Acute gastric volvulus combined with pneumatosis coli rupture misdiagnosed as gastric volvulus with perforation:A case report

BACKGROUND Acute gastric volvulus represents a rare form of surgical acute abdomen,which makes it difficult to establish an early diagnosis.As the disease progresses,it can lead to gastric ischemia,necrosis,and other serious complications.CASE SUMMARY This paper reports a 67-year-old female patient with a history of abdominal distension and retching for 1 day.After admission,a prompt and thorough exami-nation was performed to confirm the diagnosis of acute gastric volvulus.Notably,the patient had free air in the abdominal cavity.The first consideration was gastric volvulus with gastric perforation,but the patient had no complaints,such as abdominal pain or signs of peritoneal irritation in the abdomen,and imaging examination revealed no abdominal pelvic effusion.Following endoscopic reduc-tion,the abdominal organs,such as the stomach and spleen,returned to their normal anatomical positions,and the free intraperitoneal air disappeared,su-ggesting a rare case of acute gastric torsion.The source of free air within the abdominal cavity warrants careful consideration and discussion.Combined with the findings from computed tomography,these findings are hypothesized to be associated with the rupture of colonic air cysts.CONCLUSION Patients with gastric torsion combined with free gas in the abdominal cavity should consider nongastrointestinal perforation factors to avoid misdiagnosis.

The spectrum of pneumatosis intestinalis in the adult.A surgical dilemma

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.

Pneumatosis Cystoides Intestinalis Complicated during Chemotherapy for Pulmonary Nontuberculous Mycobacterial Disease

Background: Pneumatosis cystoides intestinalis (PCI) is a rare disease characterized by the presence of gas in the intestinal wall. Aim: We report two rare cases of PCI that are complicated during the chemotherapy for pulmonary nontuberculous mycobacterial (NTM) disease. Case Presentation: In this report, we described two cases (a 72-year-old woman and a 60-year-old woman) of PCI that appeared during the combined chemotherapy consisting of rifampicin, ethambutol and clarithromycin. Because there were few clinical symptoms and increased inflammatory responses, the diagnosis of PCI was delayed. However, there were fortunately no severe complications in both cases. Conclusion: Respiratory physicians should be aware of the potential development of PCI in patients during the chemotherapy for pulmonary NTM disease. It is important to detect PCI in the early stage through radiological examinations to avoid severe complications.

Prednisolone induced pneumatosis coli and pneumoperitoneum

Pneumatosis intestinalis(PI)is defined as the presence of gas within the submucosal or subserosal layer of the gastrointestinal tract.It is a radiologic sign suspicious for bowel ischemia,hence non-viable bowel must be ruled out in patients with PI.However,up to 15%of cases with PI are not associated with bowel ischemia or acute abdomen.We described an asymptomatic patient with prednisolone-induced PI and modified the Naranjo score to aid in a surgeon’s decision-making for emergency laparotomy vs non-operative management with serial assessment in patients who are immunocompromised due to long-term steroid use.

A systematic analysis of pneumatosis cystoids intestinalis

AIM:To increase the understanding,diagnosis and treatment of pneumatosis cystoides intestinalis(PCI)and to find the characteristics and potential cause of the disease in China.METHODS:We report here one case of PCI in a 70-year-old male patient who received a variety of treatment methods.Then,we systematically searched the PCI eligible literature published from an available Chinese database from May 2002 to May 2012,including CBM,CBMDisc,CMCC,VIP,Wanfang,and CNKI.The key words were pneumatosis cystoides intestinalis,pneumatosis,pneumatosis intestinalis,pneumatosis coli and mucosal gas.The patients' information,histories,therapies,courses,and outcomes were reviewed.RESULTS:The study group consisted of 239 PCI cases(male:female = 2.4:1)from 77 reported incidents.The mean age was 45.3 ± 15.6 years,and the median illness course was 6 mo.One hundred and sixty patients(66.9%)were in high altitude areas.In addition,43.5%(104/239)of the patients had potential PCI-related disease,and 16.3% had complications with intestinal obstruction and perforation.The most common symptom was abdominal pain(53.9%),followed by diarrhea(53.0%),distention(42.4%),nausea and vomiting(14.3%),bloody stool(12.9%),mucous stool(12.0%)and constipation(7.8%).Most multiple pneumocysts developed in the submucosa of the colon(69.9%).The efficacy of the treatments by combined modalities,surgery,endoscopic treatment,conservative approach,oxygen,and antibiotics were 100%,100%,100%,93.3%,68.3% and 26.3%,respectively.CONCLUSION:PCI can be safely managed by conservative treatments,presents more frequently in males,in the large bowel and submucosa,than in females,in the small intestine and subserosa.High altitude residence maybe associated with the PCI etiology.

