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Chen Y, Xiao Y, Lian G, Yi J, Liu X. Pneumatosis intestinalis associated with α-glucosidase inhibitors: a pharmacovigilance study of the FDA adverse event reporting system from 2004 to 2022. Expert Opin Drug Saf 2023:1-10. [PMID: 37929311 DOI: 10.1080/14740338.2023.2278708] [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: 06/07/2023] [Accepted: 10/13/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND A-glucosidase inhibitors (AGIs) are suitable for type 2 diabetes mellitus patients with carbohydrate-rich diets while were reported associated with the rare but potentially life-threatening pneumatosis intestinalis (PI). RESEARCH DESIGN AND METHODS Data from the US Food and Drug Administration Adverse Event Reporting System (FAERS) were examined for AGIs, acarbose, voglibose, miglitol, or other anti-hyperglycemic drug classes. The reporting odds ratio (ROR), proportional reporting ratio, gamma poisson shrinker, and bayesian confidence propagation neural network were applied to determine the safety signals, which were performed under two other models to control for bias from type 2 diabetes mellitus and other anti-hyperglycemic drugs. RESULTS We found a significantly higher reporting of PI in all AGIs group [ROR = 73.85 (61.56-88.58)]. When further subdivided, voglibose and miglitol had a larger ROR than acarbose whether models were adjusted or not. The safety signals of biguanides, sulfonylureas, thiazolidinediones, dipeptidyl peptidase 4 inhibitors inhibitors, glucagon-like peptide-1 receptor agonists, sodium-glucose co-transporter-2 inhibitors, and other drug classes were not detected in three models. CONCLUSIONS Our study identified the safety signals of the PI-AGIs pair, primarily based on disproportionality analysis while controlling for confounders such as the disease-associated risk of PI and concomitant drug exposure.
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Affiliation(s)
- Yiqian Chen
- Department of Gastroenterology, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yao Xiao
- Department of Endocrinology, Endocrinology Research Center, Xiangya Hospital of Central South University, Changsha, Hunan, China
| | - Guanghui Lian
- Department of Gastroenterology, Xiangya Hospital, Central South University, Changsha, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Jun Yi
- Department of Gastroenterology, Xiangya Hospital, Central South University, Changsha, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Xiaowei Liu
- Department of Gastroenterology, Xiangya Hospital, Central South University, Changsha, Hunan, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Central South University, Changsha, Hunan, China
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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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3
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Sharp J, Chuang K. Benign Pneumatosis Intestinalis: A Case Report and Review of the Literature. Fed Pract 2022; 39:281-285. [PMID: 36404938 PMCID: PMC9648604 DOI: 10.12788/fp.0277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
BACKGROUND Pneumatosis intestinalis is the presence of gas within the walls of the intestine on imaging and has variable clinical significance, ranging from an incidental finding to a harbinger of intra-abdominal catastrophe. There are multiple mechanisms by which this radiographic finding develops, including bacterial gas production, increased intraluminal pressure within the gastrointestinal tract, mechanical disruption of the gut mucosa, and tracking of pulmonary gas along the mesenteric vasculature. CASE PRESENTATION We present the case of a 61-year-old male veteran who had sustained a remote anoxic brain injury resulting in chronic dependence on a gastrostomy tube for enteral nutrition, found incidentally to have pneumatosis intestinalis without signs of intra-abdominal catastrophe. CONCLUSIONS Appropriate interpretation of this finding can lead to life-saving interventions and avoid unnecessary surgical procedures.
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Affiliation(s)
| | - Kelley Chuang
- Greater Los Angeles Veterans Affairs Healthcare System, California
- David Geffen School of Medicine at University of California, Los Angeles
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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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Della Seta M, Kloeckner R, Pinto Dos Santos D, Walter-Rittel TC, Hahn F, Henze J, Gropp A, Pratschke J, Hamm B, Geisel D, Auer TA. Pneumatosis intestinalis and porto-mesenteric venous gas: a multicenter study. BMC Med Imaging 2021; 21:129. [PMID: 34429069 PMCID: PMC8383372 DOI: 10.1186/s12880-021-00651-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 07/26/2021] [Indexed: 12/30/2022] Open
Abstract
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.
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Affiliation(s)
- Marta Della Seta
- Department for Radiology, Charité - University Medicine Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Roman Kloeckner
- Department for Radiology, University Hospital Mainz, Mainz, Germany
| | | | - Thula Cannon Walter-Rittel
- Department for Radiology, Charité - University Medicine Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Felix Hahn
- Department for Radiology, University Hospital Mainz, Mainz, Germany
| | - Jörn Henze
- Department for Radiology, University Hospital of Cologne, Cologne, Germany
| | - Annika Gropp
- Department for Radiology, Charité - University Medicine Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Johann Pratschke
- Department of General, Visceral and Transplant Surgery, Charité - University Medicine Berlin, Berlin, Germany
| | - Bernd Hamm
- Department for Radiology, Charité - University Medicine Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Dominik Geisel
- Department for Radiology, Charité - University Medicine Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Timo Alexander Auer
- Department for Radiology, Charité - University Medicine Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany. .,Berlin Institute of Health (BIH), Berlin, Germany.
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Pneumatosis cystoides intestinalis, a rare case in a pediatric patient following allogeneic hematopoietic stem cell transplantation: CT findings and literature review. Radiol Case Rep 2021; 16:3120-3124. [PMID: 34457100 PMCID: PMC8377547 DOI: 10.1016/j.radcr.2021.07.053] [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: 05/12/2021] [Revised: 07/18/2021] [Accepted: 07/18/2021] [Indexed: 01/04/2023] Open
Abstract
Pneumatosis cystoides intestinalis (PCI) is a rare condition characterized by the presence of gas-filled cysts in the subserosa or submucosa of the bowel wall. It is associated with various disorders including chronic obstructive pulmonary diseases, autoimmune disorders, and organ transplantation. PCI has also been observed following Hematopoietic Stem Cell Transplantation (HSCT), associated with chemotherapy, acute Graft versus Host Disease (GvHD), immunosuppression, and infections. Computed tomography (CT) provides an easy diagnosis because it highlights the presence of air bubbles in the intestinal wall and possible pneumoperitoneum. We report the case of a patient with severe acquired medullary aplasia undergoing allogeneic HSCT with subsequent development of cutaneous GvHD and an incidental finding of PCI during a CT scan of the chest in absence of gastrointestinal symptoms. Our work aims at clarifying a possible complication in pediatric patients undergoing HSCT to guide young or non-pediatric radiologists in the identification of this rare condition, helping the clinician in the correct conservative management of these patients and reserving the surgical treatment only to specific complications.
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7
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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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Davarpanah AH, Ghamari Khameneh A, Khosravi B, Mir A, Saffar H, Radmard AR. Many faces of acute bowel ischemia: overview of radiologic staging. Insights Imaging 2021; 12:56. [PMID: 33914188 PMCID: PMC8085211 DOI: 10.1186/s13244-021-00985-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 03/16/2021] [Indexed: 12/12/2022] Open
Abstract
Acute bowel ischemia (ABI) can be life threatening with high mortality rate. In spite of the advances made in diagnosis and treatment of ABI, no significant change has occurred in the mortality over the past decade. ABI is potentially reversible with prompt diagnosis. The radiologist plays a central role in the initial diagnosis and preventing progression to irreversible intestinal ischemic injury or bowel necrosis. The most single imaging findings described in the literature are either non-specific or only present in the late stages of ABI, urging the use of a constellation of features to reach a more confident diagnosis. While ABI has been traditionally categorized based on the etiology with a wide spectrum of imaging findings overlapped with each other, the final decision for patient's management is usually made on the stage of the ABI with respect to the underlying pathophysiology. In this review, we first discuss the pathologic stages of ischemia and then summarize the various imaging signs and causes of ABI. We also emphasize on the correlation of imaging findings and pathological staging of the disease. Finally, a management approach is proposed using combined clinical and radiological findings to determine whether the patient may benefit from surgery or not.
