Pneumatosis intestinalis caused by ischaemic bowel: report of three cases

Pneumatosis intestinalis is a rare condition in which gas is found in the bowel wall. It exists in a primary form or can be secondary to an underlying pathology. We present three cases of patients in whom pneumatosis intestinalis was caused by ischaemic bowel. In all three cases, the diagnosis was made using CT scan. A partial bowel resection with ileocolic anastomosis was performed in every case. All patients fully recovered after surgery.     

A rare case of segmental small bowel pneumatosis intestinalis: A case report

Introduction

Pneumatosis intestinalis is a rare condition affecting 0.03% of the population. It has a myriad of aetiological causes and hence presentation can vary immensely. The management of symptomatic pneumatosis intestinalis in an acute and outpatient setting remains a challenge to both physicians and surgeons.

Case presentation

We present a case of a 79 year old who presented in a gastroenterology outpatients department with a history suggestive of intermittent small bowel obstruction associated with abdominal pain aggravated by eating and posture. He was found to have signs suggestive of Marfan''s syndrome. Computed tomography demonstrated extensive pneumatosis intestinalis of the small bowel. Due to deterioration in symptoms, an exploratory laparotomy was performed demonstrating segmental small bowel pneumatosis intestinalis secondary to a hypermobile mesentery.

Conclusion

This case highlights the importance of both surgical and gastroenterology expertise in successfully managing symptomatic pneumatosis intestinalis.     

Benign pneumatosis intestinalis in the setting of celiac disease

Pneumatosis intestinalis is an uncommon finding that may indicate the presence of several alarming pathological conditions, including bowel ischemia, that require urgent surgical intervention. We report the case of a 51-year-old man with celiac disease who underwent resection of a large duodenal adenocarcinoma. Although he initially recovered rapidly from his procedure, he subsequently developed abdominal distention and leukocytosis. Abdominal imaging revealed extensive small bowel pneumatosis and pneumoperitoneum. Emergent surgical exploration revealed only bowel wall air cysts and dilated bowel but failed to demonstrate any intra-abdominal pathology. The patient recovered uneventfully and was discharged without any further complications or recurrence of symptoms. We review the current literature on the rare finding of pneumatosis intestinalis in the setting of celiac disease. In all reported cases, even when pneumatosis is accompanied by pneumoperitoneum, these alarming findings have proved to be of “benign” origin, that is with no evidence of bowel ischemia, perforation, or peritonitis. The available evidence suggests that pneumatosis in the setting of celiac disease may reflect the dissection of intraluminal gas into the inflamed bowel wall without accompanying intra-abdominal pathology. We conclude that pneumatosis intestinalis, even with accompanying pneumoperitoneum, does not uniformly mandate surgical exploration in patients with celiac disease.     

Pneumatosis cystoides intestinalis. Report of two cases involving the descending colon.

Two cases of pneumatosis cystoides intestinalis of the descending colon are described in which the presenting symptoms were abdominal pain and changed bowel habits, respectively. The diagnosis in both cases was established radiologically and sigmoidoscopically. Because the symptoms were persistent and severe, surgical excision of the involved segment of the large bowel was performed. The postoperative result was good and both patients remain free of symptoms.     

INTRA–OPERATIVE ENTEROSCOPY IN THE MANAGEMENT OF BLEEDING SMALL BOWEL LESIONS

This paper reviews the use of intra-operative enteroscopy at St Vincent's Hospital, Melbourne between 1982 and 1990 in the management of presumed small bowel bleeding. Intra-operative enteroscopy was found to be a moderately technically demanding procedure. The diagnostic yield in this small series of nine patients was 100%. When solitary small bowel lesions are identified, resultant directed therapy should prevent further bleeding. When multiple widespread angiodysplastic lesions are identified as occurred in three cases, the bleeding is difficult to cure.     