Computed tomography findings of pneumatosis and portomesenteric venous gas in acute bowel ischemia

AIM:To use more representative sample size to evaluate whether computed tomography(CT)scan evidence of the concomitant presence of pneumatosis and portomesenteric venous gas is a predictor of transmural bowel necrosis.METHODS:Data from 208 patients who were referred for a diagnosis of bowel ischemia were retrospectively reviewed.Only patients who underwent a surgical intervention following a diagnosis of bowel ischemia who also had a post-operative histological confirmation of such a diagnosis were included.Patients were split into two groups according to the presence of histological evidence of transmural bowel ischemia(case group)or partial bowel ischemia(control group).CT images were reviewed for findings of ischemia,including mural thickening,pneumatosis,bowel distension,portomesenteric venous gas and arterial or venous thrombi.RESULTS:A total of 248 subjects who underwent surgery for bowel ischemia were identified.Among the208 subjects enrolled in our study,transmural bowel necrosis was identified in 121 subjects(case group),and partial bowel necrosis was identified in 87 subjects(control group).Based on CT findings,including mural thickening,bowel distension,pneumatosis,pneumatosis plus portomesenteric venous gas and presence of thrombi or emboli,there were no significant differences between the case and control groups.The concomitant presence of pneumatosis and porto-mesenteric venous gas showed an odds ratio of 1.95(95%CI:0.491-7.775,P=0.342)for the presence of transmural necrosis.The presence of pneumatosis plus porto-mesenteric venous gas exhibited good specificity(83%)but low sensitivity(17%)in the identification of transmural bowel infarction.Accordingly,the positive and negative predictive values were 60% and 17%,respectively.CONCLUSION:Although pneumatosis plus porto-mesenteric venous gas is associated with bowel ischemia,we have demonstrated that their co-occurrence cannot be used as diagnostic signs of transmural necrosis.

Pneumatosis cystoides intestinalis following alpha-glucosidase inhibitor treatment:A case report and review of the literature

A 69-year-old man was diagnosed as having myasthenia gravis (MG) in September 2004,and treated with thymectomy and prednisolone. He was then diagnosed as having steroid-induced diabetes mellitus,and received sulfonylurea (SU) therapy in May 2005. An alpha-glucosidase inhibitor (αGI) was added in March 2006,resulting in good glycemic control. He experienced symptoms of abdominal distention,increased flatus,and constipation in October 2007,and was admitted into our hospital in late November with hematochezia. Plain abdominal radiography revealed small linear radiolucent clusters in the wall of the colon. Computed tomography (CT) showed intramural air in the sigmoid colon. Colonoscopy revealed multiple smooth surfaced hemispherical protrusions in the sigmoid colon. The diagnosis of pneumatosis cystoides intestinalis (PCI) was made on the basis of these findings. As the αGI voglibose was suspected as the cause of this patient's PCI,treatment was conservative,ceasing voglibose,with fasting and fluid supplementation. The patient progressed well,and was discharged 2 wk later. Recently,several reports of PCI associated with αGI therapy have been published,predominantly in Japan where αGIs are commonly used. If the use of αGIs becomes more widespread,we can expect more reports of this condition on a global scale. The possibility of PCI should be considered in diabetic patients complaining of gastrointestinal symptoms,and the gastrointestinal tract should be thoroughly investigated in these patients.