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Affiliation(s)
- Amir H Davarpanah
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, USA
| | - Afshar Ghamari Khameneh
- Department of Radiology, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Bardia Khosravi
- Department of Radiology, Shariati Hospital, Tehran University of Medical Sciences, 14117, North Kargar St., Tehran, Iran
| | - Ali Mir
- Department of Surgery, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Hiva Saffar
- Department of Pathology, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran
| | - Amir Reza Radmard
- Department of Radiology, Shariati Hospital, Tehran University of Medical Sciences, 14117, North Kargar St., Tehran, Iran.
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Abstract
Pneumatosis intestinalis is the presence of gas in the bowel wall and is divided into two categories: life-threatening pneumatosis intestinalis and benign pneumatosis intestinalis. Pneumatosis cystoides intestinalis is a rare condition characterized by gas-filled cysts in submucosa and subserosa. The pathogenesis is unclear, although some causes have been theorized. The presenting clinical findings may be very heterogeneous. Intestinal pneumatosis may lead to various complications. Distinguishing between pneumatosis cystoides intestinalis and life-threatening pneumatosis intestinalis may be challenging, although computed tomography scan allows the detection of additional findings that may suggest an underlying, potentially worrisome cause of pneumatosis intestinalis. To correctly manage the patients affected with this disease is important to differentiate the two types of pneumatosis. The patients with pneumatosis cystoides intestinalis are usually treated conservatively; the surgical treatment is reserved for complications. We described a case of a patient with pneumatosis cystoides intestinalis and gastric perforation. The medical history of the patient revealed a breast cancer treated with mastectomy and chemotherapy; the patient did not report a history of gastrointestinal disease. The abdomen CT showed abscess formation at the level of the antro-pylorus, linear pneumatosis in the gastric wall, and free abdominal air. Multiple small air bubbles was observed in intestinal wall. The intestinal wall was not thickened with normal contrast mucosal enhancement. CT examination showed neither mesenteric stranding nor portal venous gas embolism. The findings of the surgery were gastric perforated peptic ulcer and benign pneumatosis intestinalis.
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Gastric Outlet Obstruction and Sigmoid Volvulus in a Patient with Pneumatosis intestinalis: An Etiology or a Complication. Case Rep Surg 2019; 2019:4065749. [PMID: 31380139 PMCID: PMC6652069 DOI: 10.1155/2019/4065749] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 06/09/2019] [Accepted: 06/24/2019] [Indexed: 12/27/2022] Open
Abstract
Pneumatosis intestinalis (PI) is a radiographic finding which refers to the presence of gas within the wall of any part of the gastrointestinal tract. While in some cases it is an incidental finding which usually represent its benign nonischemic etiology, it may indicate a catastrophic intra-abdominal condition and distinctly characteristic of ischemic enterocolitis. Herein, we discuss the clinical signs and symptoms, the radiological features, the surgical management and outcome of an extremely rare concurrent triad of PI, gastric outlet obstruction, and the sigmoid volvulus based on a case of a patient who underwent surgery in our hospital, which, we think, can emphasize the mysterious concept of PI's mechanical etiology.
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11
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Di Pietropaolo M, Trinci M, Giangregorio C, Galluzzo M, Miele V. Pneumatosis cystoides intestinalis: case report and review of literature. Clin J Gastroenterol 2019; 13:31-36. [PMID: 31161540 DOI: 10.1007/s12328-019-00999-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2019] [Accepted: 05/28/2019] [Indexed: 12/18/2022]
Abstract
Pneumatosis intestinalis is the presence of gas in the bowel wall and is divided into two categories: life-threatening pneumatosis intestinalis and benign pneumatosis intestinalis. Pneumatosis cystoides intestinalis is a rare condition characterized by gas-filled cysts in submucosa and subserosa. The pathogenesis is unclear, although some causes have been theorized. The presenting clinical findings may be very heterogeneous. Intestinal pneumatosis may lead to various complications. Distinguishing between pneumatosis cystoides intestinalis and life-threatening pneumatosis intestinalis may be challenging, although computed tomography scan allows the detection of additional findings that may suggest an underlying, potentially worrisome cause of pneumatosis intestinalis. To correctly manage the patients affected with this disease is important to differentiate the two types of pneumatosis. The patients with pneumatosis cystoides intestinalis are usually treated conservatively; the surgical treatment is reserved for complications. We described a case of a patient with pneumatosis cystoides intestinalis and gastric perforation. The medical history of the patient revealed a breast cancer treated with mastectomy and chemotherapy; the patient did not report a history of gastrointestinal disease. The abdomen CT showed abscess formation at the level of the antro-pylorus, linear pneumatosis in the gastric wall, and free abdominal air. Multiple small air bubbles was observed in intestinal wall. The intestinal wall was not thickened with normal contrast mucosal enhancement. CT examination showed neither mesenteric stranding nor portal venous gas embolism. The findings of the surgery were gastric perforated peptic ulcer and benign pneumatosis intestinalis.
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Affiliation(s)
- Marco Di Pietropaolo
- Department of Emergency Radiology, S. Camillo Hospital, Circonvallazione Gianicolense 87, 00152, Rome, Italy.
| | - Margherita Trinci
- Department of Emergency Radiology, S. Camillo Hospital, Circonvallazione Gianicolense 87, 00152, Rome, Italy
| | - Carlo Giangregorio
- Department of Emergency Radiology, S. Camillo Hospital, Circonvallazione Gianicolense 87, 00152, Rome, Italy
| | - Michele Galluzzo
- Department of Emergency Radiology, S. Camillo Hospital, Circonvallazione Gianicolense 87, 00152, Rome, Italy
| | - Vittorio Miele
- Department of Radiology, Careggi University Hospital, L. go Giovanni Alessandro Brambilla 3, 50134, Florence, Italy
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12
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Ko S, Hong SS, Hwang J, Kim HJ, Chang YW, Lee E. Benign versus life-threatening causes of pneumatosis intestinalis: differentiating CT features. ACTA ACUST UNITED AC 2018; 64:543-548. [PMID: 30304313 DOI: 10.1590/1806-9282.64.06.543] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Accepted: 10/25/2017] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To assess the diagnostic performance of CT findings in differentiating causes of pneumatosis intestinalis (PI), including benign and life-threatening causes. METHODS All CT reports containing the word "pneumatosis" were queried from June 1st, 2006 to May 31st, 2015. A total of 42 patients with PI were enrolled (mean age, 63.4 years; 23 males and 19 females) and divided into two groups on based on electronic medical records: a benign group (n=24) and a life-threatening group (n=18). Two radiologists reviewed CT images and evaluated CT findings including bowel distension, the pattern of bowel wall enhancement, bowel wall defect, portal venous gas (PVG), mesenteric venous gas (MVG), extraluminal free air, and ascites. RESULTS CT findings including bowel distension, decreased bowel wall enhancement, PVG, and ascites were more commonly identified in the life-threatening group (all p<0.05). All cases with PVG were included in the life-threatening group (8/18 patients, 44.4%). Bowel wall defect, extraluminal free air, and mesenteric venous gas showed no statistical significance between both groups. CONCLUSION PI and concurrent PVG, bowel distension, decreased bowel wall enhancement, or ascites were significantly associated with life-threatening causes and unfavorable prognosis. Thus, evaluating ancillary CT features when we encountered PI would help us characterize the causes of PI and determine the appropriate treatment option.
