A Case of Idiopathic Pneumoperitoneum Suspected to Be Caused by Pneumatosis Intestinalis / 日本農村医学会雑誌

A man in his 40s visited our hospital with a chief complaint of upper abdominal pain after defecation. His general and local conditions were good. Intraperitoneal free air was detected on an abdominal computed tomography (CT) scan, and laboratory tests revealed leukocytosis. Esophagogastroduodenoscopy showed no abnormalities. Emergent laparotomy was performed because of the suspected intestinal perforation, but neither perforation nor peritonitis was observed. Bacterial culture of intraperitoneal lavage fluid was negative. The postoperative course was uneventful and he was discharged. Because the cause of pneumoperitoneum was unknown, the diagnosis was idiopathic pneumoperitoneum. However, we had the opportunity to evaluate abdominal CT images taken with the lung window setting 4 years before the operation, which showed pneumatosis intestinalis in the ileocecal region. It has been reported that metachronous pneumatosis intestinalis is sometimes detected in cases of pneumoperitoneum with pneumatosis intestinalis. Thus, pneumatosis intestinalis was suspected as the cause of pneumoperitoneum in this case.

Pneumatosis intestinalis as a presentation of Crohn's disease: a case report / Neumatosis intestinal como presentación de la enfermedad de Crohn: reporte de un caso

ABSTRACT Pneumatosis intestinalis (PI) is defined as presence of gas within the intestinal wall. It is a rare condition, usually associated with a wide variety of pathologies. It requires a special diagnostic approach to determine underlying etiology. We present the case of a 18 year old woman with chronic abdominal pain, who presents with peritoneal signs and pneumoperitoneum. Laparoscopy showed NI. Thereafter, Crohn´s disease was diagnosed by balloon enteroscopy.

RESUMEN La neumatosis intestinal (NI) es la presencia de gas en la pared intestinal. Es un hallazgo infrecuente, generalmente presente en una gran variedad de patologías. Requiere de un abordaje diagnóstico detallado para determinar su etiología. Presentamos el caso de una mujer de 17 años con dolor abdominal crónico, quien se presenta con signos de irritación peritoneal y neumoperitoneo. Con hallazgo quirúrgico de NI en el intestino delgado, a quién mediante enteroscopia se le diagnóstica enfermedad de Crohn.

Delayed Pneumatosis Intestinalis Induced by Blunt Trauma in a Strangulated Small Intestine

An ischemia-reperfusion injury of the intestine due to blunt trauma is very rare. Low blood flow can result in an incarceration and an ischemia-reperfusion injury of the small intestine. A 63-year-old woman fell, producing a splenic rupture. Despite the successful angio-embolization of the splenic rupture, the patient continued to suffer from hypotension. During laparotomy to identify the bowel injury, no intestinal perforation was found. However, we found a hemorrhagic infarction of the small intestine with congestion of the submucosal blood vessels. The part of bowel with the hemorrhagic infarction was resected and reconstructed with a jejuno-colic anastomosis. After surgery, she recovered from the trauma and was discharged without complications. We present this ischemia-reperfusion injury of the intestine due to blunt trauma. Meticulous examination and computed tomography scan is mandatory for diagnosis and assessment of treatment outcome.

Neumatosis intestinal secundaria a esclerosis sistémica: caso clínico / Intestinal pneumatosis secondary to systemic sclerosis: clinical case

Intestinal pneumatosis is a rare complication that can occur in systemic sclerosis (ES), its pathogenesis is not entirely specified and is characterized by the presence of gas in the submucosa wall and / or bowel subserosa. For a 37 year old woman presented with a diagnosis of diffuse variety EN who consults repeatedly by pain, bloating and intermittent episodes of chronic diarrhea associated with weight loss. The imaging study revealed an intestinal pneumatosis and pneumoperitoneum as the source of the picture...

La neumatosis intestinal es una complicación rara que puede presentarse en la Esclerosis Sistémica (ES), su etiopatogenia no está del todo precisada y se caracteriza por presencia de gas en la pared submucosa y/o subserosa del intestino. Se presenta el caso de una mujer de 37 años, con diagnóstico de ES variedad difusa quien consulta en repetidas ocasiones por dolor, distensión abdominal y episodios de diarrea crónica intermitente asociado a disminución de peso. El estudio con imágenes reveló una neumatosis intestinal y neumoperitoneo como origen del cuadro...

