|
1
|
Jones N, Humm K, Dirrig H, Espinoza MBG, Yankin I, Birkbeck R, Cole L. Clinical features and outcome of dogs and cats with gastrointestinal pneumatosis: 30 cases (2010-2021). J Vet Emerg Crit Care (San Antonio) 2024; 34:487-496. [PMID: 39185778 DOI: 10.1111/vec.13417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 06/02/2023] [Accepted: 06/28/2023] [Indexed: 08/27/2024]
Abstract
OBJECTIVES To describe the presentation, etiology, and outcome of dogs and cats diagnosed with gastrointestinal pneumatosis (GP). DESIGN Retrospective study. SETTING Three referral institutions. ANIMALS Twenty-six dogs and 4 cats. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS The most common sites of GP were the stomach (n = 19), followed by the colon (n = 8) and small intestine (n = 2). One case had pneumatosis of both the stomach and the colon. GP was most commonly associated with gastrointestinal disease in dogs (18/26 [69%]) and cats (3/4 [75%]), with common diagnoses including gastric dilatation and volvulus (n = 5), acute hemorrhagic diarrhea syndrome (n = 4), and gastrointestinal ulceration (n = 4). Of the 4 cases of gastrointestinal ulceration, 3 were dogs with a history of glucocorticosteroid or nonsteroidal anti-inflammatory drug administration and vomiting and diarrhea. Six of 30 cases (20%), all of which were dogs, were determined to have a surgical indication for exploratory celiotomy, although not solely on the basis of diagnosis of GP. Five cases underwent exploratory celiotomy, of which 1 (20%) survived to hospital discharge. Of the medically managed cases, 13 of 24 (54%) survived to hospital discharge. Overall, 14 of 30 cases (47%) survived to hospital discharge. CONCLUSIONS GP is an uncommon diagnostic imaging finding that is associated with a variety of disease processes. Its development is often related to primary gastrointestinal diseases. In the absence of other surgical disease, exploratory celiotomy based solely on the diagnosis of GP is unlikely to be indicated.
Collapse
Affiliation(s)
- Nadine Jones
- Department of Clinical Science and Services, The Royal Veterinary College, London, UK
| | - Karen Humm
- Department of Clinical Science and Services, The Royal Veterinary College, London, UK
| | - Helen Dirrig
- Department of Clinical Science and Services, The Royal Veterinary College, London, UK
| | - Melissa Beth Glenn Espinoza
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Texas A&M University, College Station, Texas, USA
| | - Igor Yankin
- Department of Veterinary Clinical Sciences, College of Veterinary Medicine, Texas A&M University, College Station, Texas, USA
| | | | - Laura Cole
- Department of Clinical Science and Services, The Royal Veterinary College, London, UK
| |
Collapse
|
|
2
|
Barden M, Kim CD, Taher MA. Computed Tomography Images of a Benign Case of Gastric Pneumatosis in a Returning Traveler. Cureus 2024; 16:e68916. [PMID: 39381461 PMCID: PMC11459221 DOI: 10.7759/cureus.68916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/08/2024] [Indexed: 10/10/2024] Open
Abstract
A 70-year-old male presented to the emergency department with travel-associated vomiting, diarrhea, and abdominal pain. He was found to have gastric pneumatosis on computed tomography. His serum lactic acid level was within normal limits, and he had a benign clinical course. Gastric pneumatosis can be found in a wide spectrum of clinical situations, from benign to life-threatening. Causes can include ischemia, infections with gas-producing organisms (emphysematous gastritis), or various situations that result in increased intraluminal pressure. As this patient had not recently undergone any endoscopic procedures and had a benign presentation and clinical course, the cause, in this case, is presumed to be related to vigorous retching during a bout of traveler's gastroenteritis.