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Affiliation(s)
- Sujin Ko
- Department of Radiology, Soonchunhyang University Seoul Hospital, Seoul, South Korea
| | - Seong Sook Hong
- Department of Radiology, Soonchunhyang University Seoul Hospital, Seoul, South Korea
| | - Jiyoung Hwang
- Department of Radiology, Soonchunhyang University Seoul Hospital, Seoul, South Korea
| | - Hyun-Joo Kim
- Department of Radiology, Soonchunhyang University Seoul Hospital, Seoul, South Korea
| | - Yun-Woo Chang
- Department of Radiology, Soonchunhyang University Seoul Hospital, Seoul, South Korea
| | - Eunji Lee
- Department of Radiology, Soonchunhyang University Seoul Hospital, Seoul, South Korea
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13
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Cystic intestinal pneumatosis revealed by peritonitis in perforated peptic ulcer: A case report. JOURNAL OF SURGERY AND MEDICINE 2018. [DOI: 10.28982/josam.426196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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15
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Pasquali M, Leonardo S, Morsiani M, Zompatori M. Oesophageal pneumatosis in a case of bowel ischaemia. BJR Case Rep 2017; 3:20170039. [PMID: 30363192 PMCID: PMC6159176 DOI: 10.1259/bjrcr.20170039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2017] [Revised: 06/21/2017] [Accepted: 07/03/2017] [Indexed: 12/18/2022] Open
Abstract
Pneumatosis intestinalis (PI) is a condition in which cystic collections of gas develop within the gastrointestinal wall, forming submucosal or subserosal "bubbles". The radiologic manifestations are often dramatic and most notably are associated with life-threatening bowel ischaemia. PI may occur as a primary type but is usually secondary in nature, attributable to a wide spectrum of causes (benign and fulminant), ranging from immunosuppression to bowel infarction. Herein, we report a case of massive and extensive PI in a patient with small bowel ischaemia, having both benign and serious clinical origins.
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Affiliation(s)
- Milena Pasquali
- Department of Experimental, Diagnostic and Specialty Medicine (DIMES), Division of Radiology, S.Orsola-Malpighi Hospital, Bologna, Italy
| | - Stefano Leonardo
- Department of Radiology, Santa Maria della Scaletta Hospital, Imola, Bologna, Italy
| | - Miria Morsiani
- Department of Radiology, Santa Maria della Scaletta Hospital, Imola, Bologna, Italy
| | - Maurizio Zompatori
- Department of Radiology, Cardiothoracic section, Policlinico Sant Orsola-Malpighi, Bologna, Italy
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16
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Abdominal radiograph pearls and pitfalls for the emergency department radiologist: a pictorial review. Abdom Radiol (NY) 2017; 42:987-1019. [PMID: 27503382 DOI: 10.1007/s00261-016-0859-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Abdominal plain films are often the first imaging examination performed on a patient with abdominal pain in the emergency department. Radiograph findings can help guide clinical management and the need for advanced imaging. A pictorial review of a range of abdominal radiograph findings is presented, including bowel gas patterns, abdominal organ evaluation, pathologic gas, calcifications, implanted devices, and foreign bodies.
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17
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Affiliation(s)
- Tianyou Yang
- Department of Pediatric Surgery, Guangzhou Women and Children's Medical Center, Affiliated Women and Children's Medical Center of Guangzhou Medical University, Guangzhou, China
| | - Jiliang Yang
- Department of Pediatric Surgery, Guangzhou Women and Children's Medical Center, Affiliated Women and Children's Medical Center of Guangzhou Medical University, Guangzhou, China
| | - Tianbao Tan
- Department of Pediatric Surgery, Guangzhou Women and Children's Medical Center, Affiliated Women and Children's Medical Center of Guangzhou Medical University, Guangzhou, China
| | - Jing Pan
- Department of Pediatric Surgery, Guangzhou Women and Children's Medical Center, Affiliated Women and Children's Medical Center of Guangzhou Medical University, Guangzhou, China
| | - Chao Hu
- Department of Pediatric Surgery, Guangzhou Women and Children's Medical Center, Affiliated Women and Children's Medical Center of Guangzhou Medical University, Guangzhou, China
| | - Yan Zou
- Department of Pediatric Surgery, Guangzhou Women and Children's Medical Center, Affiliated Women and Children's Medical Center of Guangzhou Medical University, Guangzhou, China
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18
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Treyaud MO, Duran R, Zins M, Knebel JF, Meuli RA, Schmidt S. Clinical significance of pneumatosis intestinalis - correlation of MDCT-findings with treatment and outcome. Eur Radiol 2016; 27:70-79. [PMID: 27106233 PMCID: PMC5127863 DOI: 10.1007/s00330-016-4348-9] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Revised: 03/14/2016] [Accepted: 03/29/2016] [Indexed: 12/18/2022]
Abstract
Objectives To evaluate the clinical significance of pneumatosis intestinalis (PI) including the influence on treatment and outcome. Method and Materials Two radiologists jointly reviewed MDCT-examinations of 149 consecutive emergency patients (53 women, mean age 64, range 21-95) with PI of the stomach (n = 4), small (n = 68) and/or large bowel (n = 96). PI extension, distribution and possibly associated porto-mesenteric venous gas (PMVG) were correlated with other MDCT-findings, risk factors, clinical management, laboratory, histopathology, final diagnosis and outcome. Results The most frequent cause of PI was intestinal ischemia (n = 80,53.7 %), followed by infection (n = 18,12.1 %), obstructive (n = 12,8.1 %) and non-obstructive (n = 10,6.7 %) bowel dilatation, unknown aetiologies (n = 8,5.4 %), drugs (n = 8,5.4 %), inflammation (n = 7,4.7 %), and others (n = 6,4 %). Neither PI distribution nor extension significantly correlated with underlying ischemia. Overall mortality was 41.6 % (n = 62), mostly related to intestinal ischemia (p = 0.003). Associated PMVG significantly correlated with underlying ischemia (p = 0.009), as did the anatomical distribution of PMVG (p = 0.015). Decreased mural contrast-enhancement was the only other MDCT-feature significantly associated with ischemia (p p < 0.001). Elevated white blood count significantly correlated with ischemia (p = 0.03). Conclusion In emergency patients, ischemia remains the most common aetiology of PI, showing the highest mortality. PI with associated PMVG is an alerting sign. PI together with decreased mural contrast-enhancement indicates underlying ischemia. Key Points • In emergency patients, PI may be caused by various disorders. • Intestinal ischemia remains the most common cause of PI in acute situations. • PI associated with decreased mural contrast-enhancement indicates acute intestinal ischemia. • PI associated with PMVG should alert the radiologist to possible underlying ischemia.
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Affiliation(s)
- Marc-Olivier Treyaud
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Rafael Duran
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Marc Zins
- Department of Radiology, Fondation Hôpital St Joseph, 185 Rue Raymond Losserand, 75014, Paris, France
| | - Jean-Francois Knebel
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Reto A Meuli
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Sabine Schmidt
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital, Rue du Bugnon 46, 1011, Lausanne, Switzerland.