Portomesenteric venous gas in acute bowel ischemia: Report of a case

Portomesenteric venous gas and pneumatosis intestinalis (PI) are rare but important radiographic findings. They are usually discussed separately in the literature and little is known about the clinical importance of their combination in acute bowel ischemia. Abdominal computed tomography (CT) has proven useful for detecting subtle portomesenteric venous gas or PI in the early stages of acute bowel ischemia. Although the CT findings of either portomesenteric venous gas or PI as separate entities are not pathognomonic of bowel infarction, CT evidence of the combination of both these disorders is strongly associated with transmural bowel infarction, especially band-like pneumatosis. We report a case of portomesenteric venous gas combined with band-like pneumatosis, diagnosed based on CT evidence of both findings. We performed an emergency laparotomy for suspected acute bowel ischemia, which was confirmed by the operative findings.     

小肠扭转的发病机制及早期诊断探讨（附43例报道）

目的总结成人小肠扭转的病因、发病机制及早期诊断经验。方法对2009年10月至2012年10月期间摩洛哥赛达特省哈桑二世医院收治的43例小肠扭转患者的临床资料进行回顾性分析。结果本组43例小肠扭转患者中自发性小肠扭转11例,继发性小肠扭转32例,术后腹腔粘连为主要继发原因,有19例（59．4％）。临床表现：早期持续剧烈腹痛40例,频繁呕吐29例,肠型或腹部包块28例。43例小肠扭转均手术,其中22例术前B超确诊。术中见肠坏死16例。治愈37例,死亡6例。结论小肠扭转以继发性为主,术后腹腔粘连是小肠扭转的主要原因;小肠扭转与肠梗阻可互为因果;早期小肠扭转具有腹痛剧烈、呕吐早、症状体征不符等特点,早期诊断以临床为主,B超和CT具有辅助诊断价值;该病起病急,进展快,宜早期手术介入。     

Laparoscopically assisted subtotal colectomy for idiopathic pneumatosis cystoides intestinalis

Pneumatosis cystoides intestinalis (PCI) is a rare entity in which gas filled cysts are found within the intestinal wall. Conservative management and the treatment of underlying illnesses are recommended in most patients and surgery is usually indicated when acute and life-threatening complications such as bowel necrosis, perforation or peritonitis appear. The authors report a case of idiopathic pneumatosis cystoides intestinalis which, after repeated failure of conservative treatment including the oxygen therapy in hyperbaric chamber, was successfully treated by laparoscopic subtotal colectomy. A laparoscopically assisted approach proved to be a good indication in subtotal colectomy in cases of PCI that are non-responsive to standard conservative treatment.     

Laparoscopically Assisted Subtotal Colectomy for Idiopathic Pneumatosis Cystoides Intestinalis

Pneumatosis cystoides intestinalis (PCI) is a rare entity in which gas filled cysts are found within the intestinal wall. Conservative management and the treatment of underlying illnesses are recommended in most patients and surgery is usually indicated when acute and life-threatening complications such as bowel necrosis, perforation or peritonitis appear. The authors report a case of idiopathic pneumatosis cystoides intestinalis which, after repeated failure of conservative treatment including the oxygen therapy in hyperbaric chamber, was successfully treated by laparoscopic subtotal colectomy. A laparoscopically assisted approach proved to be a good indication in subtotal colectomy in cases of PCI that are non-responsive to standard conservative treatment.     