Collapse
Affiliation(s)
| | - Chris D Kim
- Emergency Medicine, Eisenhower Health, Rancho Mirage, USA
| | | |
Collapse
|
|
3
|
Verrept S, Lefere M, De Bruecker Y. Redescending Stomach: A Rare and Potentially Lethal Complication of Gastric Herniation. J Belg Soc Radiol 2024; 108:22. [PMID: 38435134 PMCID: PMC10906332 DOI: 10.5334/jbsr.3448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 02/15/2024] [Indexed: 03/05/2024] Open
Abstract
Large gastric hernias are common and usually cause minor symptoms. Rarely, complete intrathoracic herniation of the stomach is complicated by strangulation. The underlying mechanism can be gastric volvulus or the less recognized phenomenon of gastric fundus redescent. We describe a case where this rare but potentially lethal complication of gastric herniation is present. Additionally, we show that gastric pneumatosis, a sign associated with ischemia, can be initially visualized on a plain chest radiograph in this setting. Teaching point: Redescent of the fundus is a possible, but unrecognized cause of gastric strangulation in intrathoracic stomachs.
Collapse
Affiliation(s)
- Sam Verrept
- Radiology Department, Imeldaziekenhuis, Bonheiden, Belgium
| | - Mathieu Lefere
- Radiology Department, Imeldaziekenhuis, Bonheiden, Belgium
| | | |
Collapse
|
|
4
|
Orts‐Porcar M, Ororbia A, Fina C, Herrería‐Bustillo VJ, Gómez‐Martín N, Barreiro‐Vázquez JD, González‐Rellán S, Anselmi C. Oesophageal pneumatosis: computed tomographic characteristics in three dogs (2018–2021). Vet Med Sci 2022; 8:2382-2389. [DOI: 10.1002/vms3.957] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Affiliation(s)
| | | | | | | | - Noemi Gómez‐Martín
- Hospital Veterinario Universidad Católica de Valencia, Valencia, Comunidad Valenciana Spain
| | - José Daniel Barreiro‐Vázquez
- Hospital Veterinario Universitario Rof Codina Facultade de Veterinaria, Universidade de Santiago de Compostela Lugo Galicia Spain
| | - Sonia González‐Rellán
- Departamento de Anatomía Produción Animal e Ciencias Clínicas Veterinarias Facultade de Veterinaria, Universidade de Santiago de Compostela Lugo Galicia Spain
| | | |
Collapse
|
|
5
|
Hu SF, Liu HB, Hao YY. Portal vein gas combined with pneumatosis intestinalis and emphysematous cystitis: A case report and literature review. World J Clin Cases 2022; 10:8945-8953. [PMID: 36157643 PMCID: PMC9477024 DOI: 10.12998/wjcc.v10.i25.8945] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 05/21/2022] [Accepted: 07/21/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Portal venous gas (PVG) is a rare clinical condition usually indicative of severe disorders, including necrotizing enterocolitis, bowel ischemia, or bowel wall rupture/infarction. Pneumatosis intestinalis (PI) is a rare illness characterized by an infiltration of gas into the intestinal wall. Emphysematous cystitis (EC) is relatively rare and characterized by intramural and/or intraluminal bladder gas best depicted by cross-sectional imaging. Our study reports a rare case coexistence of PVG presenting with PI and EC.
CASE SUMMARY An 86-year-old woman was admitted to the emergency room due to the progressive aggravation of pain because of abdominal fullness and distention, complicated with vomiting and stopping defecation for 4 d. The abdominal computed tomography (CT) plain scan indicated intestinal obstruction with ischemia changes, gas in the portal vein, left renal artery, superior mesenteric artery, superior mesenteric vein, some branch vessels, and bladder pneumatosis with air-fluid levels. Emergency surgery was conducted on the patient. Ischemic necrosis was found in the small intestine approximately 110 cm below the Treitz ligament and in the ileocecal junction and ascending colon canals. This included excision of the necrotic small intestine and right colon, fistulation of the proximal small intestine, and distal closure of the transverse colon. Subsequently, the patient displayed postoperative short bowel syndrome but had a good recovery. She received intravenous fluid infusion and enteral nutrition maintenance every other day after discharge from the community hospital.
CONCLUSION Emergency surgery should be performed when CT shows signs of PVG with PI and EC along with a clinical situation strongly suggestive of bowel ischemia.
