Management of pneumatosis cystoides intestinalis with pneumoperitoneum: 5-years systematic review

Introduction: Pneumatosis cystoides intestinalis (PCI) is a rare condition characterized by gas-filled cysts in the intestinal wall. Although rare, it may also involve other regions, such as the mesentery. PCI is classified as primary or secondary and is associated with multiple predisposing factors. It may be associated with either a benign condition or a potentially fatal condition, such as mesenteric ischemia. The objective of this study was to review the medical literature on the rare benign presentations of PCI, excluding cases associated with intestinal ischemia.Methods: We conducted a systematic literature review according to the PRISMA statement. We searched PubMed and LILACS databases for articles published between January 2015 and December 2020 using the following Medical Subject Headings: "pneumatosis cystoides intestinalis" and "pneumoperitoneum," "pneumatosis intestinalis," and "pneumoperitoneum" or "mesenteric pneumatosis."Results: We included 51 articles comprising 58 patients with PCI and pneumoperitoneum. Most patients were men, and mean patient age was 64.9 years. We identified an idiopathic etiology in 29.31% of cases, and the most common predisposing factor was immune dysfunction (29.31%). A total of 24.13% of patients were asymptomatic. The most commons symptoms were abdominal pain (43.10%), nausea and vomiting (41.37%), and abdominal distention (37.93%). Diagnostic surgery was conducted in 26 patients (44.82%). Only 1 patient underwent surgical treatment.Conclusions: PCI is a clinical condition that may have a benign etiology and not require surgery. Treatment of the benign etiology is conservative. Thus, life-threatening conditions should be excluded in all cases.

Neumoperitoneo tras cirugía: Una completa anamnesis es la clave / Pneumoperitoneum after cardiac surgery: A complete anamnesis is the clue

En este artículo exponemos el caso de un paciente de 82 años llevado a cirugía cardiaca para sustitución de válvula mitral. Quince años antes fue intervenido para sustituir su válvula aórtica, por lo que en realidad se trataba de una reintervención cardiaca. Después de la reesternotomía, y liberación de adherencias pericárdicas, se produjo una apertura accidental de una pequeña porción del peritoneo, procediéndose a reparar con sutura simple. En el postoperatorio, la presencia de neumoperitoneo alarmó sobre la posibilidad de una complicación intraabdominal asociada, descartada posteriormente dado el antecedente quirúrgico. En este artículo realizamos una revisión sobre lo que es el neumoperitoneo, sus causas y tratamiento, así como resaltamos causas posibles y no habitualmente consideradas como puede ser una cirugía cardiaca previa reciente, simplemente por el hecho de encontrar al paciente en diferentes contextos y no pensar en ellas.

Herein we present the case of an 82 year-old patient undergoing cardiac surgery for mitral valve replacement. Fifteen years earlier, the patient had undergone surgery to replace his aortic valve, so that it was now a cardiac reoperation. Through sternotomy, and release of pericardial adherences, there was an accidental opening of a small portion of the peritoneum, proceeding to repair with simple suture. Postoperatively, the presence of pneumoperitoneum alarmed about the possibility of an intra-abdominal complication but it was subsequently discarded with recent surgical process. Through this article we review what the pneumoperitoneum consist, its causes and management, as well as highlighting possible etiologies sometimes not considered as a recent cardiac surgery, simply because the patient in found in different contexts and we do not think about those possibilities.

A Case of Spontaneous Pneumoperitoneum Associated with Idiopathic Intestinal Pseudoobstruction / 대한소화기학회지

Pneumoperitoneum, free intra-abdominal air, usually results from the perforation of a hollow viscous. In approximately 10% of cases, however, pneumoperitoneum is not caused by gastrointestinal perforation. These cases of "spontaneous pneumoperitoneum" generally follow more benign course and may not require surgical intervention. Examples include cardiopulmonary resuscitation (CPR), malrotation, mechanical ventilator support, gynecologic manipulation, blunt abdominal trauma, and chronic intestinal pseudoobstruction in infancy (Sieber syndrome). But, it is extremely rare of spontaneous pneumoperitoneum secondary to idiopathic intestinal pseudoobstuction in adult. We herein report a patient with chronic idiopathic intestinal pseudoobstuction who developed a pneumoperitoneum.