Small bowel tumours in emergency surgery: specificity of clinical presentation

BACKGROUND: Despite advances in diagnostic modalities, small bowel tumours are notoriously difficult to diagnose and are often advanced at the time of definitive treatment. These malignancies can cause insidious abdominal pain and weight loss, or create surgical emergencies including haemorrhage, obstruction or perforation. The aim of the present study was to describe the clinical presentation, diagnostic work-up, surgical therapy and short-term outcome of 34 patients with primary and secondary small bowel tumours submitted for surgical procedures in an emergency setting and to look for a correlation between clinical presentation and the type of tumours. METHODS: From 1995 to 2005, 34 consecutive surgical cases of small bowel tumours were treated at the Department of Emergency Surgery of St Orsola-Malpighi University Hospital, Bologna, Italy. Clinical and radiological charts of these patients were reviewed retrospectively from the department database. RESULTS: All patients presented as surgical emergencies: intestinal obstruction was the most common clinical presentation (15 cases), followed by perforation (11 cases) and gastrointestinal bleeding (eight cases). Lymphoma was the most frequent histologic type (nine patients), followed by stromal tumours (eight patients), carcinoids (seven patients), adenocarcinoma (seven patients) and metastasis (three patients). Of the nine patients with lymphoma, eight were perforated, all patients with stromal tumours had bleeding, and all carcinoids patients had bowel obstruction. There were two patients with melanoma metastasis, both had bowel intussusception. Resection of the neoplasm was carried out in 32 patients and two patients were deemed unresectable and received a palliative procedure. CONCLUSIONS: The present study shows that there is a correlation between small bowel tumours and clinical emergency presentation: gastrointestinal stromal tumours (GIST) mostly bleed; carcinoids make an obstruction; lymphomas cause a perforation; and melanoma metastasis causes intussusception.     

Pneumatosis cystoides intestinalis: an unusual complication of jejunoileal bypass.

A case of pneumatosis cytoides intestinalis associated with jejunoileal bypass is reported. The association of increased colonic gas, secondary to fermentation of undigested lactose in the colon, and the reflux of the excessive gas into the excluded segment of small bowel and dissection of the gas into the bowel wall and mesentery are postulated as the causes of pneumatosis cystoides intestinalis in patients with jejunoileal bypass.     

Pneumatosis intestinalis and hepatic portal venous gas

We report two cases of pneumatosis intestinalis and hepatic portal venous gas. The first case was in a 67-year-old woman who complained of strong right lower abdominal pain and high fever on the twelfth day after pancreatoduodenectomy (PD) with portal vein (PV) resection. Abdominal X-ray and computed tomography showed hepatic portal venous gas and pneumatosis intestinalis. The emergency laparotomy performed disclosed extensive necrosis of the bowel from the jejunum to the ascending colon. All necrotic parts of the bowel were resected and a jejunostomy was performed. The residual intact small intestine was 30 cm in length. Her postoperative course was stable. This is a rare complication after PD and cannot be cured by any other treatment but surgery. The second case was in a 45-year-old woman with the chief complaint of abdominal pain and constipation. She had a past history of chronic toluene inhalation. Abdominal X-ray and computed tomography also showed hepatic portal venous gas and pneumatosis intestinalis, as well as free air, but no physical examination or laboratory test results supported a diagnosis of bowel necrosis. Hyperbaric oxygen (HBO) therapy effectively controlled the symptoms and signs.     

LAPAROSCOPIC MANAGEMENT OF ACUTE SMALL BOWEL OBSTRUCTION

Acute small bowel obstruction is commonly due to band adhesions.¹ In the past it has had an overall mortality rate of up to 11 % for elderly patients.¹ In this paper we report three cases of small bowel obstruction, treated by laparoscopic division of the causative bands. All patients recovered rapidly and were discharged within 5 days of surgery.     

Hepatic portal gas in adults: review of the literature and presentation of a consecutive series of 11 cases

BACKGROUND: Hepatic portal venous gas (HPVG) in adults is a rare entity. The underlying pathologic condition is usually an intestinal ischemia, but it has been reported in association with a variety of conditions. HYPOTHESIS: Miscomprehension of the underlying pathologic conditions has led to some confusion in the literature concerning its etiology, diagnostic methods, and clinical consequences. SETTING: Centre Hospitalier et Universitaire Vaudois, Lausanne, Switzerland, and District Hospital of Morges, Morges, Switzerland. METHOD: Between February 1, 1995, and May 30, 2000, eleven cases of HPVG were treated. These cases were retrospectively reviewed, together with a review of the literature to define the clinical significance of HPVG, the role of the computed tomographic scan, and the necessity of performing systematic emergency exploratory surgery. RESULTS: Two groups have to be distinguished-those who have HPVG with associated pneumatosis intestinalis and those who have HPVG without associated pneumatosis intestinalis. When associated with pneumatosis intestinalis, the cause is usually an intestinal ischemia and in a symptomatic patient it justifies systematic exploratory surgery. An abdominal computed tomographic scan including lung window settings to better identify air in the bowel wall will distinguish between these 2 groups. Pneumatosis intestinalis and HPVG due to bowel ischemia do not allow prediction of the severity of bowel wall damage. CONCLUSIONS: The cause of HPVG without pneumatosis intestinalis is variable. Good knowledge of the possible causes combined with the clinical picture and the abdominal computed tomographic scan is required to correctly identify the underlying cause of HPVG and to avoid unnecessary surgery.     