Collapse
Affiliation(s)
- Shi-Fu Hu
- Department of General Surgery, Tianjin Xiqing Hospital, Tianjin 300100, China
| | - Han-Bo Liu
- Department of General Surgery, Tianjin Xiqing Hospital, Tianjin 300100, China
| | - Yuan-Yuan Hao
- Department of Geriatrics, Tianjin Xiqing Hospital, Tianjin 300100, China
| |
Collapse
|
|
6
|
Hoegger MJ, Ludwig DR, Zulfiqar M, Raptis DA, Shetty AS. Enhancing the Interpretation of Unenhanced Abdominopelvic CT. Curr Probl Diagn Radiol 2022; 51:787-797. [PMID: 35135678 DOI: 10.1067/j.cpradiol.2022.01.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 01/05/2022] [Indexed: 01/04/2025]
Abstract
Unenhanced abdominopelvic CT is frequently performed in patients who are critically ill or have contraindications to intravenous contrast. These cases can be challenging to interpret for the radiologist. Attention to CT physics and care in optimizing image viewing through techniques such as windowing can maximize diagnostic yield. In this case-based review, we will discuss the CT physics concepts of attenuation, common indications and reasons for unenhanced abdominopelvic CT, and review its utility through a series of illustrative cases.
Collapse
Affiliation(s)
- Mark J Hoegger
- Mallinckrodt Institute of Radiology, Washington University, St. Louis, MO
| | - Daniel R Ludwig
- Mallinckrodt Institute of Radiology, Washington University, St. Louis, MO
| | - Maria Zulfiqar
- Mallinckrodt Institute of Radiology, Washington University, St. Louis, MO
| | - Demetrios A Raptis
- Mallinckrodt Institute of Radiology, Washington University, St. Louis, MO
| | - Anup S Shetty
- Mallinckrodt Institute of Radiology, Washington University, St. Louis, MO.
| |
Collapse
|
|
7
|
Hwee Hong Lee A, Tellambura S. Pneumatosis intestinalis: Not always bowel ischemia. Radiol Case Rep 2022; 17:1305-1308. [PMID: 35242257 PMCID: PMC8857577 DOI: 10.1016/j.radcr.2022.01.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Revised: 01/20/2022] [Accepted: 01/22/2022] [Indexed: 11/30/2022] Open
Abstract
Pneumatosis intestinalis or abnormal intramural gas within the digestive tract usually suggests bowel ischemia necessitating urgent surgery. We report the case of an 82-year-old female presenting with hypotension and nausea, with a past history of schizophrenia, low grade chronic lymphocytic leukemia, stroke, bronchitis and rheumatoid arthritis. Computed tomography performed demonstrated extensive submucosal gas within the entire small bowel, associated with free gas in the peritoneal cavity. Bowel ischemia was diagnosed radiologically. However, a benign diagnosis of fecal impaction was ultimately made due to the patient's stable clinical status. Clinical correlation and close monitoring of clinical status in this context is of greatest diagnostic assistance when encountered with this phenomenon, to prevent unnecessary harm to the patient.
Collapse
Affiliation(s)
- Adele Hwee Hong Lee
- Department of General Surgery, St Vincent's Hospital Melbourne, 41 Victoria Parade, Fitzroy, Victoria 3065, Australia
- Corresponding author. A. Lee.
| | | |
Collapse
|
|
8
|
Abramov A, Luks VL, De Bie F, Hwang R, Allukian M, Nace GW. Pneumatosis intestinalis in children beyond the neonatal period: is it always benign? Pediatr Surg Int 2022; 38:399-407. [PMID: 34837497 DOI: 10.1007/s00383-021-05048-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/20/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE The significance and management of pediatric pneumatosis intestinalis (PI) remains poorly defined. We sought to add clarity in children beyond the neonatal period. METHODS Pediatric patients 3 months-18 years admitted to a quaternary children's hospital with a diagnosis of PI were included in this retrospective study. Pathologic PI was defined as irreversible, transmural intestinal ischemia. RESULTS 167 children were identified with PI. Of these children, 155 (92.8%) had benign PI and 12 (7.2%) developed pathologic PI. The most common underlying diagnosis for pathologic PI was global developmental delay (75%), although we identified a spectrum of underlying diagnoses at risk for PI. Physical exam notable for abdominal distension (p = 0.023) or guarding (p = 0.028), and imaging with portal venous gas (p < 0.001) or bowel distension (p = 0.001) were significantly associated with pathologic PI. Only 6.6% of all children underwent an operation. For those undergoing non-surgical management of benign PI, 75% of children received antibiotics and average duration of bowel rest was 6.8 days. CONCLUSIONS PI in children is primarily a benign phenomenon and often does not warrant surgical intervention. Bowel rest and antibiotics are therapeutic strategies frequently used in the treatment of this finding.
