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The case of an 86-year-old man with cardiac and pulmonary failure, in whom pneumatosis cystoides intestinalis caused segmental obstruction of the sigmoid colon is described. The patient was treated with endoscopic puncture and sclerotherapy of the cyst walls in four sessions, giving endoscopic and radiologic regress of the lesions and symptomatic relief.
Gastrointestinal complications developed in 29 (6%) of 510 patients following renal transplantation. Thirteen patients (45%) died as a result. Gastrointestinal bleeding, usually considered the commonest complication, was seen in only 7 cases. Other complications included pancreatitis and hyperamylasemia, massive ileus, fistulas with abscesses, bowel infarction, peptic ulcers without bleeding, obstruction, gangrenous cholecystitis, esophagitis, spontaneous perforation of the sigmoid colon, and pneumatosis cystoides intestinalis. Six patients had no clinical or laboratory findings suggesting the underlying gastrointestinal complication; it was the radiographic findings that called attention to the acute problem.
Patients with free intraperitoneal air collections usually undergo emergency surgery, and the majority will have a gastrointestinal tract perforation. However, there is a subset of patients in whom no identifiable perforation is found at surgery. This entity of noniatrogenic, nonsurgical spontaneous pneumoperitoneum is being diagnosed more frequently at present and is commonly associated with other disease processes that, together, may suggest a benign process. Therefore, a diagnostic algorithm that would preclude operative intervention in this cohort of patients would be of paramount clinical importance. In this report, we present representative cases of the most common types of nonsurgical pneumoperitoneum, review the pathogenesis of this disorder, and discuss its relationship with pneumatosis cystoides intestinalis, pulmonary disorders, scleroderma, and gynecologic processes. Finally, we outline a diagnostic algorithm that may identify patients who can safely be observed, thereby reducing the incidence of negative laparotomies and, secondarily, the aggregate cost of health care.
The case of a 3-year-old girl with pneumatosis cystoides of the appendix is reported. Pneumatosis cystoides intestinalis is an uncommon disease, particularly in the appendiceal localization and in the young child. Despite of the benign nature of the disease, we emphasize the need of an early diagnosis by systematic histological examination of the removed appendices. The etiopathogenesis is obscure.
Although pneumatosis cystoides intestinalis (PCI) is a well-recognised condition, an individual surgeon is unlikely to encounter it often. The collected experience of two surgical units in Glasgow teaching hospitals over a 15-year period consisted of five patients. Surgical and radiological trainees may therefore have little or no exposure to the diagnostic difficulties this condition can cause. We report an illustrative case.
The authors report two cases of pneumatosis cystoides intestinalis involving the small intestine. The first patient, a 35-year-old man treated for duodenal ulcer since 1976, presented with digestive haemorrhage in 1981 for which a vagotomy and a gastroduodenoanastomosis were performed. He was seen in 1986 for a post-bulbar stenosis. On the plain abdomen radiography there were gaseous formations in the sub-phrenic region. At operation the post-bulbar stenosis was confirmed and a cystic pneumatosis interesting 60 cm of the ileum was present. A gastro-enteroanastomosis was performed with an ileal resection and reestablishment of the continuity. He had no recurrence of the disease. The second patient, a 77-year-old man, was admitted for a surgical treatment of a stenosing bulbar ulcer. On the chest X-ray there were many gaseous formations under the diaphragmatic cupula, characteristic of cystic pneumatosis. The surgical exploration confirmed pyloric stenosis for which a vagotomy and a gastroenteroanastomosis were practised; it was found a cystic pneumatosis interesting one meter of the small intestine, which was not resected. The postoperative course was uneventful. The authors review the literature about this benign disease, which can involve the small intestine in case of duodenal or pyloric stenosis. They stress the usefulness of plain radiography of abdomen demonstrating the presence of characteristic gaseous formations in the subphrenic region.
Pneumoperitoneum (PP) is usually the result of perforation of the gastrointestinal (GI) tract with associated peritonitis. However, other rare causes, including spontaneous PP incidental to intrathoracic, intra-abdominal, gynecologic, and miscellaneous other origins not associated with a perforated GI tract have been described in the literature. Six cases of PP without any perforated GI tract are reported. Three patients with generalized peritonitis underwent exploratory laparotomy or laparoscopy when clinical examinations suggested an acute abdomen. At surgical procedure, perforated pyometra, perforated liver abscess and a ruptured necrotic lesion of a liver metastasis were documented in these patients, respectively. We also saw 3 PP patients not associated with peritonitis. Two patients with PP caused by pneumatosis cystoides intestinalis were encountered, 1 was managed conservatively and the other received diagnostic laparoscopy. A patient in whom pneumomediastinum and pneumoretroperitoneum were accompanied by PP caused by an alveolar rupture based on decreased pulmonary compliance due to malnutrition was managed conservatively. The history of the patient and knowledge of the less frequent causes of PP can possibly contribute towards refraining from exploratory laparotomy in the absence of peritonitis.
