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PubMed1991

Differences in the clinical and radiologic patterns of rotavirus and non-rotavirus necrotizing enterocolitis.

We analyzed retrospectively 32 successive infants who developed necrotizing enterocolitis (NEC), 13 with rotavirus (RV) infection (RV+) and 19 RV-negative (RV-). All patients showed at least pneumatosis intestinalis. All patients except one had risk factors for perinatal asphyxia. Our study demonstrated significant differences between RV+ NEC and RV- NEC cases: RV+ NEC infants had a higher birth weight and were born at a later gestational age. Oral feeding was started earlier and symptoms developed later and more insidiously in RV+ patients than in RV- NEC babies. Radiology revealed a less severe and more distal colon involvement in RV+ NEC infants, whereas the RV- NEC patients mostly had small intestinal or ileocecal changes and more frequent complications of pneumoportogram and intestinal perforations. These latter infants often had a rapidly deteriorating clinical course; 84% needed surgical treatment. In conclusion RV may be a cause of NEC in susceptible infants. Historic and clinical data and a more distal colonic pneumatosis allow a differentiation of RV+ NEC from other forms of NEC.

Anti-Bacterial Agents↗
PubMed1976

Changing clinical and roentgenographic patterns of necrotizing enterocolitis.

Necrotizing enterocolitis (NEC) occasionally deviates from the classical presentation of the disease. Small bowel dilatation and pneumatosis are frequently present prior to the actual onset of the clinical presentation. Pneumatosis intestinalis, an important diagnostic sign of NEC, is quite variable; it may be present, persist, worsen, or disappear; or at times it may not be present at all. A severe complication of necrotizing enterocolitis is perforation which in 50 percent of the cases presented without obvious free intra-abdominal air. Accumulation of fluid in the abdomen is stressed as strong evidence for perforation and a strong indication for surgery. The varying features indicate that NEC has a clinical spectrum that extends from benign to severe, and recognition of all these variations will lead to better diagnosis and to a better understanding of the disease. The clinical and roentgenologic variations make classification difficult but the variety most likely represents the combination of a great number of susceptible children and a greater recognition of the disease.

Air↗
PubMed2003

Acute colonic pseudo-obstruction (Ogilvie's-syndrome) and pneumatosis intestinalis in a kidney recipient patient.

Acute colonic pseudo-obstruction (Ogilvie's syndrome) is a clinical entity characterized by massive nontoxic dilatation of the colon in the absence of mechanical obstruction and is associated with increased morbidity and mortality in the immunosuppressed patient. We present a case of a kidney transplant recipient developing a life-threatening condition with acute colonic pseudo-obstruction associated with radiologic findings of a linear pneumatosis intestinalis (PI). Urgent laparotomy and resection of the dilated cecum, colon ascendens and transversum was performed because of bowel necrosis with multiple serosal defects. Stool cultures and special stains for microorganisms were all negative, and there was no evidence for viral or fungal infection. The patient was discharged 31 days after transplantation with normal renal function. In conclusion, this steroid-induced ileus (pseudo-obstruction) is a potentially malignant early form of colonic dysmotility rarely reported in transplant recipients. Awareness and early recognition of the condition are critical for a successful outcome. Colonoscopic decompression can achieve reversal of colonic dilatation in most cases, but in some patients prophylactic laparotomy is indicated for prevention of the catastrophic consequences of perforation.

Adrenal Cortex Hormones↗
PubMed2005

Pneumatosis intestinalis and hepatic portal venous gas after CPR.

Pneumatosis intestinalis and hepatic portal venous gas are usually associated with severe intra-abdominal pathologies. As diagnostic technologies advanced, a number of variant etiologies have been identified. We report 2 cases in which pneumatosis intestinalis and hepatic portal venous gas developed after prolonged cardiopulmonary resuscitation (CPR). The pathogenic mechanism was most probably bowel infarction caused by poor mesenteric perfusion during and after CPR. Limited cardiac output during prolonged resuscitation and severe vasoconstriction after large doses of epinephrine and vasopressors might both contribute to the compromised mesenteric perfusion. The risk seems especially high for old patients with severe atherosclerosis. Once it happens, the prognosis is extremely poor. In patients of cardiac arrests receiving prolonged CPR, catastrophic complications like this should be considered in the postresuscitation phase, especially those with multiple risk factors like old age, severe atherosclerosis, and use of large doses of vasoconstrictors.

Aged↗
PubMed2005

Hepatic portal venous gas.