Collapse
Affiliation(s)
- Alexey Abramov
- Department of Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Valerie L Luks
- Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Felix De Bie
- Division of Pediatric General, Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Rosa Hwang
- Division of Pediatric General, Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Myron Allukian
- Division of Pediatric General, Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA
| | - Gary W Nace
- Division of Pediatric General, Thoracic and Fetal Surgery, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, Philadelphia, PA, 19104, USA.
| |
Collapse
|
|
9
|
Ito N, Masuda T, Yamaguchi K, Sakamoto S, Horimasu Y, Nakashima T, Miyamoto S, Iwamoto H, Fujitaka K, Hamada H, Hattori N. Pneumatosis Intestinalis following Radiation Esophagitis during Chemoradiotherapy for Lung Cancer: A Case Report. Case Rep Oncol 2021; 14:1454-1459. [PMID: 34899236 PMCID: PMC8613634 DOI: 10.1159/000518315] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Accepted: 07/05/2021] [Indexed: 11/19/2022] Open
Abstract
Pneumatosis intestinalis (PI) is a rare disease that forms emphysema lesions under the mucosa and serosa of the gastrointestinal tract. We present the first case of PI following radiation-induced esophagitis during chemoradiotherapy (CRT) for lung cancer. A 74-year-old man with severe chronic obstructive pulmonary disease (COPD) was treated with CRT for lung cancer. During the treatment, he presented with vomiting and abdominal distention. CT showed pneumatosis from the esophagus to the small intestine. Severe radiation-induced esophagitis was observed, and gastrointestinal endoscopy revealed a circumferential esophageal ulcer. From these observations, this case was diagnosed as PI following severe esophagitis. A nasogastric tube was inserted, and conservative treatment with fasting, fluid replacement, and antibiotic was performed. Four days after the onset of PI, CT showed marked improvement of the pneumatosis. When CRT is performed for lung cancer patients, we should not only consider esophagitis but also PI. The presence of COPD may be considered a specific factor for the development of severe esophagitis and the consequent PI in this case.
Collapse
Affiliation(s)
- Noriaki Ito
- Department of Respiratory Medicine, Hiroshima University Hospital, Hiroshima, Japan
| | - Takeshi Masuda
- Department of Respiratory Medicine, Hiroshima University Hospital, Hiroshima, Japan
| | - Kakuhiro Yamaguchi
- Department of Respiratory Medicine, Hiroshima University Hospital, Hiroshima, Japan
| | - Shinjiro Sakamoto
- Department of Respiratory Medicine, Hiroshima University Hospital, Hiroshima, Japan
| | - Yasushi Horimasu
- Department of Respiratory Medicine, Hiroshima University Hospital, Hiroshima, Japan
| | - Taku Nakashima
- Department of Respiratory Medicine, Hiroshima University Hospital, Hiroshima, Japan
| | - Shintaro Miyamoto
- Department of Respiratory Medicine, Hiroshima University Hospital, Hiroshima, Japan
| | - Hiroshi Iwamoto
- Department of Molecular and Internal Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Kazunori Fujitaka
- Department of Molecular and Internal Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Hironobu Hamada
- Department of Physical Analysis and Therapeutic Sciences, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| | - Noboru Hattori
- Department of Molecular and Internal Medicine, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
| |
Collapse
|
|
10
|
Clancy K, Dadashzadeh ER, Handzel R, Rieser C, Moses JB, Rosenblum L, Wu S. Machine learning for the prediction of pathologic pneumatosis intestinalis. Surgery 2021; 170:797-805. [PMID: 33926706 PMCID: PMC8405549 DOI: 10.1016/j.surg.2021.03.049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Revised: 03/19/2021] [Accepted: 03/22/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND The radiographic finding of pneumatosis intestinalis can indicate a spectrum of underlying processes ranging from a benign finding to a life-threatening condition. Although radiographic pneumatosis intestinalis is relatively common, there is no validated clinical tool to guide surgical management. METHODS Using a retrospective cohort of 300 pneumatosis intestinalis cases from a single institution, we developed 3 machine learning models for 2 clinical tasks: (1) the distinction of benign from pathologic pneumatosis intestinalis cases and (2) the determination of patients who would benefit from an operation. The 3 models are (1) an imaging model based on radiomic features extracted from computed tomography scans, (2) a clinical model based on clinical variables, and (3) a combination model using both the imaging and clinical variables. RESULTS The combination model achieves an area under the curve of 0.91 (confidence interval: 0.87-0.94) for task I and an area under the curve of 0.84 (confidence interval: 0.79-0.88) for task II. The combination model significantly (P < .05) outperforms the imaging model and the clinical model for both tasks. The imaging model achieves an area under the curve of 0.72 (confidence interval: 0.57-0.87) for task I and 0.68 (confidence interval: 0.61-0.74) for task II. The clinical model achieves an area under the curve of 0.87 (confidence interval: 0.83-0.91) for task I and 0.76 (confidence interval: 0.70-0.81) for task II. CONCLUSION This study suggests that combined radiographic and clinical features can identify pathologic pneumatosis intestinalis and aid in patient selection for surgery. This tool may better inform the surgical decision-making process for patients with pneumatosis intestinalis.