Postsurgical pneumoperitoneum - comparison of abdominal ultrasound findings with plain radiography

To compare abdominal ultrasonography findings with plain radiography in the detection of postsurgical pneumoperitoneum. Cross-sectional, observational. Radiology Department, PNS Shifa Hospital, Karachi, from October, 2005 to April, 2006. Thirty patients of either gender who underwent laparotomies were included in the study. Patients were examined with plain radiography and abdominal ultrasound to detect postsurgical pneumoperitoneum within 24 hours of surgery. Upright chest radiography and left lateral decubitus views of abdomen were used to detect free air. McNemar test was applied to compute relationship between sonographic and radiographic findings. Among 30 patients, 22 [73.3%] were females and 8 [26.7%] were males [M: F = 1: 2.75]. Average age was 38.07 +/- 12.41 years. Out of 30 patients of postsurgical pneumoperitoneum, 27 [90%] were detected on ultrasonography while 3 [10%] were not detected. On plain X-rays, 4 patients were observed in group-I [no free air] and 26 in group-II [1-10 mm thickness]. Significant [p<0.001] relationship was observed between the two findings. Since both modalities can diagnose pneumoperitoneum reliably, ultrasonography can be a useful alternative imaging modality for the detection of pneumoperitoneum

Pneumatosis Intestinalis with Pneumoperitoneum Mimicking Intestinal Perforation in a Patient with Myelodysplastic Syndrome after Hematopoietic Stem Cell Transplantation

Pneumatosis intestinalis (PI) is an uncommon disorder characterized by an accumulation of gas in the bowel wall, and has been associated with a variety of disorders and procedures. We describe a 35-year-old man who undertook hematopoietic stem cell transplantation due to myelodysplastic syndrome. An abdominal X-ray demonstrated extensive PI with pneumoperitoneum mimicking hollow organ perforation. However, the patient had no abdominal symptoms and there was no evidence of peritoneal inflammation. After two weeks of conservative management, including bowel rest and antibiotics, his pneumoperitoneum resolved spontaneously without any complications. Of the many factors that affect the gastrointestinal tract mucosal integrity, intramural pressure, and bacterial flora-produced intraluminal gas interact to produce PI. If the condition is accompanied by bowel ischemia, portomesenteric venous gas, metabolic acidosis, and abdominal sepsis, or if PI is severe in extent immediate surgical intervention is indicated. The described case supports that a mechanical rather than a bacterial etiology underlies the pathogenesis of PI.

Imágenes en abdomen: aire donde no tiene que haber aire / Images abdomen: air which does not have to be air

La presencia de aire en lugares del abdomen donde normalmente no tiene que haber aire representa, en general, un riesgo potencial de muerte para el paciente si no se hace un diagnóstico temprano y un manejo agresivo, ya sea médico o quirúrgico. El diagnóstico por imágenes juega un rol fundamental en estos casos. Las principales causas son la perforación de vísceras huecas y la producción de gas en procesos infecciosos. En general, el estudio de estos pacientes comienza con radiología o ecografía pero el método más sensible y específico es la TC, la que detecta muy bien la localización y la extensión del gas anormal.

Massive Pneumoperitoneum After Scuba Diving

Pneumoperitoneum usually indicates rupture of a hollow viscus and considered a surgical emergency. But air may also enter the peritoneum from the lung or the genital organs in female without visceral perforation. While scuba diving, the rapid ascent is usually controlled by placing in a decompression chamber and the excess gas volume is exhaled. Failure to allow this excess gas to escape will result in overdistension of air passage, which may rupture resulting in pulmonary interstitial emphysema or, if air enters the circulation, air embolus can occur. Pneumo-peritoneum is a rare complication of diving accidents. While the majority of cases are not related to an intraabdominal catastrophy, more than 20% have been the result of gastric rupture. We report a 42-yr-old male patient with massive pneumoperitoneum after scuba diving, who presented himself with dyspnea and abdominal distension. Knowledge of this rare condition and its benign course may allow the emergency physician and surgeon to order appropriate studies to help avoid unnecessary surgical treatment. It is important to determine promptly whether the air emanated from a ruptured viscus or was introduced from an extraperitoneal source. Free air in the abdomen does not always indicate a ruptured intra-abdominal viscus.

Non - operative management of perforated peptic ulcer

The aim of this study was to see the morbidity and mortality in peptic ulcer perforation cases by non-operative management in selected cases. Design: The cases were selected on the basis of structured protocol. Setting: This study was carried out in the Department of Surgery of Khulna Medical College Hospital located in southern Bangladesh over a period of 10 years. Subjects: The patients were diagnosed as perforated peptic ulcer clinically and radiologically. All patients in this series had pneumoperitoneum in plain x-ray abdomen. They included 54 patients of peptic ulcer perforation cases had the following parameters: early presentation [<12 hours], soft abdomen with minimum tenderness and relatively younger patients. All patients were chosen who were haemodynamically stable. Ultrasonography was done in doubtful cases and also to see the amount of free fluid inside the abdominal cavity. Methodology: After diagnosis, all patients were managed in a similar fashion-like nil by mouth, continuous gastric aspiration, application of intravenous fluids and antibiotics and antiulcer therapy. In the selected 54 patients, male: female were 49:05. Nine had history of NSAID intake. There was no mortality. Morbidity analysis showed that three had hepatic abscess, four had pelvic abscess, six took prolonged time for improvement, in two cases conservative treatment had to be abandoned and laparotomy was done in the same hospital admission. Non-operative procedure is a safe and effective measure for the management of perforated peptic ulcer in selected cases

Ruptured splenic abscess presenting as pneumoperitoneum.