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19
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Lassandro F, Mangoni de Santo Stefano ML, Porto AM, Grassi R, Scaglione M, Rotondo A. Intestinal pneumatosis in adults: diagnostic and prognostic value. Emerg Radiol 2016; 17:361-5. [PMID: 20393776 DOI: 10.1007/s10140-010-0868-9] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Intestinal pneumatosis (IP) has been traditionally associated with intestinal infarction and poor outcome in adults; recent studies have questioned its clinical value. To assess its diagnostic and prognostic significance, we have retrospectively evaluated 102 patients correlating the CT finding of gastrointestinal parietal gas with clinical data and outcome. Fifty-three patients (52%) had surgical evidence of intestinal infarction. In the remaining patients, a variety of lesions were found including intestinal obstruction, cancer, volvulus, ulcer, hernia, trauma, Crohn's disease, diverticulitis, and iatrogenic causes. We observed the presence of portal vein gas (PVG) associated to IP in 25.5% of cases. In patients having both IP and PVG, intestinal infarction was observed in 69.2% of cases. In our series, overall mortality was 30.4% (31/102), and when PVG was present, it rose to 50% (13/26). In our study, IP has been observed in a broad range of lesions with very different prognosis, the most frequent of which was intestinal infarction. When associated to PVG, there was a much higher prevalence of intestinal infarct, and the prognosis was definitively worse.
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20
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Nakagawa S, Akimoto T, Takeda SI, Okada M, Miki A, Yamamoto H, Muto S, Kusano E, Nagata D. Antineutrophil Cytoplasmic Antibody-associated Glomerulonephritis Complicated by Pneumatosis Intestinalis. CLINICAL MEDICINE INSIGHTS-CASE REPORTS 2015; 8:65-70. [PMID: 26309421 PMCID: PMC4533850 DOI: 10.4137/ccrep.s26155] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2015] [Revised: 06/17/2015] [Accepted: 06/19/2015] [Indexed: 12/18/2022]
Abstract
Pneumatosis intestinalis is a characteristic imaging phenomenon indicating the presence of gas in the bowel wall. The link between pneumatosis intestinalis and various kinds of autoimmune diseases has been reported anecdotally, while information regarding the cases with antineutrophil cytoplasmic antibodies (ANCA)–associated vasculitis complicated by concurrent pneumatosis intestinalis is lacking. In this report, we describe our serendipitous experience with one such case of pneumatosis intestinalis in a patient with ANCA-associated glomerulonephritis. We also discuss several therapeutic concerns that arose in the current case, which had an impact on the pathogenesis of the disease.
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Affiliation(s)
- Saki Nakagawa
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Tochigi, Japan
| | - Tetsu Akimoto
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Tochigi, Japan
| | - Shin-Ichi Takeda
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Tochigi, Japan
| | - Mari Okada
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Tochigi, Japan
| | - Atsushi Miki
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Tochigi, Japan
| | - Hisashi Yamamoto
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Tochigi, Japan
| | - Shigeaki Muto
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Tochigi, Japan
| | - Eiji Kusano
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Tochigi, Japan
| | - Daisuke Nagata
- Division of Nephrology, Department of Internal Medicine, Jichi Medical University, Tochigi, Japan
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21
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22
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23
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Lassandro F, Valente T, Rea G, Lassandro G, Golia E, Brunese L, Laghi A. Imaging assessment and clinical significance of pneumatosis in adult patients. LA RADIOLOGIA MEDICA 2015; 120:96-104. [PMID: 25297049 DOI: 10.1007/s11547-014-0461-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Accepted: 09/15/2014] [Indexed: 12/18/2022]
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24
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Hassani KIM, Yazough I, Laalim SA, Toughrai I, Mazaz K. [Intestinal cystic pneumatosis secondary to a peptic ulcer: report of three cases]. Pan Afr Med J 2015; 20:150. [PMID: 27386026 PMCID: PMC4919673 DOI: 10.11604/pamj.2015.20.150.3017] [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: 06/25/2013] [Accepted: 08/22/2013] [Indexed: 12/03/2022] Open
Abstract
La pneumatose kystique intestinale (PNK) est une pathologie rare qui se caractérise par la présence de kystes gazeux dans la paroi intestinale. Elle est asymptomatique ou pauci symptomatique, et le plus souvent découverte lors d'un examen d'imagerie ou d'endoscopie. Nous rapportons une série de trois cas de pneumatose kystique secondaire à un ulcère peptique. A travers ce travail nous essayons de mettre la lumière sur les différents aspects cliniques, radiologiques et thérapeutiques de cette pathologie.
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Affiliation(s)
- Karim Ibn Majdoub Hassani
- Faculté de Médecine et de Pharmacie de Fès, Université Sidi Mohammed Ben Abdellah, Département de Chirurgie, CHU Hassan II, Fès, Maroc
| | - Issam Yazough
- Faculté de Médecine et de Pharmacie de Fès, Université Sidi Mohammed Ben Abdellah, Département de Chirurgie, CHU Hassan II, Fès, Maroc
| | - Said Ait Laalim
- Faculté de Médecine et de Pharmacie de Fès, Université Sidi Mohammed Ben Abdellah, Département de Chirurgie, CHU Hassan II, Fès, Maroc
| | - Imane Toughrai
- Faculté de Médecine et de Pharmacie de Fès, Université Sidi Mohammed Ben Abdellah, Département de Chirurgie, CHU Hassan II, Fès, Maroc
| | - Khalid Mazaz
- Faculté de Médecine et de Pharmacie de Fès, Université Sidi Mohammed Ben Abdellah, Département de Chirurgie, CHU Hassan II, Fès, Maroc
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25
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Choi JY, Cho SB, Kim HH, Lee IH, Lee HY, Kang HS, Lee HY, Lee SY. Pneumatosis intestinalis complicated by pneumoperitoneum in a patient with asthma. Tuberc Respir Dis (Seoul) 2014; 77:219-22. [PMID: 25473410 PMCID: PMC4250922 DOI: 10.4046/trd.2014.77.5.219] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Revised: 07/28/2014] [Accepted: 08/13/2014] [Indexed: 12/16/2022] Open
Abstract
Pneumatosis intestinalis (PI) is a very rare condition that is defined as the presence of gas within the subserosal or submucosal layer of the bowel. PI has been described in association with a variety of conditions including gastrointestinal tract disorders, pulmonary diseases, connective tissue disorders, organ transplantation, leukemia, and various immunodeficiency states. We report a rare case of a 74-year-old woman who complained of dyspnea during the management of acute asthma exacerbation and developed PI; but, it improved without any treatment.
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Affiliation(s)
- Joon Young Choi
- Division of Respiratory, Allergy and Critical Care, Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Sung Bae Cho
- Division of Respiratory, Allergy and Critical Care, Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Hyun Ho Kim
- Division of Respiratory, Allergy and Critical Care, Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - In Hee Lee
- Division of Respiratory, Allergy and Critical Care, Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Hea Yon Lee
- Division of Respiratory, Allergy and Critical Care, Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Hye Seon Kang
- Division of Respiratory, Allergy and Critical Care, Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Hwa Young Lee
- Division of Respiratory, Allergy and Critical Care, Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Sook Young Lee
- Division of Respiratory, Allergy and Critical Care, Department of Internal Medicine, The Catholic University of Korea College of Medicine, Seoul, Korea
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26
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Fernandes AR, Smith WG. Case 4: Gastric pneumatosis in an eight-month-old girl. Paediatr Child Health 2014; 19:463-4. [PMID: 25414579 DOI: 10.1093/pch/19.9.463a] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/20/2014] [Indexed: 01/04/2023] Open
Affiliation(s)
| | - William Gary Smith
- Orillia Pediatric Teaching Associates, Orillia Soldiers Memorial Hospital, Orillia, Ontario
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27
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Spektor M, Chernyak V, McCann TE, Scheinfeld MH. Gastric pneumatosis: Laboratory and imaging findings associated with mortality in adults. Clin Radiol 2014; 69:e445-9. [PMID: 25219954 DOI: 10.1016/j.crad.2014.07.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2014] [Revised: 07/20/2014] [Accepted: 07/17/2014] [Indexed: 12/18/2022]
Abstract
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.