Collapse
Affiliation(s)
- Kadie Clancy
- Department of Computer Science, University of Pittsburgh, PA
| | | | - Robert Handzel
- Department of Surgery, University of Pittsburgh Medical Center, PA
| | - Caroline Rieser
- Department of Surgery, University of Pittsburgh Medical Center, PA
| | - J B Moses
- Department of Surgery, University of Pittsburgh Medical Center, PA
| | - Lauren Rosenblum
- Department of Surgery, University of Pittsburgh Medical Center, PA
| | - Shandong Wu
- Departments of Radiology, Biomedical Informatics, and Bioengineering, University of Pittsburgh, PA.
| |
Collapse
|
|
11
|
Pneumatosis intestinalis and spontaneous perforation associated with drug toxicity in oncologic patients: a case series. Acta Gastroenterol Belg 2021; 84:497-499. [PMID: 34599575 DOI: 10.51821/84.3.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Pneumatosis Intestinalis (PI) is a rare radiological finding defined as the presence of extra-luminal gas within the intestinal wall. Several anti-tumor drugs can induce a damage of the gastrointestinal walls as an adverse effect, causing loss of mucosal integrity and endoluminal gas diffusion, responsible for PI development. We retrospectively analyzed 8 cases of PI detected through radiological imaging in oncologic patients undergoing various therapeutic regimens: five patients were receiving chemotherapy, two molecular targeted therapy (MTT) and one immunotherapy. Three patients were asymptomatic and pneumatosis was incidentally detected at routinary follow-up CT and then treated conservatively. Five patients presented acute abdomen symptoms and in these cases bowel perforation was the cause of death. Our experience confirms PI and perforation as rare complications of drug toxicity, especially in oncologic patients treated with combinations of different anticancer drugs and documented the second reported case of PI associated with atezolizumab and alectinib single administration.
Collapse
|
|
12
|
Abstract
It is essential for the colon and rectal surgeon to understand the evaluation and management of patients with both small and large bowel obstructions. Computed tomography is usually the most appropriate and accurate diagnostic imaging modality for most suspected bowel obstructions. Additional commonly used imaging modalities include plain radiographs and contrast imaging/fluoroscopy, while less commonly utilized imaging modalities include ultrasonography and magnetic resonance imaging. Regardless of the imaging modality used, interpretation of imaging should involve a systematic, methodological approach to ensure diagnostic accuracy.
