referred to the outpatient gastroenterology clinic for further investigation of numerous polyp-like lesions found on colonoscopy. There was no history of cigarette smoking, drug abuse or extraintestinal complaints. The patient was in a good general condition and his laboratory tests were normal. No relevant abnormalities were found on chest X-ray, esophagogastroduodenoscopy or abdominal ultrasound, but computed tomography showed intramural gas-filled bubbles in the cecum and splenic flexure without signs of perforation or any other significant pathology in the abdominal cavity. The final diagnosis of pneumatosis cystoides coli (PCC), possibly related to treatment with acarbose, was established. On a follow-up visit after discontinuation of acarbose the patient reported no complaints and remained asymptomatic for the next 12 months. Discussion: To conclude, drug-related PCC should be considered in a differential diagnosis of gastrointestinal symptoms and/or polyp-like lesions disclosed on colonoscopy in diabetic patients treated with acarbose (AU)

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Case of pneumatosis intestinalis and hepatic portal venous gas following a laparoscopic right hemicolectomy.

Hepatic portal venous gas (HPVG) in most cases signifies either mechanical migration of air into the portal system due to bowel ischaemia (pneumatosis intestinalis) or portal sepsis due to gas-forming organisms. Successful management of portal sepsis involves early identification of the condition, intensive resuscitation, broad-spectrum antibiotics and a laparotomy for possible bowel ischaemia. In this report, we discuss the case of a patient with pneumatosis intestinalis and HPVG after an elective laparoscopic right hemicolectomy. After an initial slow recovery, on postoperative day seven, the patient had profuse diarrhoea and confusion, and was hyponatraemic. A CT scan revealed pneumatosis intestinalis and HPVG. A laparotomy showed no obvious cause for HPVG and there was no ischaemic bowel. She was managed with intensive care, hyperbaric oxygen therapy, broad-spectrum antibiotics and total-parenteral nutrition. She has made a good recovery. This case highlights the presenting features, differential diagnoses, and management of pneumatosis intestinalis and HPVG.

Benign pneumatosis intestinalis in a pediatric patient with multiple risk factors including granulomatosis with polyangiitis: a case report and review of the literature.

OBJECTIVE: To describe the first reported case of pneumatosis intestinalis (PI) in a pediatric patient with granulomatosis with polyangiitis (GPA) and multiple other risk factors and review the literature for PI in adult and pediatric rheumatologic conditions. METHODS: A PubMed search was completed using the search phrase "pneumatosis intestinalis." Searches were limited to humans and the English language, and remaining articles involving patients with rheumatologic diagnoses were identified and included in our discussion. RESULTS: This is the first reported of case of PI in a patient with underlying GPA or antineutrophil cytoplasmic antibody-associated vasculitides. Out of 90 previously reported cases of PI in patients with rheumatologic conditions, 79 cases were in adults and 11 in children. There were 30 patients with systemic sclerosis, 18 with MCTD/overlap syndrome, 18 with dermatomyositis or polymyositis, 16 with SLE, and 8 with other diagnoses. Overall, 81% of the patients were on corticosteroids or other immunosuppressants prior to development of PI. The most common presenting symptom was abdominal pain, and 51% of patients had associated pneumoperitoneum. CONCLUSIONS: PI can be associated with a broad spectrum of rheumatic diseases, including GPA, and should be included in the differential diagnosis of patients with rheumatologic conditions and nonspecific gastrointestinal symptoms.

[Pneumatosis cystoides intestinalis during palliative chemotherapy for colorectal cancer]. / Pneumatose kystique colique au cours d'une chimiothérapie palliative pour un cancer colorectal.

Pneumatosis cystoides intestinalis is a rare disease characterized by the presence of gas into the colonic wall. Symptoms are non specific and, most of the time, the diagnosis is done by an abdominal CT scan. We report a case of pneumatosis cystoides intestinalis which occurred in a patient with a colorectal cancer in palliative stage. This patient was treated by 5 fluorouracil (5FU), folinic acid and oxaliplatin chemotherapy, after a first lign of chemotherapy with 5FU, irinotecan and cetuximab. The association of chemotherapy is most likely probable.