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Affiliation(s)
- Michael Spektor
- Yale University School of Medicine, Department of Diagnostic Radiology, USA
| | | | - Thomas E McCann
- Yale University School of Medicine, Department of Diagnostic Radiology, USA
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28
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Ng DWJ, Chia CS, Tan GHC, Tan YG, Teo MCC. A case of portomesenteric venous gas found with extensive secondary pneumatosis intestinalis in the small bowel, stomach and distal oesophagus on radiographic images with an insidious presentation. Clin J Gastroenterol 2014; 7:140-3. [PMID: 26183630 DOI: 10.1007/s12328-014-0464-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2013] [Accepted: 02/07/2014] [Indexed: 12/18/2022]
Abstract
Portomesenteric gas together with pneumatosis intestinalis is a rare radiological finding and is usually associated with bowel ischaemia, extensive bowel necrosis and a high mortality rate. We report a case of portomesenteric venous gas found with extensive secondary pneumatosis intestinalis in the small bowel, stomach and distal oesophagus on radiographic images with an insidious presentation. Here we review the case and discuss the pathophysiology, diagnosis and management of portomesenteric gas associated with bowel ischaemia.
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Affiliation(s)
- Deanna Wan Jie Ng
- Department of Surgical Oncology, National Cancer Centre Singapore, Singapore, Singapore,
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29
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Geffroy Y, Boulay-Coletta I, Jullès MC, Nakache S, Taourel P, Zins M. Increased unenhanced bowel-wall attenuation at multidetector CT is highly specific of ischemia complicating small-bowel obstruction. Radiology 2013; 270:159-67. [PMID: 24029649 DOI: 10.1148/radiol.13122654] [Citation(s) in RCA: 84] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
PURPOSE To evaluate performance of increased bowel-wall attenuation on unenhanced 64-section multidetector computed tomographic (CT) images for diagnosing bowel-wall ischemia in patients with mechanical small-bowel obstruction (SBO) and to evaluate the diagnostic accuracy of multidetector CT in detecting small-bowel ischemia complicating SBO, with surgical and histopathologic findings as reference standard. MATERIALS AND METHODS The local institutional review board approved this retrospective study; informed consent requirement was waived. In 44 patients (10 men, 34 women; age range, 30-100 years) who were admitted because they were suspected of having SBO and treated surgically within the next 7 days, 45 multidetector CT scans were retrospectively reviewed. Two gastrointestinal radiologists performed independent blinded reviews of images to identify specific signs of ischemia; disagreements were resolved in consensus with a third gastrointestinal radiologist. Results were compared with both findings in prospective radiology reports and surgical and histopathologic findings. Fisher exact and χ(2) tests were used to assess associations between CT signs and ischemia, and the κ statistic was used to assess interobserver agreement. RESULTS In 19 of 45 (42%) multidetector CT scans, ischemia was confirmed at surgery and/or histopathologic examination. Increased bowel-wall attenuation on unenhanced images was significantly associated with ischemia (P < .0001); in this highly selected population, this sign had a 100% (24 of 24) specificity and a 56% (10 of 18) sensitivity. Sensitivity and specificity of multidetector CT for ischemia were 63% (12 of 19) and 92% (24 of 26), respectively, for the prospective reports and 84% (16 of 19) and 96% (25 of 26), respectively, for the consensus review. Decreased segmental bowel-wall enhancement was the most accurate 64-section multidetector CT sign for diagnosing ischemia (sensitivity, 78% [14 of 18]; specificity, 96% [24 of 25]; P < .0001). The small-bowel feces sign was significantly associated with ischemia (P = .0308). CONCLUSION Increased bowel-wall attenuation on unenhanced 64-section multidetector CT images is a specific sign for ischemia complicating SBO. Diagnostic accuracy of 64-section multidetector CT for ischemia associated with SBO was excellent.
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Affiliation(s)
- Yann Geffroy
- From the Department of Radiology, Fondation Hôpital Saint-Joseph, 185 rue Raymond Losserand, 75014 Paris, France (Y.G., I.B., M.C.J., S.N., M.Z.); Department of Radiology, Hôpital d'Instruction des Armées Laveran (Marseille), Marseille, France (Y.G.); and Department of Radiology, CHU Lapeyronie, Montpellier, France (P.T.)
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Firetto MC, Lemos AA, Marini A, Avesani EC, Biondetti PR. Acute bowel ischemia: analysis of diagnostic error by overlooked findings at MDCT angiography. Emerg Radiol 2013; 20:139-147. [PMID: 23053162 DOI: 10.1007/s10140-012-1078-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2012] [Accepted: 09/12/2012] [Indexed: 01/17/2023]
Abstract
To retrospectively evaluate the frequency and type of findings that were missed in the original reports of multi-detector CT angiography (MDCTA) in patients with suspected acute bowel ischemia. From January 2007 to March 2011, a series of 35 patients who underwent MDCTA of the abdomen and pelvis and had surgery were included. The reports of the initial CT were retrospectively compared with the discharge diagnosis and surgical reports. Discrepant or missing findings were re-evaluated and divided into relevant or not relevant regarding the diagnosis. In 23 of the 35 patients (66 %), all findings were correctly diagnosed in the initial MDCTA report. In the remaining 12 of the 35 patients (34 %), lesions that were not reported were present at surgery. In 10 of the 12 (83 %) patients, the overlooked findings were relevant and subtle: gas in the portal vein (n = 3), gas in the bowel wall (n = 3), gas in the portal vein and bowel wall (n = 2), thrombotic occlusion of the superior mesenteric artery (n = 1), and thrombotic occlusion of the inferior mesenteric artery (n = 1). In 2 of the 12 (17 %) patients in whom the MDCTA-overlooked findings were classified as non-relevant, bowel ischemia was found at surgery. With retrospective image interpretation, 83 % of the patients with occlusive mesenteric ischemia at surgery were correctly identified, whereas the remaining 17 % with non-occlusive mesenteric ischemia at surgery showed non-relevant findings at MDCTA. About 33 % of relevant findings of bowel ischemia were overlooked by the initial MDCTA interpretation, most were subtle findings. However, secondary reading revealed most of these findings and can serve to improve diagnostic performance.
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Affiliation(s)
- Maria Cristina Firetto
- Department of Radiology, Foundation Cà Granda, IRCCS Policlinico Hospital, Via F. Sforza 35, 20122 Milan, Italy
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31
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Duran R, Denys AL, Letovanec I, Meuli RA, Schmidt S. Multidetector CT features of mesenteric vein thrombosis. Radiographics 2013; 32:1503-22. [PMID: 22977032 DOI: 10.1148/rg.325115100] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Mesenteric vein thrombosis (MVT) accounts for 5%-15% of all mesenteric ischemic events and is classified as either primary or secondary. Primary MVT is idiopathic, whereas secondary MVT can result from a variety of underlying diseases and risk factors, including primary hypercoagulable states or prothrombotic disorders, myeloproliferative neoplasms, cancer (most frequently of the pancreas or liver), diverse inflammatory conditions, recent surgery, portal hypertension, and miscellaneous causes such as oral contraceptives or pregnancy. Clinical symptoms of MVT are rather nonspecific and are mainly characterized by abdominal pain. The mortality rate for MVT remains high, since even now the diagnosis is often delayed. Multidetector computed tomography (CT) is the modality of choice in this context. Although venous bowel ischemia occurs only infrequently with MVT, radiologists should be familiar with its multidetector CT features. Familiarity with the possible causes of MVT, the underlying pathogenic mechanisms associated with MVT, and the correlation between multidetector CT features and these pathogenic mechanisms is necessary to optimize medical management and improve patient care.