Collapse
Affiliation(s)
- David W Nelms
- Department of Colon and Rectal Surgery, Ochsner Medical Center, New Orleans, Louisiana
| | - Brian R Kann
- Department of Colon and Rectal Surgery, Ochsner Medical Center, New Orleans, Louisiana
| |
Collapse
|
|
13
|
Fitzpatrick LA, Rivers-Bowerman MD, Thipphavong S, Clarke SE, Rowe JA, Costa AF. Pearls, Pitfalls, and Conditions that Mimic Mesenteric Ischemia at CT. Radiographics 2021; 40:545-561. [PMID: 32125953 DOI: 10.1148/rg.2020190122] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Acute mesenteric ischemia (AMI) is a life-threatening condition with a high mortality rate. The diagnosis of AMI is challenging because patient symptoms and laboratory test results are often nonspecific. A high degree of clinical and radiologic suspicion is required for accurate and timely diagnosis. CT angiography of the abdomen and pelvis is the first-line imaging test for suspected AMI and should be expedited. A systematic "inside-out" approach to interpreting CT angiographic images, beginning with the bowel lumen and proceeding outward to the bowel wall, mesentery, vasculature, and extraintestinal viscera, provides radiologists with a practical framework to improve detection and synthesis of imaging findings. The subtypes of AMI are arterial and venoocclusive disease, nonocclusive ischemia, and strangulating bowel obstruction; each may demonstrate specific imaging findings. Chronic mesenteric ischemia is more insidious at onset and almost always secondary to atherosclerosis. Potential pitfalls in the diagnosis of AMI include mistaking pneumatosis as a sign that is specific for AMI and not an imaging finding, misinterpretation of adynamic ileus as a benign finding, and pseudopneumatosis. Several enterocolitides can mimic AMI at CT angiography, such as inflammatory bowel disease, infections, angioedema, and radiation-induced enterocolitis. Awareness of pitfalls, conditions that mimic AMI, and potential distinguishing clinical and imaging features can assist radiologists in making an early and accurate diagnosis of AMI. ©RSNA, 2020.
Collapse
Affiliation(s)
- Laura A Fitzpatrick
- From the Department of Diagnostic Radiology, Queen Elizabeth II Health Sciences Centre and Dalhousie University, Victoria General Building, 1276 S Park St, 3rd Floor, Halifax, NS, Canada B3H 2Y9 (L.A.F., M.D.R.B., S.E.C., J.A.R., A.F.C.); and Joint Department of Medical Imaging, University Health Network, Mount Sinai Hospital, Women's College Hospital, and University of Toronto, Toronto, Ontario, Canada (S.T.)
| | - Michael D Rivers-Bowerman
- From the Department of Diagnostic Radiology, Queen Elizabeth II Health Sciences Centre and Dalhousie University, Victoria General Building, 1276 S Park St, 3rd Floor, Halifax, NS, Canada B3H 2Y9 (L.A.F., M.D.R.B., S.E.C., J.A.R., A.F.C.); and Joint Department of Medical Imaging, University Health Network, Mount Sinai Hospital, Women's College Hospital, and University of Toronto, Toronto, Ontario, Canada (S.T.)
| | - Seng Thipphavong
- From the Department of Diagnostic Radiology, Queen Elizabeth II Health Sciences Centre and Dalhousie University, Victoria General Building, 1276 S Park St, 3rd Floor, Halifax, NS, Canada B3H 2Y9 (L.A.F., M.D.R.B., S.E.C., J.A.R., A.F.C.); and Joint Department of Medical Imaging, University Health Network, Mount Sinai Hospital, Women's College Hospital, and University of Toronto, Toronto, Ontario, Canada (S.T.)
| | - Sharon E Clarke
- From the Department of Diagnostic Radiology, Queen Elizabeth II Health Sciences Centre and Dalhousie University, Victoria General Building, 1276 S Park St, 3rd Floor, Halifax, NS, Canada B3H 2Y9 (L.A.F., M.D.R.B., S.E.C., J.A.R., A.F.C.); and Joint Department of Medical Imaging, University Health Network, Mount Sinai Hospital, Women's College Hospital, and University of Toronto, Toronto, Ontario, Canada (S.T.)
| | - Judy A Rowe
- From the Department of Diagnostic Radiology, Queen Elizabeth II Health Sciences Centre and Dalhousie University, Victoria General Building, 1276 S Park St, 3rd Floor, Halifax, NS, Canada B3H 2Y9 (L.A.F., M.D.R.B., S.E.C., J.A.R., A.F.C.); and Joint Department of Medical Imaging, University Health Network, Mount Sinai Hospital, Women's College Hospital, and University of Toronto, Toronto, Ontario, Canada (S.T.)