Clinical outcomes in surgical and non-surgical management of hepatic portal venous gas

BACKGROUNDS/AIMS: Hepatic portal venous gas (HPVG) is a rare condition, with poor prognosis and a mortality rate of up to 75%. Indications for surgical and non-surgical management of HPVG including associated complications and mortality remain to be clarified. METHODS: From January 2008 to December 2014, 18 patients with HPVG diagnosed through abdominal computed tomography (CT) imaging were retrospectively identified. Clinical symptoms, laboratory data, underlying diseases, treatment, and mortality rate were analyzed. Patients were classified into 2 groups: surgical management recommended (SR, n=10) and conservative management (CM, n=8). The SR group was further subdivided into patients who underwent surgical management (SM-SR, n=5) and those who were managed conservatively (NS-SR, n=5). RESULTS: Conditions underlying HPVG included mesenteric ischemia (38.9%), intestinal obstruction (22.2%), enteritis (22.2%), duodenal ulcer perforation (5.6%), necrotizing pancreatitis (5.6%), and diverticulitis (5.6%). In terms of mortality, 2 patients (40%) died in the SM-SR group, 1 (12.5%) in the CM group, and 100% in the NS-SR group. Higher scores from Acute Physiology and Chronic Health Evaluation (APACHE) II predicted the mortality rates of the NS-SR and CM groups. CONCLUSIONS: Identification of HPVG requires careful consideration for surgical management. If surgical management is indicated, prompt laparotomy should be performed. However, even in the non-surgical management condition, aggressive laparotomy can improve survival rates for patients with high APACHE II scores.

A Case of Necrotizing Colitis Presenting with Hepatic Portal Venous Gas and Pneumatosis Intestinalis / 대한소화기학회지

Hepatic portal venous gas is a very rare radiologic sign which is characterized by gas accumulation in the portal venous circulation. Pneumatosis intestinalis is also very rare and is characterized by multiple air cysts in the serosal or submucosal layers of the gastrointestinal tract walls. These two findings are caused by various pathological conditions and can develop individually or simultaneously. The latter is clinically more significant because it is frequently related to bowel ischemia or necrosis, and represents a poor prognosis. However, prognosis is more influenced by the severity of underlying disease rather than hepatic portal venous gas or pneumatosis intestinalis itself. If bowel ischemia or necrosis is the primary cause, emergency operation is very important to improve patient's prognosis. Herein, we report a case of necrotizing colitis presenting as hepatic portal venous gas and pneumatosis intestinalis which was successfully managed by early surgery.

Pneumatosis intestinalis after adult living donor liver transplantation: report of three cases and collective literature review

BACKGROUNDS/AIMS: Pneumatosis intestinalis (PI) is a condition in which multiple gas-filled mural cysts develop in the gastrointestinal tract. Although its exact etiology remains obscure, PI is rarely observed in liver transplant (LT) recipients. METHODS: In 317 cases of adult living donor LT (LDLT) performed during 2011, PI developed in three patients during the 3 year follow-up. RESULTS: Of these three patients, the two who demonstrated PI at 6 weeks and 2 months after LT, respectively, were asymptomatic and showed no signs of secondary complications. Diagnosis was made incidentally using abdominal radiographs and computed tomography (CT) scans. PI was identified in the right ascending colon with concomitant pneumoperitoneum. These two patients received supportive care and maintained a regular diet. Follow-up CT scans demonstrated spontaneous resolution of PI with no complications. The third patient was admitted to the emergency room 30 months after LDLT. His symptoms included poor oral intake and intermittent abdominal pain with no passage of gas. Abdominal radiography and CT scans demonstrated PI in the entire small bowel, with small bowel dilatation, pneumoperitoneum, and pneumoretroperitoneum, but no peritonitis. Physical examination revealed abdominal distension but no tenderness or rebound tenderness. After 1 week of conservative treatment, including bowel rest and antibiotics therapy, PI and pneumoperitoneum resolved spontaneously without complications. CONCLUSIONS: We suggest that adult LDLT recipients who develop asymptomatic or symptomatic PI with no signs of secondary complications can be successfully managed with conservative treatment.