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Affiliation(s)
- Rafael Duran
- Department of Diagnostic and Interventional Radiology, Centre Hospitalier Universitaire Vaudois, Rue du Bugnon 46, 1011 Lausanne, Switzerland
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Pneumatosis intestinalis after liver transplantation. Eur J Radiol 2011; 80:629-36. [DOI: 10.1016/j.ejrad.2010.08.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2010] [Revised: 07/21/2010] [Accepted: 08/02/2010] [Indexed: 12/18/2022]
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Pneumatosis intestinalis and pneumoperitoneum after bilateral lung transplantation in adults. AJR Am J Roentgenol 2011; 196:W273-9. [PMID: 21343474 DOI: 10.2214/ajr.10.4468] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE The purpose of this article is to determine the clinical features, imaging findings, and possible causes of pneumatosis intestinalis (PI) or pneumoperitoneum that developed in bilateral lung transplant recipients. MATERIALS AND METHODS From December 2004 to July 2009, seven (2%) of 321 bilateral lung transplant recipients (two women and five men; age range, 25-66 years) who developed PI or pneumoperitoneum, or both, were identified. Medical records were reviewed to determine the clinical presentation, laboratory findings, and medications at the time of presentation of PI or pneumoperitoneum. Hospital course and time to resolution of PI or pneumoperitoneum were recorded. Common factors that might explain the cause of the PI and pneumoperitoneum were evaluated. Two experienced abdominal radiologists reviewed all imaging studies and recorded the specific findings for each patient. RESULTS All patients had minimal or no symptoms, normal laboratory study results, and no systemic, intestinal, or proven respiratory infections. All patients but one were receiving triple immunosuppressive agents (i.e., prednisone, azathioprine, and tacrolimus). The imaging findings were similar in five of the patients with the PI dominated by a linear and cystic appearance and involving only the colon. Three of the six patients with PI had both PI and pneumoperitoneum. The mean time to resolution of PI was 24 days. No definite cause for the PI and pneumoperitoneum could be determined in the seven patients. CONCLUSION Bilateral lung transplant recipients may develop benign PI or pneumoperitoneum after surgery. Benign PI in bilateral lung transplant recipients has a similar and specific linear and cystic appearance and is not due to ischemic bowel. No specific cause for the PI and pneumoperitoneum could be determined.
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Wang JH, Furlan A, Kaya D, Goshima S, Tublin M, Bae KT. Pneumatosis intestinalis versus pseudo-pneumatosis: review of CT findings and differentiation. Insights Imaging 2010; 2:85-92. [PMID: 22347936 PMCID: PMC3259395 DOI: 10.1007/s13244-010-0055-2] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2010] [Accepted: 11/18/2010] [Indexed: 12/18/2022] Open
Abstract
Pneumatosis intestinalis is defined as the presence of gas within the wall of the gastrointestinal tract. Originally described on plain abdominal radiographs, it is an imaging sign rather than a specific diagnosis and it is associated with both benign and life-threatening clinical conditions. The most common life-threatening cause of pneumatosis intestinalis is bowel ischaemia. Computed tomography (CT) is usually requested to detect underlying disease. The presence of pneumatosis intestinalis often leads physicians to make a diagnosis of serious disease. However, an erroneous diagnosis of pneumatosis intestinalis may be made (i.e. pseudo-pneumatosis) when intraluminal beads of gas are trapped within or between faeces and adjacent mucosal folds. The purpose of this pictorial essay is to review and describe the CT imaging findings of pneumatosis and pseudo-pneumatosis intestinalis and to discuss key discriminatory imaging features.
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Affiliation(s)
- Jin Hong Wang
- Department of Radiology, University of Pittsburgh School of Medicine, Presbyterian South Tower, 200 Lothrop St, Pittsburgh, PA 15213 USA
| | - Alessandro Furlan
- Department of Radiology, University of Pittsburgh School of Medicine, Presbyterian South Tower, 200 Lothrop St, Pittsburgh, PA 15213 USA
| | - Diana Kaya
- Department of Radiology, University of Pittsburgh School of Medicine, Presbyterian South Tower, 200 Lothrop St, Pittsburgh, PA 15213 USA
| | - Satoshi Goshima
- Department of Radiology, Gifu University School of Medicine, Yanagido, Gifu, 501-1193 Japan
| | - Mitchell Tublin
- Department of Radiology, University of Pittsburgh School of Medicine, Presbyterian South Tower, 200 Lothrop St, Pittsburgh, PA 15213 USA
| | - Kyongtae T. Bae
- Department of Radiology, University of Pittsburgh School of Medicine, Presbyterian South Tower, 200 Lothrop St, Pittsburgh, PA 15213 USA
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Wasnik A, Kaza RK, Al-Hawary MM, Liu PS, Platt JF. Multidetector CT imaging in mesenteric ischemia--pearls and pitfalls. Emerg Radiol 2010; 18:145-56. [PMID: 21132342 DOI: 10.1007/s10140-010-0921-8] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2010] [Accepted: 11/10/2010] [Indexed: 12/18/2022]
Abstract
Mesenteric ischemia is a complex and devastating disease which still remains a diagnostic challenge to the clinicians due to non-specific clinical and laboratory findings. Several imaging features have been described with multidetector computed tomography which allows the diagnosis of mesenteric ischemia with high sensitivity and specificity. However, there are imaging features which overlap with other pathologies including benign inflammation and infection. Knowledge of imaging findings in mesenteric ischemia and its potential mimics is important in early and definitive diagnosis.
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Affiliation(s)
- Ashish Wasnik
- Division of Abdominal Imaging, Department of Radiology, University of Michigan Health System, 1500 E. Medical Center Drive, Taubman Center, B1-132 F, Ann Arbor, MI 48109, USA.
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Yikilmaz A, Karahan OI, Senol S, Tuna IS, Akyildiz HY. Value of multislice computed tomography in the diagnosis of acute mesenteric ischemia. Eur J Radiol 2010; 80:297-302. [PMID: 20719444 DOI: 10.1016/j.ejrad.2010.07.016] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2010] [Revised: 07/15/2010] [Accepted: 07/19/2010] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To define the value of multislice computed tomography (CT) in the diagnosis of acute mesenteric ischemia (AMI). MATERIALS AND METHODS Two hundred patients (age range: 20-92 years) who were referred to the emergency CT department with a clinical suspicion of AMI were prospectively included in the study. CT examinations were performed with a multislice (16) CT scanner and the protocol included pre-contrast, arterial and venous phase acquisitions. Images were evaluated by using multiplanar reconstruction, maximum intensity projection and volume-rendering techniques at the CT workstation. RESULTS Ninety-four patients (47%) underwent surgery for AMI or for other causes of acute abdominal pain. One hundred-six patients (53%) were followed conservatively according to clinical, radiologic and laboratory findings. Of the 94 patients who underwent surgery, 49 (25%) were found to have AMI. All of these 49 patients with a proven AMI diagnosis were diagnosed with CT. In the other 45 patients who underwent surgery, CT findings were negative for AMI. None of the patients, who were followed conservatively, were eventually diagnosed as having AMI except 1 patient. This patient was unfit for surgery although his clinical and radiologic findings were consistent with AMI and died in 3 days. The sensitivity and specificity values of CT for the detection of AMI were calculated to be 100% for each. CONCLUSIONS Multislice CT is an effective imaging technique for the diagnosis of AMI with excellent sensitivity and specificity values.