BACKGROUND: Hepatic portal venous gas is an unusual entity associated with a variety of abdominal catastrophes. There is usually a grave prognosis when hepatic portal venous gas is associated with ischemic bowel disease. We reported a 57-year-old man with hepatic portal venous gas associated with extensive infarction of the jejunum and a concomitant perforation at a site in the terminal ileum leading to two operations performed 24 hours apart. Progressive ischemia and infarction after the initial laparotomy resulted in massive resection of the small bowel. METHODS: A follow-up abdominal radiography showed progressive dilatation of the small intestine and thickening of the bowel wall. Computed tomography of the abdomen showed pneumatosis intestinalis and gas collection within the intrahepatic and extrahepatic portal vein and superior mesenteric vein and free gas in the peritoneal cavity. RESULTS: At surgery, a long segment of ischemic change of the jejunum with focal necrosis and one perforation in the terminal ileum with no relation to the ischemic area was discovered. These two areas were resected respectively, and anastomosis was performed. Extensive necrosis of the residual bowel was found on the second-look operation performed 24 hours later, and subsequent resection of involved bowel was performed, resulting in a short-bowel condition. CONCLUSIONS: When hepatic portal venous gas associated with ischemic bowel disease is encountered, coexistence of other abdominal condition with no relation to ischemic segment should be considered.

Emergency Treatment↗
PubMed2001

Pneumatosis intestinalis following cytotoxic or immunosuppressive treatment.

Pneumatosis intestinalis (PI) is an uncommon condition characterized by the presence of gas within the bowel wall. We describe 5 cases of PI that occurred after cytotoxic or immunosuppressive treatment for hematological disorders. All patients were neutropenic shortly before or at the time of diagnosis of PI, but did not show specific symptoms. The diagnosis was made by conventional X-ray and confirmed by abdominal computed tomography. Since there were no signs of secondary complications such as peritonitis, ischemia, or perforation, conservative treatment with broad-spectrum antibiotics and parenteral nutrition was initiated. All patients but 1 achieved complete resolution of PI after recovery from myelosuppression. Benign pneumoperitoneum due to PI should be considered in the differential diagnosis of free intra-abdominal air after chemotherapeutic or immunosuppressive therapy. It can be managed successfully by conservative treatment in the absence of secondary complications, if there is recovery of myelopoiesis.

Adult↗
PubMed1993

[Pneumatosis intestinalis--histology, immunocytochemistry and new theory of morphogenesis].

Based on the light microscopical and immunocytochemical findings in two cases of pneumatosis intestinalis, a new theory is advanced on the morphogenesis of the cysts that can be observed in this disease. The cavities identifiable in both cases in the submucosa of the small intestine and of the colon, respectively, were partially lined by histiocytes and foreign-body giant cells. Most of the lumina found in the subserosa of the stomach, small intestine and colon had an identical aspect. In addition, there were numerous true cysts here with a narrow, single-layered cells seam, showing the immunocytochemical characteristics of the mesothelium, but not the capillary endothelia. Thus, contrary to previous assumptions, pneumatosis interstinalis apparently does not develop from cystic dilatation of gas-filled lymph vessels that shrink and disappear in the process of an inflammatory foreign body reaction. Rather, the disease initially seems to manifest itself through gas-filled pseudocysts partially bordered by histiocytes and foreign-body giant cells, which become secondarily mesothelialized in the subserosa. Lymph vessels would thus not have significance for the morphogenesis of this disease.

Aged↗
PubMedDate not supplied

[Intestinal pneumatosis in pediatrics. Report of 72 cases].

We analyzed 72 cases of pneumatosis intestinalis at the Hospital Infantil de México during a 32 years period. We found the higehst incidence in children under 6 months of age. In the new-born period, the entity is associated with necrotizing entrocolitis and in the older children group, this alteration is associated with gastroenteritis. The diagnosis was made by radiology in 93% of the cases and in 7%, it was made at the surgical event. We propose 3 mechanisms in the pathophysiology of the entity having all of them disruption of the integrity of the intestinal mucosa and higher pressure of the intraluminal gas. The mortality rate was high because we included cases from the initiation of the hospital's activities (1943). The conclusion is: 1) The prognosis is based on an early diagnosis. 2) It is imperative to take proper care of the complication. 3) It is also very important to give a rest for variable period of time to the injured intestine with parenteral feeding and eventually, elemental feeding.

Age Factors↗
PubMed1989

Factors associated with age of onset of necrotizing enterocolitis.