| | - Andreu F Costa
- From the Department of Diagnostic Radiology, Queen Elizabeth II Health Sciences Centre and Dalhousie University, Victoria General Building, 1276 S Park St, 3rd Floor, Halifax, NS, Canada B3H 2Y9 (L.A.F., M.D.R.B., S.E.C., J.A.R., A.F.C.); and Joint Department of Medical Imaging, University Health Network, Mount Sinai Hospital, Women's College Hospital, and University of Toronto, Toronto, Ontario, Canada (S.T.)
| |
Collapse
|
|
14
|
Alpuim Costa D, Modas Daniel P, Vieira Branco J. The Role of Hyperbaric Oxygen Therapy in Pneumatosis Cystoides Intestinalis-A Scoping Review. Front Med (Lausanne) 2021; 8:601872. [PMID: 33681242 PMCID: PMC7926085 DOI: 10.3389/fmed.2021.601872] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 01/28/2021] [Indexed: 12/24/2022] Open
Abstract
Pneumatosis cystoides intestinalis (PCI) is characterized by gas-filled cysts within gastrointestinal tract wall from esophagus to rectum, with preferential involvement of large and small intestine. PCI is rare with an estimated incidence of 0.03 to 0-2% in general population. PCI can be distinguished into idiopathic (15%) or secondary (85%) and the clinical picture ranges from completely asymptomatic to life-threatening intraabdominal complications. Although etiology of PCI appears to be multifactorial, the exact pathophysiology is poorly understood and two main theories have been proposed (mechanical and bacterial). Over the last decades, an enormous therapeutic armamentarium was considered in PCI's management, including hyperbaric oxygen therapy (HBOT). Treatment comprises conservative treatment in mild cases to surgery in highly symptomatic and complicated PCI. In the late 70s, HBOT started to be used in selected cases of PCI not responding to conservative measures. Since then, several case reports, case series, and reviews have been published in the literature with variable outcomes. The overall response rate and complete response were 92.1% (n = 82/89) and 65.2% (n = 58/89), respectively, with a median follow-up of 7 months. Furthermore, HBOT is extremely safe, with few reported complications in the literature when used for PCI. Nevertheless, a randomized, controlled, and double-blind clinical trial is unlikely to occur given the rarity of PCI, logistical issues of HBOT, and methodological considerations related to adequate blinding with a sham-controlled group. HBOT in combination with personalized diet and antibiotics may be beneficial for moderate to severe PCI in patients with no indication for emergency exploratory laparotomy. The purpose of this article is to synthesize the existing data, analyse results of previous studies, identify gaps in knowledge, and discuss PCI' management, including the proposal of an algorithm, with a special focus on HBOT.
Collapse
Affiliation(s)
- Diogo Alpuim Costa
- Centro de Medicina Subaquática e Hiperbárica (CMSH), Portuguese Navy, Lisbon, Portugal
- Centro de Investigação Naval (CINAV), Base Naval Do Alfeite, Portuguese Navy, Almada, Portugal
- CUF Oncology, Haematology and Oncology Department, Lisbon, Portugal
- NOVA Medical School, Faculdade de Ciências Médicas, Lisbon, Portugal
| | - Pedro Modas Daniel
- Centro de Medicina Subaquática e Hiperbárica (CMSH), Portuguese Navy, Lisbon, Portugal
- Centro de Investigação Naval (CINAV), Base Naval Do Alfeite, Portuguese Navy, Almada, Portugal
| | - João Vieira Branco
- Centro de Medicina Subaquática e Hiperbárica (CMSH), Portuguese Navy, Lisbon, Portugal
| |
Collapse
|
|
15
|
Leturia Etxeberria M, Biurrun Mancisidor MC, Ugarte Nuño A, Arenaza Choperena G, Mendoza Alonso M, Esnaola Albizu M, Serdio Mier A, Gredilla Sáenz M, Gomez Usabiaga V. Imaging Assessment of Ectopic Gas Collections. Radiographics 2020; 40:1318-1338. [DOI: 10.1148/rg.2020200028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Maria Leturia Etxeberria
- From the Department of Radiology, Donostia University Hospital, Paseo Dr. Beguiristain 109, 20014 Donostia–San Sebastián, Gipuzkoa, Spain