Spontaneous pneumoperitoneum follows perforation of hollow viscus; rarely, it may arise from pulmonary interstitial emphysema or intestinal inflammatory disease. We report a 30-year-old man with ruptured splenic abscess who presented with acute abdomen and had pneumoperitoneum. He was treated with splenectomy and is asymptomatic 2 months later.

Neumoperitoneo espontáneo no quirúrgico en un recién nacido / Non surgical spontaneous pneumoperitoneum in a newborn

El neumoperitoneo espontáneo no quirúrgico es un cuadro extraordinariamente infrecuente en pediatría. Su aparición implica un gran dilema diagnóstico y el manejo clínico. Este cuadro ha sido reportado a partir de la década del 50 en pacientes adultos para hacer hincapié en la presencia de neumoperitoneo en ausencia de lesión de algún órgano intraabdominal. Se presenta el caso de un recién nacido de 3 semanas de edad con esta afección asociada a una neumopatía aguda

Pneumoperitônio näo-cirúrgico: relato de caso / Pneumoperitoneum not-surgery: case study

Este relato diz respeito a um caso de pneumoperitônio näo-cirúrgico que teve resoluçäo espontânea (tratamento conservador). Apresenta-se, também, uma revisäo da literatura sobre o assunto, salientando-se a importância da história clínica e da acuracidade diagnóstica, a fim de se evitar uma abordagem cirúrgica desnecessária.

Transillumination for the diagnosis of pneumoperitoneum.

Transillumination of the abdomen with a cold fibreoptic light source was used for the rapid diagnosis of pneumoperitoneum in a sick premature infant with necrotising enterocolitis. The diagnosis was confirmed at laparotomy. The neonate survived the surgical procedure of resection and anastomosis of the perforated gut. Although additional diagnostic investigations such as X-rays and paracentesis of the abdomen were also positive in this case, transillumination of the abdomen proved to be a useful tool for early diagnosis. Transillumination thus is a valuable modality for early diagnosis of pneumoperitoneum, especially where facilities for in-house X-rays are not available.

Pneumoperitônio pós-cesária: relato de caso / Pneumoperitoneum after cesarean section: a case report

A associação de pneumoperitônio, dor abdominal e íleo paralítico no período pós-operatório relaciona-se, na maioria dos casos, à perfuração de vísceras ocas. Os autores apresentam um caso de pós-operatório de cesariana por DPPNI em que a paciente evoluiu com importante distensão e dor abdominal. Realizada radiografia de tórax e abdome evidenciou-se importante dilatação das alças de intestino grosso e delgado e pneumoperitônio, foi submetida a laparotomia exploradora com a hipótese diagnóstica de perfuração intestinal. Na cirurgia, no entanto, não foi encontrada lesão gastrintestinal; foi confirmado o diagnóstico de pneumoperitônio, identificando-se hemoperitônio e hematoma subaponeurótico infectados (E.coli). A evolução pós-operatória foi satisfatória, mantendo-se antibioticoterapia (ceftriaxona + metronidazol) por 4 dias. A paciente teve alta no 7§ dia pós-laparotomia. Depois de revisão da literatura pertinente, os autores concluem que o presente caso de pneumoperitônio relacionou-se possivelmente à infecção por bactéria produtora de gás em paciente com quadro clínico de íleo paralítico.

Gastric emphysema simulating perforated hollow viscus: case report and review of literature

Gastric emphysema is a benign condition in which air from non bacterial sources accumulate within the wall of the stomach. This pathology is usually associated with gastric and, or small bowel obstruction. A case report of gastric emphysema is presented, together with a pertinent review of the literature

Pneumotorax e pneumoperitonio: uma associacao rara / Pneumothorax and pneumoperitonium: a rare association

A associacao de pneumotorax e pneumoperitonio e rara devido a diferenca de pressao entre o torax e o abdomen que e maior que 40cm H2O, tanto na inspiracao como na expiracao. Neste trabalho, apresentaremos dois casos desta associacao ocorridos na UTI do Hospital d Pronto Socorro de Porto Alegre (HPS), revisando sua fisiopatogenia, diagnostico e terapeutica