Neumoperitoneo masivo: el reto de no operar / Conservative management of pneumoperitoneum secondary to pneumatosis intestinalis

Background: In Cystic Pneumatosis Intestinalis, intramural gas filled cysts are formed in the gastrointestinal wall. Its pathogenesis is unknown and its clinical manifestations are variable. Case report: We report a 33 years old HIV positive woman in retroviral treatment presenting with abdominal pain and signs of peritoneal irritation. An abdominal CT scan showed intra and retroperitoneal gas and pneumatosis intestinalis in the right and transverse colon. The patient was managed conservatively with nasogastric aspiration with a favorable evolution and was discharged ten days after admission.

Introducción: Se denomina neumatosis quística intestinal (NQI) a la formación de quistes intramurales rellenos de gas ubicados en la pared del sistema gastrointestinal, de patogénesis desconocida y de manifestaciones clínicas muy variables. Caso clínico: Presentamos un caso de neumoperitoneo masivo por NQI intestinal en una paciente VIH+ que acude a urgencias por dolor y distensión abdominal y que, a pesar de las espectaculares imágenes de la radiografía simple de abdomen y la tomografía computarizada (TC), se trató conservadoramente. Este caso pone de manifiesto el reto diagnóstico y la duda que supone para el cirujano acostumbrado a "operar para curar", no operar un cuadro que hasta hace poco tiempo inexcusablemente suponía una laparotomía exploradora.

Neumatosis intestinal y gas porto-mesentérico: hallazgos radiológicos y significado clínico en un caso de catástrofe abdominal / Pneumatosis intestinalis and portall venus gas: radiological findings and clinical significance in a case of abdominal catastrophe

Presentamos el caso de una mujer de 56 años de edad, con dolor abdominal de cinco días de duración asociado a manifestaciones inespecíficas y sin etiología clara del dolor. Se realizaron estudios en busca del origen del dolor con los que se documentó neumatosis intestinal grave, que posteriormente se agravó a pesar del manejo medico. Debido al mal estado hemodinámico y el rápido deterioro clínico luego de la evaluación médica no pudo ser llevada a cirugía y la paciente fallece.

We report a 56-year-old woman with abdominal pain 5 days duration associated with nonspecific manifestations without etiology of pain. We conducted studies in search of the source of pain between these severe intestinal pneumatosis that progress despite medical management and could not be taken to surgery due to hemodynamic state to a rapid deterioration after medical evaluation and documented patient dies. Finally, we review this case and the most frequent finding of portomesenteric venous gas.

Three Cases of Preterm Infants Showing Pneumatosis Intestinalis without Progression to Typical Necrotizing Enterocolitis

Necrotizing enterocolitis (NEC) is a major gastrointestinal disorder in premature infants associated with high morbidity and mortality rates. When NEC is clinically suspected, radiological and laboratory studies should be performed to confirm the diagnosis and to aid in the management of patients. As the clinical manifestations of NEC are usually nonspecific, diagnoses are often made using abdominal radiographic findings, such as pneumatosis intestinalis. Clinicians typically consider the presence of pneumatosis intestinalis on radiographs as the definite evidence of stage II NEC. Here, we report 3 cases of preterm infants who had radiographic findings of pneumatosis intestinalis but did not have any other associated laboratory and clinical evidence of NEC, except bloody stools. The infants' systemic manifestations were mild or absent, and all of them completely recovered within 2-3 days, as demonstrated by the resolution of pneumatosis intestinalis on abdominal radiographs. The combination of hematochezia and intestinal pneumatosis in preterm infants strongly suggests the diagnosis of NEC. In our cases, there was no laboratory evidence of inflammation or platelet consumption, and the clinical course was benign without any sings of surgical abdomen. Additionally, our patients had barium-induced colitis or milk protein allergy, which are other possible causes of pneumatosis intestinalis. Because pneumatosis intestinalis can result from causes other than NEC, it is important to consider clinical, laboratory, and radiological findings to confirm the diagnosis of NEC.

Pneumatosis Intestinalis Developed due to CMV Infection in a Pediatric Severe Aplastic Anemia Patient after Hematopoietic Stem Cell Transplantation / 임상소아혈액종양

A 10-year old girl diagnosed as severe aplastic anemia was transplanted with peripheral stem cells from a CMV seropositive full matched unrelated donor. The conditioning regimen consisted of busulfan, fludarabine, and anti-thymocyte globulin (ATG). At D+114, abdominal pain, fever, and blood-tinged watery diarrhea developed. At D+116, pneumatosis intestinalis (PI) was detected on simple abdominal X-ray and computed tomography (CT). Ganciclovir was started intravenously because CMV antigenemia was detected at D+117. Two days later, PI sign disappeared on simple abdominal X-ray, and hematochezia began to decrease. CMV antigenemia disappeared 10 days after starting ganciclovir. We describe a 10-year old girl with severe aplastic anemia who developed PI in the presence of CMV infection and gastro-intestinal graft-versus-host-disease (GVHD) after allogeneic stem cell transplantation and was treated successfully with ganciclovir.