Pneumatosis cystoides intestinalis:A single center experience

AIM： To share our experience of the management and outcomes of patients with pneumatosis cystoides in- testinalis （PCI）. METHODS： The charts of seven patients who under- went surgery for PCI between 2001 and 2009 were re- viewed retrospectively. Clinical features, diagnoses and surgical interventions of patients with PCI are discussed. RESULTS： Seven patients with PCI （3 males, 4 fe- males; mean age, 50 ~ 16.1 years; range, 29-74 years） were analyzed. In three of the patients, abdominal pain was the only complaint, whereas additional vomiting and/or constipation occurred in four. Leukocytosis was detected in four patients, whereas it was within normal limits in three. Subdiaphragmatic free air was observed radiologically in four patients but not in three. Six of the patients underwent an applied lapa- rotomy, whereas one underwent an applied explorative laparoscopy. PCI localized to the small intestine only was detected in four patients, whereas it was localized to the small intestine and the colon in three. Three patients underwent a partial small intestine resection and four did not after PCI was diagnosed. Five patients were diagnosed with secondary PCI and two with pri- mary PCI when the surgical findings and medical his- tory were assessed together. Gastric atony developed in one case only, as a complication during a postopera- tive follow-up of 5-14 d. CONCLUSION： Although rare, PCl should be consid- ered in the differential diagnosis of acute abdomen. Diagnostic laparoscopy and preoperative radiological tests, including computed tomography, play an impor- tant role in confirming the diagnosis.

Pneumatosis cystoides intestinalis associated with massive free air mimicking perforated diffuse peritonitis

While pneumatosis cystoides intestinalis （PCI） is a rare disease entity associated with a wide variety of gastrointestinal and non-gastrointestinal disorders, PCI associated with massive intra- and retroperitoneal free air is extremely uncommon, and is difficult to diagnose differentially from perforated peritonitis. We present two cases of PCI associated with massive peritoneal free air and/or retroperitoneal air that mimicked perforated peritonitis. These cases highlight the clinical importance of PCI that mimics perforated peritonitis, which requires emergency surgery. Preoperative imaging modalities and diagnostic laparoscopy are useful to make an accurate diagnosis.

Gastrointestinal sarcoidosis associated with pneumatosis cystoides intestinalis

A 39-year-old male reported fevers,weight loss,watery loose stools,and decreased visual acuity in his right eye over the prior five years.He was pancytopenic,had an elevated American council on exercise level,total bilirubin,and alkaline phosphatase.Computed tomography revealed massive hepatosplenomegaly and emphysematous lung changes.Liver biopsy showed non caseating granulomas.The patient was diagnosed with extrapulmonary sarcoidosis and was treated with prednisone.The patient symptomatically improved but 5 mo later presented with abdominal pain caused by perforation of the cecum.He underwent a cecectomy and pathology revealed pneumatosis cystoides intestinalis.This represents the first reported association between pneumatosis cystoides intestinalis and sarcoidosis.The etiology of pneumatosis cystoides intestinalis in this case was likely multifactorial and involved both effects of the corticosteroids as well as the advanced nature of the gastrointestinal sarcoidosis.Furthermore this case has the unique features of emphysematous lung changes and pancytopenia which are uncommon with sarcoidosis.

Pneumatosis intestinalis with obstructing intussusception:A case report and literature review

Pneumatosis intestinalis(PI) often represents a benign condition that should not be considered as an argument for surgery. We report a patient with PI and obstructing intussusception who underwent urgent colectomy and review the literatures regarding PI with intussusception. A 20-year-old man presented at our hospital with a 3-d intermittent lower abdominal pain history. He underwent steroid therapy for membranoproliferative glomerulonephritis for 4 years. Computed tomography revealed ascending colon intussusception with air within the wall. Intraoperative colonoscopy revealed numerous soft polypoid masses with normal overlying mucosa and right hemicolectomy was performed. Histological examination of colonic wall sections revealed large cysts in the submucosal layer. The pathological diagnosis was PI. Nine cases of intussusception associated with primary PI have been reported. Although primary PI often represents a benign condition that should not be considered as an argument for surgery,if the case involves intussusception and obstruction,emergent laparotomy should be considered.