To investigate factors associated with risk and age of onset for necrotizing enterocolitis (NEC), a retrospective case-control review was performed of patients with NEC and control infants matched for birthweight and date of admission. NEC cases were defined by Bell staging criteria and were included if pneumatosis intestinalis, histologic confirmation, or a recognized complication of NEC was identified in association with clinical signs and symptoms. NEC was significantly related to birthweight and premature post-conceptional age. In contrast to control infants, patients with NEC had higher 5 minute Apgar scores, less significant respiratory disease, and more rapid feeding practices. Two distinct subgroups of patients with NEC based on postnatal age of onset were apparent. Patients with early onset NEC (21 days or less postnatal age) had less significant respiratory disease and were fed more rapidly than late onset patients. Late onset NEC (more than 21 days postnatal age) occurred frequently in convalescing, relatively well premature infants who were still, however, of preterm postconceptional age. Relatively well premature infants with minimal respiratory disease are still at risk for NEC. Advances in neonatal care and survival of very low birthweight infants may account for a shift in prevalence to older infants who are yet of preterm postconceptional age.

Age Factors↗
PubMed1990

Pneumatosis intestinalis. Surgical management and clinical outcome.

Pneumatosis intestinalis (PI) occurs in a wide variety of patients, some of whom require urgent surgery, while others can be observed with resolution of symptoms and radiographic findings. During 1 year, 27 patients with PI were prospectively evaluated for clinical, laboratory, and radiographic features that would be useful in predicting the need for surgery, the pathologic findings, and patient outcome. Sixteen of the twenty-seven patients underwent laparotomy, with only one negative exploration. Of the 11 patients not explored, there were two deaths in moribund patients. Seven of nine patients with jejunostomy tubes, recent gastrointestinal anastomoses, inflammatory bowel disease, lactulose therapy, or chemotherapy who did not have clinical evidence of an acute surgical abdomen or metabolic acidosis survived without surgery (two deaths unrelated to the gastrointestinal tract). Patients presenting with bowel obstruction and PI required surgery in seven of nine cases, did not have necrotic bowel, and had 11% mortality. Eight patients with ischemic bowel had a 75% mortality rate, despite surgery. Patients with PI and clinical evidence of bowel obstruction or ischemia usually require urgent surgery, while asymptomatic patients without metabolic acidosis can be safely observed.

Female↗
PubMed1987

Pneumatosis intestinalis in children after allogeneic bone marrow transplantation.

Four children, ages 3 to 8 years, developed pneumatosis intestinalis (PI) after allogeneic bone marrow transplantation (BMT) for acute leukemia or severe aplastic anemia. PI was detected at a median of 48 days (range, 10-63 days) after BMT and was associated with abdominal symptoms and clinical signs. All patients had severe systemic and/or high-grade cutaneous acute graft-versus-host disease (AGVHD) at some time after BMT and were receiving corticosteroids at the time of development of PI; however, PI was associated with concomitant severe AGVHD in only one patient. One patient with PI had Hafnia alvei bacteremia and another patient had gastroenteritis due to rotavirus and adenovirus. All patients were treated with supportive care and systemic broad-spectrum antibiotics, and PI resolved 2-16 days after onset. Two patients died with BMT-associated complications unrelated to PI. Multiple factors contribute to the development of PI after BMT, and the prognosis for recovery from PI is good with medical management alone. Overall survival in these patients is dependent on the frequency and severity of other conditions, such as AGVHD and opportunistic infections, after BMT.

Acute Disease↗
PubMed2004

Serum lactic acid determines the outcomes of CT diagnosis of pneumatosis of the gastrointestinal tract.

Computed tomography (CT) diagnosis of pneumatosis involving the gastrointestinal tract can represent a broad range of clinical entities from a benign process to ischemic bowel. The purpose of this study is to define the significance and outcome of pneumatosis intestinalis (PI). All CT scans from 5/93 to 12/01 with the finding of PI were reviewed. Eighty-six CT scans had the finding of PI, with the colon being the most frequent location (51%), followed by small bowel (36%) and gastric (9%). Forty per cent of patients underwent surgery, with an overall mortality rate of 42 per cent and a surgical mortality rate of 47 per cent. Univariate analysis demonstrated significant correlation between serum lactic acid (LA) > 2.0 mmol/L [odds ratio (OR) = 23.4; 95% confidence interval (C.I.), 7.21-75.92] and serum creatinine > 1.5 mg/dL (OR = 3.05; 95% C.I., 1.25-7.42) with mortality. Age was suggestive but not a significant risk factor for mortality (P = 0.09). Multivariate analysis found serum LA > 2.0 (OR = 30.37; 95% C.I., 7.31-126.2) to be the only significant predictor of mortality. CT diagnosis of PI is associated with significant in-hospital mortality, especially in the elderly. Serum LA level > 2.0 mmol/L at time of diagnosis is associated with a greater than 80 per cent mortality. Surgical consultation is necessary to determine which patients need urgent surgical intervention.