Pneumatosis Intestinalis Developed due to CMV Infection in a Pediatric Severe Aplastic Anemia Patient after Hematopoietic Stem Cell Transplantation / 임상소아혈액종양

A 10-year old girl diagnosed as severe aplastic anemia was transplanted with peripheral stem cells from a CMV seropositive full matched unrelated donor. The conditioning regimen consisted of busulfan, fludarabine, and anti-thymocyte globulin (ATG). At D+114, abdominal pain, fever, and blood-tinged watery diarrhea developed. At D+116, pneumatosis intestinalis (PI) was detected on simple abdominal X-ray and computed tomography (CT). Ganciclovir was started intravenously because CMV antigenemia was detected at D+117. Two days later, PI sign disappeared on simple abdominal X-ray, and hematochezia began to decrease. CMV antigenemia disappeared 10 days after starting ganciclovir. We describe a 10-year old girl with severe aplastic anemia who developed PI in the presence of CMV infection and gastro-intestinal graft-versus-host-disease (GVHD) after allogeneic stem cell transplantation and was treated successfully with ganciclovir.

Bedside Ultrasound for the Diagnosis of Bowel Necrosis in a Patient with an Altered Mental Status

Bowel necrosis generally requires an immediate operation and causes a high mortality rate. Unfortunately, in patients with altered consciousness, diagnosis can be very difficult. In our case, a 45-year-old male, with an altered mentality due to brain injury (from head trauma) and alcohol intoxication, was brought into our emergency department. Due to his altered state, he had no initial complaints about any other symptoms besides a headache. After a physical examination, no other signs were observed, except for swelling on the head. However, a worsening of wide anion gap metabolic acidosis was observed upon laboratory examination. A bedside ultrasound was performed to evaluate the reason for this metabolic acidosis, and pneumatosis intestinalis and hepatic portal venous gas was observed. Eventually bowel necrosis was diagnosed, an emergency operation was executed, and the patient recovered.

Pneumatosis Intestinalis Developed due to CMV Infection in a Pediatric Severe Aplastic Anemia Patient after Hematopoietic Stem Cell Transplantation / 임상소아혈액종양

A 10-year old girl diagnosed as severe aplastic anemia was transplanted with peripheral stem cells from a CMV seropositive full matched unrelated donor. The conditioning regimen consisted of busulfan, fludarabine, and anti-thymocyte globulin (ATG). At D+114, abdominal pain, fever, and blood-tinged watery diarrhea developed. At D+116, pneumatosis intestinalis (PI) was detected on simple abdominal X-ray and computed tomography (CT). Ganciclovir was started intravenously because CMV antigenemia was detected at D+117. Two days later, PI sign disappeared on simple abdominal X-ray, and hematochezia began to decrease. CMV antigenemia disappeared 10 days after starting ganciclovir. We describe a 10-year old girl with severe aplastic anemia who developed PI in the presence of CMV infection and gastro-intestinal graft-versus-host-disease (GVHD) after allogeneic stem cell transplantation and was treated successfully with ganciclovir.

A Case of Pneumatosis Intestinalis Associated with Sunitinib Treatment for Renal Cell Carcinoma / 대한소화기학회지

Sunitinib as a multitarget tyrosine kinase inhibitor is one of the anti-tumor agents, approved by the United States Food and Drug Administration to use treat gastrointestinal stromal tumor and metastatic renal cell carcinoma. The agent is known to commonly induce adverse reactions such as fatigue, nausea, diarrhea, stomatitis, esophagitis, hypertension, skin toxicity, reduciton in cardiac output of left ventricle, and hypothyroidism. However, it has been reported to rarely induce adverse reactions such as nephrotic syndrome and irreversible reduction in renal functions, and cases of intestinal perforation or pneumatosis interstinalis as such reactions have been consistently reported. In this report, a 66-year old man showing abdominal pain had renal cell carcinoma and history of sunitinib at a dosage of 50 mg/day on a 4-weeks-on, 2-weeks-off schedule. Seven days after the third cycle he was referred to the hospital because of abdominal pain. Computed tomography showed pneumoperitoneum with linear pneumatosis intestinalis in his small bowel. The patient underwent surgical exploration that confirmed the pneumatosis intestinalis at 100 cm distal to Treitz's ligament. We report a rare case of intestinal perforation with pneumatosis intestinalis after administration of sunitinib to a patient with metastatic renal cell carcinoma.