Pneumatosis cystoides intestinalis

Pneumatosis cystoides intestinalis(PCI) is a rare condition that may be associated with a variety of diseases.The presenting clinical picture may be very heterogeneous and represent a challenge for the clinician.In the present paper we describe both a common and an uncommon clinical presentation of PCI and review the pertaining literature.Our cases confirm that,apart from asymptomatic cases,the clinical presentation of PCI may be widely different and suggest that a new onset of stipsis might be the presenting symptom.Diagnosis might be suggested by a simple X-ray of the digestive tract showing a change in the characteristics of the intestinal wall in two-thirds of these patients.However,one third of the patients do not have a suggestive X-ray and require a computed tomography(CT) scan/nuclear magnetic resonance that may reveal a thickened bowel wall containing gas to confirm the diagnosis and distinguish PCI from intraluminal air or submucosal fat.CT also allows the detection of additional findings that may suggest an underlying,potentially worrisome cause of PCI such as bowel wall thickening,altered contrast mucosal enhancement,dilated bowel,soft tissue stranding,ascites and the presence of portal air.Our results also point out that clinicians and endoscopists should be aware of the possible presentations of PCI in order to correctly manage the patients affected with this disease and avoid unnecessary surgeries.The increasing number of colonoscopies performed for colon cancer screening makes PCI more frequently casually encountered and/or provoked,therefore the possible endoscopic appearances of this disease should be well known by endoscopists.

Unusual radiological finding of lethal pneumatosis intestinalis and portomesenteric vein gas

Pneumatosis intestinalis and portomesenteric vein gas are rare and potentially severe radiological findings that occur both in pediatric and adult populations.They actually are radiographic signs of underlying intra-abdominal pathology,abnormality or diagnostic medical interference.If combined with other radiological or clinical signs of intestinal ischemia or sepsis,the prognosis is dismal and urgent laparotomy is mandatory.We report two cases of surgical treatment with ominous outcome in an effort to characterize this finding correctly as an absolute surgical indication or as an additional diagnostic criterion that simply marks a further breakdown of the systems in patients with a long list of severe medical conditions.

Symptomatic pneumatosis intestinalis(including portal venous gas) after laparoscopic total colectomy

The development of intramural intestinal gas may indi-cate a serious postoperative complication and thereforeany radiological indication of such "pneumatosis intes-tinalis"(PI) in an unwell patient after surgery shouldput the clinical team on high-alert. However immedi-ate recourse to relook laparotomy may not be alwaysnecessary and, further, in some cases may possiblyaccelerate the deterioration especially if it proves to benon-therapeutic. Careful and close clinical monitoring,as is described in this clinical report, may allow discrimi-native identification of those in whom this finding is infact transient and therefore benign and who thereforecan be successfully treated without operative re-inter-vention. We describe the presenting features and back-ground scenario of PI early after laparoscopic total col-ectomy for medically refractory, severe ulcerative colitisand detail the critical postoperative decision pivots.

Gastric pneumatosis intestinalis associated with malignancy:An unusual case report

Pneumatosis intestinalis(PI)is an uncommon disease defined as gas-filled cysts that are found in the wall of the gastrointestinal(GI)tract.The exact causes of PI are still unclear,but it may associated with coexisting diseases,such as some GI disorders,connective tissue disease,some medication and drugs,and rarely malignancy.The most common localization is the small intestine.Gastric PI secondary to malignancy has been rarely documented.We report on a 94-year- old man with gastric PI associated with inoperable adenocarcinoma localized in the duodenum.Following the gastrojejunostomy and choledochojejunostomy bypass,his general condition improved and PI disappeared,but he died due to poor performance status and malignancy 6 mo later.We suggest that in patients presenting with PI,malignancy should be considered in the differential diagnosis.

Dysplasia in perforated intestinal pneumatosis complicating a previous jejuno-ileal bypass:A cautionary note

We present the case of an elderly woman who developed a bowel perforation related to pneumatosis intestinalis, 33 years after a jejuno-ileal bypass for severe obesity. Final histological examination revealed the presence of dysplasia in the resected specimen. On the basis of our case and a review of the literature, we discuss the etiopathogenesis, the clinical aspects and the treatment of this rare condition.