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Affiliation(s)
- Ali Yikilmaz
- Erciyes University, School of Medicine, Gevher Nesibe Hospital, Department of Radiology, Talas Yolu, 38038 Melikgazi, Kayseri, Turkey.
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Portal venous gas and thrombosis complicating superior mesenteric artery syndrome (Wilkie's syndrome) in a child. J Pediatr Surg 2010; 45:826-9. [PMID: 20385295 DOI: 10.1016/j.jpedsurg.2010.01.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2009] [Revised: 12/29/2009] [Accepted: 01/06/2010] [Indexed: 01/04/2023]
Abstract
We report a case of a 10-year-old girl presenting with portal venous gas and thrombosis associated with superior mesenteric artery syndrome. To our knowledge, this is the first reported case of superior mesenteric artery syndrome complicated by gastric wall pneumatosis, portal venous gas, and thrombosis in childhood. Although these complications usually lead to bowel resection in adults and result in a high mortality rate, our pediatric patient was successfully treated nonoperatively with intensive care management and jejunal tube feedings. Presence of portal venous gas may occur in superior mesenteric artery syndrome in children and does not necessarily lead to bowel injury, allowing conservative medical management as a first-line treatment.
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Wayne E, Ough M, Wu A, Liao J, Andresen KJ, Kuehn D, Wilkinson N. Management algorithm for pneumatosis intestinalis and portal venous gas: treatment and outcome of 88 consecutive cases. J Gastrointest Surg 2010; 14:437-48. [PMID: 20077158 DOI: 10.1007/s11605-009-1143-9] [Citation(s) in RCA: 106] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2009] [Accepted: 12/14/2009] [Indexed: 01/31/2023]
Abstract
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.
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Affiliation(s)
- Erik Wayne
- Department of Surgery, University of Louisville, Louisville, KY 40202, USA
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Management algorithm for pneumatosis intestinalis and portal venous gas: treatment and outcome of 88 consecutive cases. J Gastrointest Surg 2010. [PMID: 20077158 DOI: 10.1007/s11605–009–1143–9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/10/2023]
Abstract
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.
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Khalil PN, Huber-Wagner S, Ladurner R, Kleespies A, Siebeck M, Mutschler W, Hallfeldt K, Kanz KG. Natural history, clinical pattern, and surgical considerations of pneumatosis intestinalis. Eur J Med Res 2009; 14:231-9. [PMID: 19541582 PMCID: PMC3352014 DOI: 10.1186/2047-783x-14-6-231] [Citation(s) in RCA: 108] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Objective Pneumatosis intestinalis has been increasingly detected in recent years with the more frequent use of computed tomography for abdominal imaging of the intestine. The underlying causes of the gas found during radiographic studies of the bowel wall can vary widely and different hypotheses regarding its pathophysiology have been postulated. Pneumatosis intestinalis often represents a benign condition and should not be considered an argument for surgery. However, it can also require life-threatening surgery in some cases, and this can be a difficult decision in some patients. Methods The spectrum of pneumatosis intestinalis is discussed here based on various computed tomographic and surgical findings in patients who presented at our University Medical Centre in 2003-2008. We have also systematically reviewed the literature to establish the current understanding of its aetiology and pathophysiology, and the possible clinical conditions associated with pneumatosis intestinalis and their management. Results Pneumatosis intestinalis is a primary radiographic finding. After its diagnosis, its specific pathogenesis should be ascertained because the appropriate therapy is related to the underlying cause of pneumatosis intestinalis, and this is sometimes difficult to define. Surgical treatment should be considered urgent in symptomatic patients presenting with an acute abdomen, signs of ischemia, or bowel obstruction. In asymptomatic patients with otherwise inconspicuous findings, the underlying disease should be treated first, rather than urgent exploratory surgery considered. Extensive and comprehensive information on the pathophysiology and clinical findings of pneumatosis intestinalis is provided here and is incorporated into a treatment algorithm. Conclusions The information presented here allows a better understanding of the radiographic diagnosis and underlying aetiology of pneumatosis intestinalis, and may facilitate the decision-making process in this context, thus providing fast and adequate therapy to particular patients.
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Affiliation(s)
- Philipe N Khalil
- Department of Surgery, Downtown Medical Centre, Ludwig-Maximilians University, Munich, Germany.
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Soyer P, Martin-Grivaud S, Boudiaf M, Malzy P, Duchat F, Hamzi L, Pocard M, Vahedi K, Rymer R. [Linear or bubbly: a pictorial review of CT features of intestinal pneumatosis in adults]. ACTA ACUST UNITED AC 2009; 89:1907-20. [PMID: 19106848 DOI: 10.1016/s0221-0363(08)74786-3] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Pneumatosis intestinalis is a rare condition, which is defined by the presence of gas within the bowel wall. In adult patients, pneumatosis intestinalis can be depicted in various circumstances. Owing to the routine use of CT to investigate patients with abdominal pain, pneumatosis intestinalis can be seen as an incidental finding or can be observed in association with a life-threatening disease such as bowel infarction. On CT images, pneumatosis intestinalis can display two different appearances; one that has a cystic or bubbly appearance can be considered as a chronic pneumatosis and is suggestive for a benign cause while the other, which has a linear appearance can be considered as a symptom and is more frequently secondary to a life-threatening cause. However, none of these two CT characteristics can be considered pathognomonic for any of these two categories of causes. In such situations, the analysis of the location, extent and, if any, associated findings may help to differentiate between benign and life-threatening causes. In these patients who present with abdominal signs that mimic symptoms that would warrant surgical exploration, the analysis of associated findings is critical to rule out a life-threatening cause of pneumatosis intestinalis and to obviate the need for unnecessary laparotomy. In adult patients with a known specific disease such as celiac disease, chronic pseudointestinal obstruction or other chronic diseases, even with accompanying pneumoperitoneum, pneumatosis intestinalis does not uniformly mandate surgical exploration. This pictorial review presents the more and the less common pneumatosis intestinalis CT features in adult patients, with the aim of making the reader more familiar with this potentially misleading sign.
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Affiliation(s)
- P Soyer
- Service de Radiologie Viscérale, Hôpital Lariboisière, APHP, GHU Nord & Université Diderot- Paris 7, 2, rue Ambroise Paré, 75010 Paris, France.