Adolescent↗
PubMed1992

Recurrent pneumatosis intestinalis in young infants.

In 67 infants with necrotizing enterocolitis (NEC) at Children's Hospital of Michigan from 1987-1990, three had recurrent pneumatosis intestinalis (PI) after the neonatal period and after hospital discharge. All three infants were premature (26-34 weeks), and one had an additional risk factor of gastroschisis. All three had their initial episode of NEC within the first month of life. Two had bowel resections, and one was treated medically. 15 h to seven months after discharge from the hospital, all three infants developed recurrent PI at ages ranging from 2.5 to 9 months. Two of the infants had free intraperitoneal air. Though all three infants had PI, only one had true recurrent NEC with ischemic bowel and died. This baby was the only one with rotazyme positive stools. The second infant, who had surgery for gastroschisis, had incomplete obstruction secondary to adhesions resulting in PI. Since surgery this infant has thrived. The third infant had extensive PI of the colon with free air. At surgery there was no evidence of bowel perforation. The free air was attributed to rupture of one of the many colonic cysts of PI. Subsequently, the child has done well. Recurrent PI in infants who have had NEC is unusual and the causes are varied. Because more neonates are surviving NEC, the pediatric radiologist needs to be aware of this delayed complication.

Age Factors↗
PubMed1975

Necrotizing enterocolitis in the newborn: operative indications.

Fifty-two premature, low birth weight infants presented mainly in the first week of life with sudden manifestations of intestinal ileus and an x-ray picture of pneumatosis intestinalis. Twenty-two of 32 patients treated with gastric decompression, antibiotics, intensive supportive therapy and intravenous hyperalimentation survived. Twenty other patients had progression of their disease and required operation. Twelve of these patients survived. Review of this material indicated that some medically treated patients might have survived if they had been operated upon. Indications for operation included free perforation and clinical signs of deterioration. Abdominal physical findings and x-rays were not reliable except as signs of far advanced pathology. Confirmation of ascites by paracentesis and gram stain of fluid was helpful when present. If patients were adequately treated and then developed sudden hyponatremia or progressive acidosis, they invariably had gangrenous bowel and required operation. The most striking finding was that a sudden, profound drop in the platelet count to levels below 100,000 reliably predicted the presence of gangrenous bowel and the need for operation. Other clotting studies indicated that disseminated intravascular coagulation is an important accompaniment of NNE with the complication of bowel gangrene prior to perforation. Gastrostomy and resection of involved bowel with staged anastomosis proved to be the most successful form of surgical management. Overall suvival was 66 per cent.

Blood Cell Count↗
PubMed1995

Pneumatosis intestinalis: a review.

Pneumatosis intestinalis (PI) is an uncommon but important condition in which gas is found in a linear or cystic form in the submucosa or subserosa of the bowel wall. PI is a sign, not a disease; therefore, its relevance should be interpreted within the whole clinical context. PI has been found in several distinctive clinical settings: 1) in premature infants with necrotizing enterocolitis; 2) in adults with obstructive pulmonary disease; 3) in adults and children with a wide variety of associated conditions, including pyloric stenosis, jejunoileal bypass, progressive systemic sclerosis, transplantation, ischemic bowel, and drug therapy, particularly steroids, chemotherapy, and immunosuppression; 4) in adults as a primary benign problem; and 5) as an incidental finding in endoscopic mucosal biopsies. The two most important tasks of the physician include: 1) recognition of the entity of PI so that patients are not misdiagnosed and mismanaged as having malignancy or polyposis; and 2) differentiation of the benign variety, in which no intervention is indicated, from the life-threatening form, in which immediate surgery is necessary. Once life-threatening illnesses such as bowel necrosis, perforation, and infections are excluded, patients symptomatic from the cysts per se may be treated with oxygen and/or antibiotics. Because the reports of treatment of PI are at best anecdotal, the decision to treat and the treatment chosen should be carefully balanced with the risks.

Humans↗
PubMed2005

[Pneumatosis intestinalis in 9 children with an oncologic disease].