Asymptomatic pneumatosis intestinalis following chemotherapy for B lymphoblastic leukemia with recurrent genetic abnormalities in an adolescent patient / 대한혈액학회지

Pneumatosis intestinalis (PI) is a rare condition characterized by multiple pneumocysts in the submucosa or subserosa of the bowel. Here, we report a rare case of asymptomatic PI after chemotherapy induction in an 18-yr-old man with B lymphoblastic leukemia with recurrent genetic abnormalities. The patient was treated conservatively and recovered without complications. The possibility of PI should be considered as a complication during or after chemotherapy for hematologic malignancies. Conservative treatment should be considered unless there are complications, including peritonitis, bowel perforation, and severe sepsis.

Pneumatosis intestinalis after adult liver transplantation / 대한외과학회지

Pneumatosis intestinalis is an uncommon disorder characterized by an accumulation of gas in the bowel wall. We described three cases undertaking liver transplantation. The patients developed diarrhea in three cases and high fever in two. An abdominal X-ray and computed tomography scan demonstrated extensive pneumatosis intestinalis in the colon with pneumoperitoneum mimicking hollow organ perforation. However, the patients had no abdominal symptoms and there was no evidence of peritonitis. The infection work-up was negative except one case with cytomegalovirus antigenemia. After one week of conservative management including bowel rest and antibiotic therapy, their pneumoperitoneum resolved spontaneously without any complication. Pneumatosis intestinalis should be considered as a differential diagnosis after adult liver transplantation with patients suffering from watery diarrhea and fever. Pneumoperitoneum, air-density in mesentery and retroperitoneum in patients with pneumatosis intestinalis without signs of peritonitis improved with conservative management, which included bowel rest and antibiotic therapy.

Pneumatosis Intestinalis with Hepatic Portal Venous Gas in a Hemodialysis Patient / 대한신장학회지

Pneumatosis intestinalis is an uncommon but important condition in which gas is found in a linear or cystic form in the submucosa or subserosa of the bowel wall. It occurs in several clinical settings in adults who have a wide variety of underlying disorders that determine prognosis. Especially, hepatic portal venous gas with pneumatosis intestinalis has been rarely described in chronic dialysis patients. We report a case of 53-year-old man with hemodialysis-dependent end stage renal disease who developed a pneumatosis intestinalis accompanied hepatic portal venous gas. This patient was treated conservatively with intravenous antibiotics, fluid therapy, and oxygen supply without surgical approach.

A Case of Pneumatosis Intestinalis in Refractory Acute Precursor B-Cell Lymphoblastic Leukemia-Lymphoma / 대한내과학회지

Pneumatosis intestinalis (PI) is an imaging phenomenon that represents air in the bowel wall. The cause of PI is variable, although specific etiologic factors remain unknown. It is an infrequent complication in leukemia patients and is associated with several medical and surgical conditions. PI often represents a benign condition, but it can also require surgery. Therefore, the assessment of PI with or without complications can be difficult. Herein, we report on an unusual case of a 63 year-old woman with refractory acute precursor B-cell lymphoblastic leukemia-lymphoma who presented with PI resulting from the leukemic process, and finally expired due to sepsis.

Abdominal Tuberculosis in a Child Presenting with Radiological Evidence of Pneumatosis Intestinalis and Portal Venous Gas.

Pneumatosis intestinalis, in association with portal venous gas, is a rare finding in children and young adults. In radiological studies, it is characterized by gas-filled cysts within the bowel-wall. It is often a sign of the serious significant underlying illness and is associated with a poor prognosis. A case of pneumatosis intestinalis and portal venous gas associated with abdominal tuberculosis in a child is presented here. Despite responding well to anti-tubercular treatment, he died suddenly at home, two months after discharge. It is recommended that cases with pneumatosis intestinalis should be carefully observed, although symptoms appear to be improving.