Pneumatosis cystoides intestinalis associated with toxic epidermal necrolysis: A case report

Toxic epidermal necrolysis(TEN) is a severe adverse drug reaction, which is characterized by erythema, blisters, and/or erosions of the mucous membranes and skin, but intestinal involvement is rare. In contrast, pneumatosis cystoides intestinalis(PCI) is a rare condition associated with a wide variety of underlying diseases, but to date no patient has presented with PCI associated with TEN. A 55-year-old man was admitted to intensive care unit for treatment of TEN caused by phenobarbital. On day 8 after admission, he presented with progressive abdominal distention and hypotension. Computed tomography(CT) showed gas in the superior mesenteric vein and air filled cysts in the walls of the small intestine. He was suspected of having septic shock due to PCI. As there were no indications of bowel ischemia or necrosis, the patient was managed conservatively with antibiotics and oxygen therapy. On day 10 after admission, he was weaned off catecholamines, with CT on day 11 showing complete resolution of gas in the superior mesenteric vein and air filled cysts. To our knowledge, this article describes the first patient presenting with PCI associated with TEN.

Pneumatosis intestinalis and pneumoperitoneum on computed tomography:Beware of non-therapeutic laparotomy

Pneumatosis intestinalis(PI) is defined as gas within the gastrointestinal wall and is associated with a variety of disorders.As a concurrent occurrence with pneumoperitoneum,it can easily to be mistaken for bowel ischemia with perforated peritonitis.In fact,air dissection or rupture from subserosal cysts may be the cause of intraperitoneal and intraluminal free air,with clinical symptoms such as abdominal pain and fullness occurring as a result.We hereby report a case of an 82-year-old male with a history of chronic obstructive pulmonary disease who was diagnosed with bowel ischemia and received emergency laparotomy because of the appearance of PI and pneumoperitoneum on abdominal computed tomography scan.However,no perforated hollow organ or necrotic bowel segment was found,only diffusely distributed massive intraperitoneal air and PI of gastrointestinal tract.The laparotomy seemed non-therapeutic for this patient.This is significant warning for clinicians to differentiate the associated conditions of PI,and to evaluate whether or not emergency surgery is necessary.

Incidental finding of esophageal pneumatosis

Pneumatosis of the gastrointestinal tract is a rare condition characterized by the presence of air filled cavities in the gastrointestinal tract wall.Its occurrence has been described throughout the gastrointestinal tract from the esophagus to the rectum,however it is most commonly reported in the small intestine.Despite multiple case reports in literature,its pathogenesis still remains unclear.Pneumatosis may be idiopathic or associated with a variety of disorders namely peptic ulcer disease,jejunoileal bypass,intestinal obstruction and non-gastrointestinal disorders like asthma,chronic obstructive pulmonary disease,systemic lupus erythematosus,infectious enteritis,etc.We here present a rare case of pneumatosis of the esophagus diagnosed incidentally at an esophagogastroduodenoscopy(EGD).A 78-year-old asymptomatic woman underwent EGD and colonoscopy at our hospital for evaluation of anemia.Few months prior to EGD,she had undergone excision of laryngocele at our hospital.EGD revealed extensive submucosal blebs distributed throughout the esophagus,otherwise unremarkable stomach and duodenum.Colonoscopy showed a tubular adenomatous polyp.Since our patient was asymptomatic she did not require any surgical intervention.Management of pneumatosis depends on the underlying cause.

Pneumatosis intestinalis after systemic chemotherapy for colorectal cancer:A case report

BACKGROUND Pneumatosis intestinalis(PI),also known as intramural gas in the small intestine,is a rare condition encountered by patients with cancer after receiving chemotherapy.CASE SUMMARY A 78-year-old man with a history of colorectal cancer developed epigastric pain and diarrhea after receiving combination chemotherapy of fluorouracil,leucovorin,irinotecan,and cetuximab.Abdomen radiography revealed in-tramural air in the small intestinal wall.A computed tomography scan of the abdomen revealed the features of PI with air expanding into the mesentery.After surgery,the patient remained symptom-free throughout a 9 mo follow-up period during which he received chemotherapy of fluorouracil,leucovorin,and irinotecan.CONCLUSION Although chemotherapy-induced PI is rare among patients with cancer,the differential diagnosis of PI and fulminant complications(such as ischemia,infarction,and perforation of the gastrointestinal tract)should be conducted,in which case an urgent surgical intervention is required.