Eight cases of pneumatosis cystoides intestinalis (PCI) affecting the descending colon at first misdiagnosed in seven of them, are reported. The mechanism of cyst formation remains unclear but certain specific endoscopic and X-ray findings should help in differentiating PCI from other intramural tumors, i.e. polyposis. Diagnostic investigations and management approaches are described. No treatment is necessary in most instances because of the benign nature of PCI.
A case of pneumatosis cystoides intestinalis in the large bowel with complete resolution after eight weeks of metronidazole treatment is reported. This symptomatic case, with an acute onset classified as the primary (idiopathic) type, became asymptomatic after a few days and was followed until complete endoscopic and radiologic resolution. No recurrence was noticed during 15-month follow-up. This lends support to the assumption that anaerobic bacteria contribute to the etiopathogenesis of this condition. The choice of metronidazole as an easy ambulatory therapy is encouraged.
OBJECTIVE: We report the first patient to developed abdominal compartment syndrome (ACS) with intrahepatic portal venous gas (IHPVG) and pneumatosis cystoides intestinalis following emergency upper gastrointestinal endoscopy. CASE PRESENTATION: A 53-year-old man underwent an emergency upper gastrointestinal endoscopy for suspicion of upper gastrointestinal bleeding. The patient developed intra-abdominal hypertension and ACS associated with IHPVG after the endoscopy. Although the patient developed severe shock following ACS, he was managed conservatively and successfully recovered. CONCLUSIONS: An emergency upper gastrointestinal endoscopy may be associated with intra-abdominal hypertension and ACS. Our report provides an additional case of a survivor who required no surgical intervention for ACS and IHPVG following endoscopy.
Pneumatosis cystoides intestinalis (PCI), also called emphysema intestinalis or colitis cystica is a rare entity of unknown etiology. Characteristic signs can be found in endoscopy. We report the case of a 63 years old man in whom the misinterpretation of the colonoscopic signs resulted in resection of the ascending colon. After surgical therapy the patient is up to now asymptomatic with no signs of recurrence. Treatment of PCI is necessary only in symptomatic cases. The first choice of treatment is oxygen therapy in combination with metronidazole for six weeks. High recurrence rates are found with either oxygen treatment or antibiotic application alone. Surgical therapeutic intervention is recommended only in cases with serious complications. Limited resection of the affected part of the bowel should be carried out.
Pneumatosis cystoides intestinalis (PCI), a condition involving submucosal or subserosal gas-containing cysts of the wall of the gastrointestinal tract, is a rare entity. It is mostly diagnosed between the third and fifth decades of life without a clear sexual predominance. Different aetiopathogenetic factors are under discussion, the most probable being a bacteriologic cause (Clostridium perfringens) in combination with minimal leaks in the mucosal barrier. There are no pathognomonic symptoms; the clinical picture ranges from incidental findings to haematochezia. Diagnosis is based on plain abdominal film and X-ray following barium enema. Methods of treatment in symptomatic cases are oxygen and antibiotic (metronidazole) therapies and, in severe cases, resection of the diseased part of the intestine.
Evidence is presented that many of the enteric and systemic manifestations after jejunoileal bypass can be related to an inflammatory process within the bypassed small bowel rather than to the surgically induced sequelae of a short bowel syndrome with malabsorption. Invasion of the excluded segment by fecal flora was associated with a histologically demonstrable inflammatory response of the mucosa. The disorder was of variable severity and duration and occurred in the majority of 28 bypass patients. Progression to a clinical syndrome resembling an acute abdomen occurred in about 15% of the patients. Small bowel ileus and, in some patients, obstruction of the colon were suggested by physical signs and x-ray findings. Surgical exploration in such instances demonstrated an inflammaotry process of the excluded small bowel loops with severe distention of this segment and of the colon, but not organic obstruction. Pneumatosis cystoides intestinalis was a sequal in two patients. Exudative protein loss was documented in the severe cases. Most of the systemic sequelae are comparable to those seen with inflammatory diseases of the bowel such as Crohn's disease. Fever, excessive weight and lean tissue loss, and the involvement of skin, blood vessels, joints and possibly, the liver suggest an immune response as a common factor in the pathogenesis. The clinical improvement with antibiotics such as metronidazole or with restitution of normal bowel continuity indicates that the bacterial flora in the excluded small bowel segment or its byproducts are causally related to the systemic complications. Hyperoxaluria may be primarily the sequela of steatorrhea and not of the inflammatory process.
