Clinical significance of pneumatosis intestinalis – correlation of MDCT-findings with treatment and outcome

Abstract

ObjectivesTo evaluate the clinical significance of pneumatosis intestinalis (PI) including the influence on treatment and outcome.Method and MaterialsTwo radiologists jointly reviewed MDCT-examinations of 149 consecutive emergency patients (53 women, mean age 64, range 21-95) with PI of the stomach (n = 4), small (n = 68) and/or large bowel (n = 96). PI extension, distribution and possibly associated porto-mesenteric venous gas (PMVG) were correlated with other MDCT-findings, risk factors, clinical management, laboratory, histopathology, final diagnosis and outcome.ResultsThe most frequent cause of PI was intestinal ischemia (n = 80,53.7 %), followed by infection (n = 18,12.1 %), obstructive (n = 12,8.1 %) and non-obstructive (n = 10,6.7 %) bowel dilatation, unknown aetiologies (n = 8,5.4 %), drugs (n = 8,5.4 %), inflammation (n = 7,4.7 %), and others (n = 6,4 %). Neither PI distribution nor extension significantly correlated with underlying ischemia. Overall mortality was 41.6 % (n = 62), mostly related to intestinal ischemia (p = 0.003). Associated PMVG significantly correlated with underlying ischemia (p = 0.009), as did the anatomical distribution of PMVG (p = 0.015). Decreased mural contrast-enhancement was the only other MDCT-feature significantly associated with ischemia (p p < 0.001). Elevated white blood count significantly correlated with ischemia (p = 0.03).ConclusionIn emergency patients, ischemia remains the most common aetiology of PI, showing the highest mortality. PI with associated PMVG is an alerting sign. PI together with decreased mural contrast-enhancement indicates underlying ischemia.Key Points• In emergency patients, PI may be caused by various disorders.• Intestinal ischemia remains the most common cause of PI in acute situations.• PI associated with decreased mural contrast-enhancement indicates acute intestinal ischemia.• PI associated with PMVG should alert the radiologist to possible underlying ischemia.

Pneumatosis Cystoides Intestinalis Secondary to Sunitinib Treatment for Gastrointestinal Stromal Tumor

“…In the present case, there was no indication for surgery because there were no signs of intestinal perforation, ischemia, or obstruction. It has been suggested that the WBC is significantly correlated with ischemia complicating PCI [4]. The WBC was within the normal range in the present patient.…”

Portograma aéreo y neumatosis intestinal como hallazgos incidentales en postoperatorio de cirugía abdominal

“…Causas no isquémicas: obstrucción intestinal, íleo paralítico, ulcera gástrica perforada, carcinomas (colon), trauma abdominal, descompresión hiperbárica, procesos inflamatorios intraabdominales (enfermedad de Crohn, colitis ulcerativa, apendicitis, diverticulitis, pancreatitis, ingestión de cáusticos), entidades infecciosas intraabdominales (colangitis, pileflebitis, abscesos, tuberculosis e infección por Clostridium difficile), enfermedades autoinmunes (esclerodermia, lupus eritematoso sistémico, dermatomiositis, sarcoidosis), procedimientos quirúrgicos abdominales y medicamentos (esteroides, quimioterapia, inhibidores de la α-glucosidasa). Causas iatrogénicas: procedimientos endoscópicos, colangiopancreatografía endoscópica retrograda, estudios baritados, sondas de nutrición enteral 2,4,5,7,8 .…”

“…La isquemia intestinal aguda, es la causa más importante de PA y/o NI, con peor pronóstico y mortalidades descritas hasta del 80-90% 3,5,7,8,9 . La probabilidad de isquemia intestinal aumenta significativamente cuando la NI se acompaña de aire en el sistema venoso portomesentérico 5 . La presencia de PA se consideraba previamente como signo de necrosis intestinal que justificaba la necesidad de cirugía urgente 8 .…”

“…La fisiopatología de estos hallazgos se considera multifactorial 5,12 . La disrupción de la integridad de la mucosa es una característica común a todas las teorías postuladas 5 . Se describen tres teorías: a) Bacteriana.…”

“…Propone que el principal mecanismo es la lesión de la mucosa intestinal, que permite la entrada de bacterias o aire a la pared intestinal y posteriormente entra al sistema venoso portal 2,4,5,7. La teoría de la lesión mucosa parece la mejor explicación para la NI asociada a inflamación, isquemia, uso de esteroides y antecedente de quimioterapia 2,5 .…”