| | - Maria Carmen Biurrun Mancisidor
- From the Department of Radiology, Donostia University Hospital, Paseo Dr. Beguiristain 109, 20014 Donostia–San Sebastián, Gipuzkoa, Spain
| | - Ane Ugarte Nuño
- From the Department of Radiology, Donostia University Hospital, Paseo Dr. Beguiristain 109, 20014 Donostia–San Sebastián, Gipuzkoa, Spain
| | - Gorka Arenaza Choperena
- From the Department of Radiology, Donostia University Hospital, Paseo Dr. Beguiristain 109, 20014 Donostia–San Sebastián, Gipuzkoa, Spain
| | - Miguel Mendoza Alonso
- From the Department of Radiology, Donostia University Hospital, Paseo Dr. Beguiristain 109, 20014 Donostia–San Sebastián, Gipuzkoa, Spain
| | - Maite Esnaola Albizu
- From the Department of Radiology, Donostia University Hospital, Paseo Dr. Beguiristain 109, 20014 Donostia–San Sebastián, Gipuzkoa, Spain
| | - Alberto Serdio Mier
- From the Department of Radiology, Donostia University Hospital, Paseo Dr. Beguiristain 109, 20014 Donostia–San Sebastián, Gipuzkoa, Spain
| | - María Gredilla Sáenz
- From the Department of Radiology, Donostia University Hospital, Paseo Dr. Beguiristain 109, 20014 Donostia–San Sebastián, Gipuzkoa, Spain
| | - Virginia Gomez Usabiaga
- From the Department of Radiology, Donostia University Hospital, Paseo Dr. Beguiristain 109, 20014 Donostia–San Sebastián, Gipuzkoa, Spain
| |
Collapse
|
|
16
|
Dibra R, Picciariello A, Trigiante G, Labellarte G, Tota G, Papagni V, Martines G, Altomare DF. Pneumatosis Intestinalis and Hepatic Portal Venous Gas: Watch and Wait or Emergency Surgery? A Case Report and Literature Review. AMERICAN JOURNAL OF CASE REPORTS 2020; 21:e923831. [PMID: 32653891 PMCID: PMC7377522 DOI: 10.12659/ajcr.923831] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Patient: Female, 60-year-old Final Diagnosis: Pneumatosis intestinalis Symptoms: Abdominal pain Medication:— Clinical Procedure: — Specialty: Surgery
Collapse
Affiliation(s)
- Rigers Dibra
- Department of Emergency and Organ Transplantation, University "Aldo Moro" of Bari, Bari, Italy
| | - Arcangelo Picciariello
- Department of Emergency and Organ Transplantation, University "Aldo Moro" of Bari, Bari, Italy
| | - Giuseppe Trigiante
- Department of Emergency and Organ Transplantation, University "Aldo Moro" of Bari, Bari, Italy
| | - Grazia Labellarte
- Department of Emergency and Organ Transplantation, University "Aldo Moro" of Bari, Bari, Italy
| | - Giovanni Tota
- Department of Emergency and Organ Transplantation, University "Aldo Moro" of Bari, Bari, Italy
| | - Vincenzo Papagni
- Department of Emergency and Organ Transplantation, University "Aldo Moro" of Bari, Bari, Italy
| | - Gennaro Martines
- Department of Emergency and Organ Transplantation, University "Aldo Moro" of Bari, Bari, Italy
| | - Donato F Altomare
- Department of Emergency and Organ Transplantation, University "Aldo Moro" of Bari, Bari, Italy
| |
Collapse
|
|
17
|
Brandi N, Parmeggiani A, Brocchi S, Balacchi C, Gaudiano C, Golfieri R. Conservative treatment and radiological follow-up in a case of pneumatosis intestinalis associated with enteral tube feeding. Minerva Gastroenterol (Torino) 2020; 67:211-213. [PMID: 32623867 DOI: 10.23736/s2724-5985.20.02715-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Nicolò Brandi
- Department of Radiology, St. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy -
| | - Anna Parmeggiani
- Department of Radiology, St. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Stefano Brocchi
- Department of Radiology, St. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Caterina Balacchi
- Department of Radiology, St. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Caterina Gaudiano
- Department of Radiology, St. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Rita Golfieri
- Department of Radiology, St. Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
| |
Collapse
|
|
18
|
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.
Collapse
|
|
19
|
|