The obturator hernia: Difficult to diagnose,easy to repair

Background The aim of this paper is to present a simple method for obturator hernia repair in two cases with strangulated obturator hernia.Methods The authors report on two cases of mechanical bowel obstruction due to incarcerated obturator hernia in elderly, thin women. Both patients presented with clinical and radiological signs of small bowel obstruction. Neither of them had the Howship-Romberg or Hannington-Kiff sign.Results At laparotomy, incarcerated small bowel in a right-sided obturator hernia was observed in both patients. The small bowel was not necrotic, and no bowel resection was performed. The hernial defect was closed in two layers with interrupted and purse-string nonabsorbable sutures.Conclusions Obturator hernia is rare and difficult to diagnose. Often the diagnosis is reached only at laparotomy for small bowel obstruction. The double-layer repair with interrupted and purse-string nonabsorbable sutures could be useful, especially in emergency laparotomies for incarcerated obturator hernia.     

大肠一期吻合术与肠道准备的关系

目的:通过比较大肠手术前肠道准备的不同,探讨大肠手术前肠道准备与术后并发症之间的关系。方法:总结40例大肠一期切除吻合病例,其中12例行传统肠道准备,20例行全肠道灌洗,8例行部分传统肠道准备加结肠水疗。结果:全组无1例术后腹腔及切口感染,术后吻合口瘘1例。结论:大肠手术各种术前肠道准备与术后并发症无明显相关,术中严格操作,围手术期合理应用抗生素是关键。     

Preoperative evaluation by magnetic resonance imaging in patients with bowel obstruction

BACKGROUND: Bowel obstruction is a problematic condition because the main clinical issue is to determine whether emergency laparotomy or observation with a long tube is required. The recent development of imaging diagnostic modalities such as magnetic resonance imaging (MRI) is thought to be promising to support therapeutic decisions in patients with bowel obstruction. METHODS: Twenty-seven patients with bowel obstruction who underwent laparotomy were evaluated by plain x-ray film, computed tomography (CT) scan, and MRI preoperatively with regard to the presence or absence of bowel obstruction, and the site and cause of bowel obstruction. Diagnostic accuracies were compared among these radiological modalities. RESULTS: The presence of bowel obstruction was detected in 22 (81.5%) of 27 patients by plain abdominal x-ray film, in 24 (92.3%) of 26 patients by CT scan, and in 25 (92.6%) of 27 patients by MRI. The sites of obstruction were consistent with surgical findings in 25 (92.6%) of 27 patients by MRI, and in 15 (57.7%) of 26 patients by CT scan. The causes of bowel obstruction were accurately diagnosed by MRI in 25 (92.6%) of 27 patients, and in 23 (88.5%) of 26 patients by CT scan. CONCLUSIONS: MRI could identify the presence and the site and cause of bowel obstruction in most of the cases. MRI is assumed to be superior to CT scan in the preoperative diagnosis of bowel obstruction.     