Pneumatosis cystoides intestinalis (PCI) is a rare entity in which gas is found in cysts located in the intestinal wall. PCI is a sign, not a disease; therefore, its relevance should be interpreted within the whole clinical context. PCI has been found in several distinctive clinical settings, which the authors review in the light of their 3 new cases. Morphologic and endoscopic examinations showed "polypoid" intraluminal formations corresponding to pneumocysts which should not be misdiagnosed with a diffuse polyposis. The most important tasks of the physician include: 1) recognition of the entity of PCI so that patients are not misdiagnosed and mismanaged as having malignancy or polyposis; and 2) differentiation of the benign noncomplicated cases from life-threatening forms (bowel necrosis, perforation, and infections), in which immediate surgery is necessary, and which are associated with high mortality.
Pneumoperitoneum often occurs after the perforation of the gastrointestinal tract. However, pneumoperitoneum without the perforation has been reported as one of the complications of collagen diseases, the cause of which is usually the rupture of pneumatosis cystoides intestinalis (PCI). PCI is sometimes observed in the patients with scleroderma and mixed connective tissue disease but rarely in the patients with systemic lupus erythematosus. We reported here a case of systemic lupus erythematosus developed the pneumoperitoneum without the perforation of gastrointestinal tract. A 51-year-old female who had been diagnosed as systemic lupus erythematosus and taken steroid for 12 years, visited our hospital because of general malaise. She had no abdominal symptoms but the roentgenographic examinations revealed the pneumoperitoneum. The laparotomy was performed and there were no findings of the perforation of the gastrointestinal tract. Because PCI is hardly recognized macroscopically after the rupture and the pneumoperitoneum due to PCI is often asymptomatic, we considered the cause of the pneumoperitoneum in this case was the rupture of PCI. The mechanisms of the formation of PCI in patients with collagen diseases were also discussed in this paper.
We have examined complications involving the defunctionalized bowel in 119 intestinal bypass patients. In this group, we found a 66% of incidence of bypass enteropathy. Pneumatosis cystoides intestinalis was present in three patients, severe blood loss in three, localized ulcerations in two, intermittent or chronic intussusception of the proximal jejunal stump in 10, and extensive stenosis relating to tight fibrous adhesions in one patient. The stenosis may become manifest as an obstructive process only after reconstitution of normal bowel continuity. Bacterial overgrowth in the bypassed small bowel was the primary cause for most of the lesions. A consistent diagnostic finding, suggesting disease in the excluded bowel, was ileal distention and the presence of gas-fluid levels on upright abdominal x-rays. Definitive diagnoses of ulceration, intussusception, and/or obstruction were sometimes possible only during laparotomy. Because the bypassed bowel cannot be examined with conventional techniques, these various abnormalities must be suspected when ill-defined abdominal complaints are observed in bypass patients. Metronidazole, to suppress anaerobic organisms, or suitable broad spectrum antibiotics can relieve the various lesions of the inflammatory process, whereas appropriate surgical procedures may be required for some of the chronic or recurrent complications.
We report a case of systemic sclerosis (SSc) complicated with benign pneumoperitoneum without apparent pneumatosis cystoides intestinalis (PCI). A 43-year-old woman was admitted to our hospital because of prominent abdominal distension in April 1997. Raynaud's phenomenon has been detected since 1991. She was suffering from recurrent diarrhea, constipation, and subileus. The diagnosis of SSc was made in 1996 based on the sclerosis in her face, forearms, and chest, and hypomotility of the esophagus. On admission, she presented no signs of peritoneal irritation. The laboratory data revealed that white blood cell count was 7,400/mm3 and C-reactive protein was 0.1 mg/dl. Chest and abdominal roentgenograms showed massive free air under the diaphragm, dilatation of small and large intestine, and air-fluid level. PCI was not apparent. Pneumoperitoneum was improved after four weeks with intravenous hyperalimentation. But she presented recurrent severe diarrhea and high fever whenever she tried to take food orally. Klebsiella pneumoniae was proved in her jejunal juice by bacteriologic examination. Intravenous prostaglandin F2 alpha and oral fosfomycin calcium intake made her condition better. Benign pneumoperitoneum without PCI is rarely reported in the patients with SSc. In her condition, weakness of intestinal wall, hypomotility of intestine, unusual bacterial overgrowth, and elevated intraluminal pressure made intraluminal gas go through the wall of the fragile intestine of SSc. As operation of intestine of SSc usually cause miserable outcome, pneumoperitoneum accompanied with SSc even if PCI is apparent or not must be treated with conventional manner while there is no signs of peritoneal irritation.