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Clinical and CT features of benign pneumatosis intestinalis in pediatric hematopoietic stem cell transplant and oncology patients. Pediatr Radiol 2008; 38:1074-83. [PMID: 18665358 PMCID: PMC3612433 DOI: 10.1007/s00247-008-0944-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2008] [Revised: 05/29/2008] [Accepted: 06/18/2008] [Indexed: 12/18/2022]
Abstract
BACKGROUND Pneumatosis intestinalis in children is associated with a wide variety of underlying conditions and often has a benign course. The CT features of this condition have not been systematically investigated. OBJECTIVE Defining benign pneumatosis intestinalis as pneumatosis intestinalis that resolved with medical management alone, we sought to: (1) determine whether the incidence of benign pneumatosis intestinalis had increased at our pediatric cancer hospital; (2) characterize CT features of benign pneumatosis intestinalis; and (3) determine the relationship between imaging features and clinical course of benign pneumatosis intestinalis in this cohort. MATERIALS AND METHODS Radiology reports from November 1994 to December 2006 were searched for "pneumatosis intestinalis," "free intraperitoneal air," and "portal venous air or gas." Corresponding imaging was reviewed by two radiologists who confirmed pneumatosis intestinalis and recorded the presence of extraluminal free air, degree of intramural gaseous distension, number of involved bowel segments, and time to pneumatosis resolution. RESULTS The search revealed 12 boys and 4 girls with pneumatosis intestinalis; 11 were hematopoietic stem cell transplant recipients. The annual incidences of benign pneumatosis have not changed at our institution. Increases in intramural distension marginally correlated with the number of bowel segments involved (P=0.08). Three patients had free air and longer times to resolution of pneumatosis (P=0.03). CONCLUSION Male children may be at increased risk of benign pneumatosis intestinalis. The incidence of benign pneumatosis at our institution is proportional to the number of hematopoietic stem cell transplants. The degree of intramural distension may correlate with the number of bowel segments involved. Patients with free air have a longer time to resolution of benign pneumatosis.
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Abstract
Pneumatosis cystoides coli (PCC) is an uncommon condition in which multiple gas-filled cysts in the walls of the colon. Patients with PCC initially complain of various symptoms including abdominal discomfort, constipation, diarrhea, hematochezia, vomiting, and fever. We recently diagnosed PCC by computed tomography (CT) colonography in 2 patients. Two patients visited the outpatient clinic presenting with hematochezia, diarrhea, or abdominal pain. No underlying cause of PCC was found. Colonoscopy revealed multiple submucosal nodules covered with normal mucosa in the colon. However, CT colonography showed multiple gas-filled cysts within the walls of colon.
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Oktar SO, Karaosmanoğlu D, Yücel C, Erbaş G, Ilkme A, Canpolat I, Ozdemir H. Portomesenteric venous gas: imaging findings with an emphasis on sonography. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2006; 25:1051-8. [PMID: 16870898 DOI: 10.7863/jum.2006.25.8.1051] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
OBJECTIVE Portomesenteric venous gas is a rare condition with an unclear pathogenesis. Most studies in the medical literature mention computed tomography (CT) as the primary imaging tool for this entity. The objective of this study was to outline the advantages and disadvantages of sonography in the evaluation of patients with portomesenteric venous gas. METHODS We describe 7 patients (3 female and 4 male; age range, 47-83 years) with portomesenteric venous gas. Both CT and sonographic examinations were performed in each patient. Our patient population consisted of 2 patients with superior mesenteric artery occlusion, 3 with ischemia of the colon, small bowel, or both, 1 with gastric ulcer perforation, and 1 with ischemic bowel disease presumably secondary to complications of continuous ambulatory peritoneal dialysis. RESULTS Portal venous gas was observed in all 7 patients with sonography and in 6 patients with CT. Computed tomography was unable to show gas in the portal venous system in 1 patient. Sonography showed patchy hepatic gas accumulation (likely within small peripheral portal vein branches) with no correlative findings on CT. Computed tomography showed important associated findings, including pneumatosis intestinalis. CONCLUSIONS In cases with portomesenteric gas, CT is the preferred modality for showing the underlying etiology. However, with its real-time imaging capability, sonography may also be a very valuable imaging modality in the evaluation of this entity.
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Abstract
Emphysematous gastritis (or phlegmonous gastritis) and gastric emphysema (or gastric pneumatosis) are variations of conditions associated with the presence of intramural air in the stomach. The presence of air in the gastric wall is a very rare clinical condition, associated with bacterial infection, increased intragastric pressure from gastric outlet obstruction, gastric mucosal disruption or air dissection from the mediastinum. In adults, this can occur in the setting of instrumentation-related injury, gastric outlet obstruction by gastric, duodenal or pancreatic malignancies or bowel ischemia. Here we describe a case of gastric emphysema related to repeated biliary stenting and partial duodenal obstruction in a patient with inoperable periampullary cancer, and provide the first description of the endoscopic ultrasonographic findings of gastric emphysema in the literature. In our case, endoscopic ultrasound showed a band of bright echogenicity arising from the submucosa layer, representing air in the gastric wall.
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Affiliation(s)
- Maw-Soan Soon
- Department of Gastroenterology, Changhua Christian Medical Center, 135 Nanhsiao Street Changhua, 500 Taiwan, China
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Segatto E, Mortelé KJ, Ji H, Wiesner W, Ros PR. Acute small bowel ischemia: CT imaging findings. Semin Ultrasound CT MR 2003; 24:364-76. [PMID: 14620718 DOI: 10.1016/s0887-2171(03)00074-x] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Small bowel ischemia is a disorder related to a variety of conditions resulting in interruption or reduction of the blood supply of the small intestine. It may present with various clinical and radiologic manifestations, and ranges pathologically from localized transient ischemia to catastrophic necrosis of the intestinal tract. The primary causes of insufficient blood flow to the small intestine are various and include thromboembolism (50% of cases), nonocclusive causes, bowel obstruction, neoplasms, vasculitis, abdominal inflammatory conditions, trauma, chemotherapy, radiation, and corrosive injury. Computed tomography (CT) can demonstrate changes because of ischemic bowel accurately, may be helpful in determining the primary cause of ischemia, and can demonstrate important coexistent findings or complications. However, common CT findings in acute small bowel ischemia are not specific and, therefore, it is often a combination of clinical, laboratory and radiologic signs that may lead to a correct diagnosis. Understanding the pathogenesis of various conditions leading to mesenteric ischemia and being familiar with the spectrum of diagnostic CT signs may help the radiologist recognize ischemic small bowel disease and avoid delayed diagnosis. The aim of this article is to provide a review of the pathogenesis and various causes of acute small bowel ischemia and to demonstrate the contribution of CT in the diagnosis of this complex disease.
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Affiliation(s)
- Enrica Segatto
- Department of Radiology, Division of Abdominal Imaging and Intervention, Brigham & Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
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Abstract
Pneumatosis Intestinalis is a rare benign and often asymptomatic disease; we report the case of a 74 year-old woman with a pneumatosis coli revealed by a pseudo-obstruction; the diagnosis was suspected at radiology. The course under medical treatment was uneventfull.
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Abstract
Bowel ischemia may be caused by many conditions and manifest with typical or atypical and specific or nonspecific clinical, laboratory, and radiologic findings. It may mimic various intestinal diseases and be confused with certain nonischemic conditions clinically and at computed tomography (CT). Bowel ischemia severity ranges from mild (generally transient superficial changes of intestinal mucosa) to more dangerous and potentially life-threatening transmural bowel wall necrosis. Causes of critically reduced blood flow to the bowel are diverse, ranging from occlusions of mesenteric arteries or veins to complicated bowel obstruction and overdistention. CT can demonstrate changes in ischemic bowel segments accurately, is often helpful in determining the primary cause of ischemia, and can demonstrate important coexistent findings or complications. Unfortunately, common CT findings in bowel ischemia are not specific, and specific findings are rather uncommon. Therefore, it often is a combination of nonspecific clinical, laboratory, and radiologic findings-especially detailed knowledge about the pathogenesis of acute bowel ischemia in different conditions-that helps most in correct interpretation of CT findings. To improve understanding of this complex heterogeneous entity, this article provides an overview of the anatomy and physiology of mesenteric perfusion and discussions of causes and pathogenesis of acute bowel ischemia, CT findings in various types of acute bowel ischemia, and potential pitfalls of CT.
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Affiliation(s)
- Walter Wiesner
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115, USA
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