Systematic review of small bowel diaphragm disease requiring surgery

Aim To perform a systematic review of all cases of small bowel diaphragm disease requiring surgery. Small bowel diaphragm disease is a rare complication of small bowel enteropathy secondary to the use of non‐steroidal anti‐inflammatory drugs (NSAIDs). The objective was to determine the presenting symptoms, duration of NSAID use, mode of diagnosis and type of surgery associated with cases of small bowel diaphragm disease requiring surgery. Method A comprehensive search of the world literature between January 1980 and December 2010 was undertaken. The search terms ‘diaphragm disease’ and ‘mucosal diaphragm disease’ in combination with the terms ‘surgery’, ‘intestine’ or ‘small bowel’ were used. All cases of small bowel diaphragm disease requiring surgery in adult patients within the the last 30 years were included. Data including age, gender, mode of presentation, NSAID use, mode of diagnosis, form of surgery, affected area of small bowel and mortality were recorded and analysed. Results There were 55 cases of small bowel diaphragm disease requiring surgery (31F:18M) with a median age of 69 years. NSAID use occurred in 44 cases and the mean duration of NSAID use was 7 years. The most common presentation was with anaemia in combination with obstructive symptoms. The diagnosis was established by a laparotomy in 51% of cases followed by capsule endoscopy in 25% of cases. Operations performed included small bowel resection (56), combined resection and strictureplasty (three), strictureplasty (one) and hemicolectomy (two). There was only one death. Conclusion Small bowel diaphragm disease presenting as a surgical emergency is likely to become more common due to the increased use of NSAIDs. A history of NSAID use in patients with iron deficiency anaemia or obstructive symptoms should lead to a high index of suspicion for this condition and should be preoperatively investigated.     

Laparoscopic management of acute small bowel obstruction

Background As minimally invasive surgery gains ground, it is entering realms previously considered to be relative contraindications for laparoscopy. We reviewed our experience with the laparoscopic approach to the management of small bowel obstruction (SBO).Methods From December 1997 to November 2002, 65 patients underwent laparoscopic treatment for SBO. The operating surgeon attempted to identify a transitional point between distended and collapsed bowel and then address the obstruction at that point.Results Postoperative adhesions were the cause of the obstruction in 44 patients. Tumor was identified in five cases, hernia in four, bezoar in three, intussusception in three, acute appendicitis and pseudoobstruction in two cases each, and terminal ileitis in one case. The diagnostic accuracy of laparoscopy was 96.9%. Thirty-four patients (52%) were treated by laparoscopy alone. Thirteen patients (20%) required a small target incision for segmental resection. Eighteen operations were converted to formal laparotomy. The mean laparoscopy time was 40 min (range, 25-160). Patients resumed oral intake in 1-3 days. The complication rate was 6.4%. There were two deaths, but none related to laparoscopy. The mean hospital stay was 4.2 days.Conclusions Laparoscopy is a useful minimally invasive technique for the management of acute SBO. It is an excellent diagnostic tool and, in most cases, a therapeutic surgical approach in patients with SBO. However, a significant number of patients will require conversion.Presented in part at the 10th annual congress of the European Association for Endoscopic Surgery (EAES), Lisbon, Portugal, 2-5 June, 2002     

Laparoscopic adhesiolysis in acute small bowel obstruction: a preliminary experience.

OBJECTIVE: The aim of this study is to evaluate laparoscopy as another tool for management of cases of adhesive acute small bowel obstruction. METHODS: Fourteen patients suffering from suspected adhesive small bowel obstruction were explored laparoscopically over a period of 24 months. The Veress needle was inserted either in a virgin part of the abdomen away from previous scars or under direct vision using an open technique. Careful inspection of the entire abdomen was done, and the small bowel was "run" in a retrograde fashion starting at the cecum. The point of obstruction was localized and adhesiolysis was performed, thus resolving the problem. RESULTS: Laparoscopic exploration was able to determine the site and cause of obstruction precisely in all 14 cases, with resolution of the problem laparoscopically in 12 patients (85.7%). Two cases were converted to open surgery (14.3%). There were no mortalities and low morbidity (7.1%). The mean hospital stay was 3.7 days. CONCLUSION: Laparoscopic surgery can be an advantageous alternative to open surgery in acute small bowel obstruction, thus providing a new technique for its diagnosis and treatment with all the advantages of minimally invasive surgery.