OBJECTIVE: To acquire knowledge regarding the rare condition pneumatosis intestinalis (PI) in children treated for malignant disease. DESIGN: Retrospective. METHOD: In 1998-1999 PI was diagnosed in 9 of the 140 children with malignant disease in the department of Paediatric Oncology of the UMC St Radboud, Nijmegen, the Netherlands. By examination of the records of these 9 children, data were collected on the symptomatology, diagnostics, treatment and prognosis of PI. RESULTS: The 9 children included 7 boys and 2 girls, varying in age from 2 to 12 years. In 7 patients the underlying disease was acute lymphocytic leukaemia and in 2 it was a stage IV neuroblastoma. The presenting symptoms were nonspecific and included: a distended abdomen, abdominal pain, diarrhoea and constipation. In all children, PI was located in the colon. Supplemental blood and microbiological analysis did not reveal any typical abnormalities. 8 children were treated with lactitol because of constipation. A laparotomy was performed in the first patient, while the other 8 were treated with gastric suctioning, parenteral nutrition and antibiotics. All 9 children recovered within a few weeks. CONCLUSION: With supportive care, PI in children with malignant disease is mostly a self-limiting condition. A pneumoperitoneum in PI is no indication for surgery, except in the presence of an acute abdomen. Chemotherapy can be continued.

Antineoplastic Agents↗
PubMed2002

Conservative management of pneumatosis intestinalis and pneumoperitoneum following bone-marrow transplantation.

Pneumatosis intestinalis (PI), with or without pneumoperitoneum (PP), may complicate allogenic bone-marrow transplantation (BMT). The aim of our study was to establish the incidence and outcome of this complication following BMT in children. A departmental database was used to identify children who underwent BMT in the 4-year period up to December 1999. The medical records of children who developed PI with or without PP were obtained for further study. All patients were managed without recourse to surgery. Conservative management included 7 days of intravenous antibiotics and 10 days of intestinal rest supported by parenteral nutrition. In the study period, 138 BMTs were carried out. Six children (4%) with a total of 7 episodes of PI/PP were identified, 1 boy and 5 girls with a median age of 8.5 years (range 0.8-11). Neutropenia was noted in 3 children at the time of presentation. Other risk factors identified included alternative BMT donors (5/6), steroid therapy (6/7), and graft-versus-host disease (5/6). Organisms were isolated from stool cultures sent at the time of diagnosis in 3 out of 7 instances. Diarrhoea was the predominant presenting symptom. All patients recovered from the acute episode, but 5 died at a mean of 12 months from the development of PI/PP (range 6-17 months). This mortality of 83% compares with a mortality of 33% (43 of 132) for the remainder of children who underwent BMT during the study period. Thus, while initial recovery can be anticipated, the medium-term mortality in this group of children is high.

Anti-Bacterial Agents↗
PubMed1989

Pneumatosis intestinalis in children beyond the neonatal period.

Pneumatosis intestinalis (PI) is a well-recognized manifestation of necrotizing enterocolitis (NEC) in the newborn--a condition that often requires surgical intervention for infarcted bowel. However, little information is available concerning PI in older children or its management. Sixteen older infants and children (greater than 2 months) had x-ray findings of PI (intramural air). There were eight girls and eight boys ranging in age from 2 months to 8 years. Associated conditions included short bowel syndrome (SBS) (8), congenital heart disease (2), iron ingestion (1), nesidioblastosis (1), hemolytic anemia (1), rheumatoid arthritis (1), bronchopulmonary dysplasia (BPD) (1), and malrotation (1). Clinical presentation included abdominal distension (13), bloody diarrhea (12), bilious emesis (5), and lethargy (5). Two patients on steroids had unsuspected PI identified as an incidental operative finding during pancreatectomy for nesidioblastosis (1) and splenectomy for hemolytic anemia (1), respectively. Only four other children (iron toxicity, postcardiac catheterization, rheumatoid arthritis, and BPD required surgical intervention. Each manifested peritioneal irritation, acidosis, and hypotension or had pneumoperitoneum on abdominal x-ray. In ten of 14 patients, PI was managed nonoperatively with nasogastric suction, fluid resuscitation, intravenous (IV) antibiotics (seven to ten days), and repeated abdominal x-ray and physical examinations. Children with SBS comprised 50% of the total number of patients and eight of ten treated by observation. All had associated viral syndromes (rotavirus) or rhotozyme-positive stools and developed bloody diarrhea. There were two deaths (12.5%) in patients with iron toxicity and congenital heart disease who required resection of gangrenous bowel. All of the other patients survived.(ABSTRACT TRUNCATED AT 250 WORDS)

Age Factors↗