Diagnostic laparoscopy for pneumatosis intestinalis

    Diagnostic laparoscopy for pneumatosis intestinalis. To do or not to do? T. Karabuga, O. Yoldas, I. Ozsan, U.M. Yıldırım, U. Aydin PII: DOI: Reference:

S0735-6757(14)00308-8 doi: 10.1016/j.ajem.2014.04.042 YAJEM 54272

To appear in:

American Journal of Emergency Medicine

Received date: Accepted date:

13 April 2014 18 April 2014

Please cite this article as: Karabuga T, Yoldas O, Ozsan I, Yıldırım UM, Aydin U, Diagnostic laparoscopy for pneumatosis intestinalis. To do or not to do?, American Journal of Emergency Medicine (2014), doi: 10.1016/j.ajem.2014.04.042

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ACCEPTED MANUSCRIPT Diagnostic laparoscopy for pneumatosis intestinalis.

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To do or not to do? Karabuga T1, Yoldas O1, Ozsan I1, Yıldırım UM2, Aydin U1.

1.İzmir University, Faculty of Medicine, Department of General Surgery

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2.İzmir University, Faculty of Medicine, Department of Radiology

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Running Title: Surgery for pneumatosis intestinalis

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Key Words: Pneumatosis intestinalis, laparoscopy, lymphoma

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Corresponding Author: Unal Aydın E-mail: [email protected] Tel

: +90 505 210 3413

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Adress: Yeni Girne Bulvarı 1825 sk. Karşıyaka / İzmir

ACCEPTED MANUSCRIPT Abstract Pneumatosis intestinalis (PI) is a rare clinical condition which is commonly associated with mesenteric vascular ischemia, bowel obstruction and chemotherapy. Although

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the pathophysiology of PI remains unclear, two theories , one mechanical and the other bacterial, have been proposed. Non operative medical treatment and observation should be considered in mild cases, but occasionally the situation requires emergency surgical intervention. In cases of suspectful complicated PI, the clinician should not

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be avoid performing diagnostic laparoscopy to rule out bowel ischemia and

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perforation.

ACCEPTED MANUSCRIPT Introduction Pneumatosis intestinalis (PI) is a serious condition which is characterized by the presence of intramural gas within the bowel wall. PI is a clinical sign rather than a

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disease. Conservative treatment with fasting and antibiotics can be considered in mild cases [1]. However, the situation is occasionally requires surgical intervention and can be life threatening. Lee et al. demonstrated that the mesenteric vascular ischemia, bowel obstruction and chemotherapy were the most common causes of PI. 20 % of

medical history or no related diagnosis [2].

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their patients were cathegorized as idiopathic PI because of having no significant past

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The treatments and outcomes of patients with PI have only been examined by small case series studies; moreover, none of these studies have compared the outcomes of

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surgery and non-surgical methods directly [3-6].

Here we represent a case of pneumatosis intestinalis in which a decision for

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laboratory findings.

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observative treatment was not possible because of the patients’ serious clinical and

ACCEPTED MANUSCRIPT Case A 63-year-old man was suffered from abdominal pain and constipation while under treatment for diffuse large B-cell non-Hodgkin’s lymphoma at hematology

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department. His chemotherapy protocol was consisting of Rituximab 375mg/m2, Etoposide 40 mg/m2, Cytarabine 2 mg/m2, Cisplatin 25 mg/m2. Laboratory examination revealed mild leukocytosis ( white blood cell, WBC, 12.400). Plain abdominal radiograph and abdominal ultrasonography revealed no abnormality except

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minimally dilated colonic segments. After progressive abdominal distension and severe pain especially in lower quadrants of the abdomen, the patient was consulted to

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general surgery department. Physical examination revealed abdominal distention with severe rebound tenderness. Consecutive WBC counts were 17.300, 22.700 and

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30.800, respectively. Abdominal computed tomography revealed pneumatosis intestinalis in descending and sigmoid colon (Figure 1), but there was no sign of perforation and portal venous gas radiologically. Due to the patients’ severe clinical

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signs such as fever, tachypnea and peritoneal irritation findings, and progressive increase in WBC levels, we decided to perform a diagnostic laparoscopy to rule out microperforations and bowel ischemia. On laparoscopy, pneumatosis intestinalis was observed at mesocolon and wall of the

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sigmoid colon and descending colon extending to the middle part of the transverse colon (Figure 2, Figure 3). There was no sign of ischemia, perforation, free liquid or small intestinal extension. No additional surgical process was performed.

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Postoperative course was uneventful with fasting and antibiotic treatment. The patient was discharged on postoperative fourth day.

ACCEPTED MANUSCRIPT Discussion Pneumatosis intestinalis, which is characterized by the presence of extraluminal gas within the bowel wall, is a serious clinical sign rather than a disease. Although the

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pathophysiology of PI remains unclear, mainly two theories have been proposed. The mechanical theory postulates that gas enters the wall of the bowel from either the luminal surface through breaks in the mucosa or through the serosal surface by tracking along mesenteric blood vessels and the gas may spread along the mesentery

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to distant sites [7,8]. The bacterial theory postulates that luminal bacteria produce excessive amounts of hydrogen gas through fermentation of carbohydrates and other

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foodstuffs. As the pressure of the gas within the intestinal lumen increases, gas may be forced directly through the mucosa and become trapped within the mucosa[3,9].

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Two types of PI, bubble-like or cystic (with isolated air bubbles in the bowel wall) and band-like or linear, have been reported [10,11]. The latter one is associated with bowel obstruction, volvulus, intussusception, hemorrhage and bowel infarction in

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about 90% of cases.

PI is reported to be en emerging complication of small molecule tyrosine kinase inhibitors [12-14] and is well described in association with bevacizumab , sorafenib and sunitinib. There have been 16 cases of PI complicating imatinib mesylate therapy

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reported to the FDA, but only two of them are published cases [15]. 14 of these cases have occurred in the setting of acute lymphoblastic leukaemia treatment. One of the drugs in chemotherapy protocol is thought to be the reason of PI in our case.

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PI is also reported to be in association with various clinical conditions such as myasthenia gravis [16], Crohn’s disease [17], obstructing sigmoid cancer [18] and appendicitis [19]. Immunosuppression seems to be the common point of most of the diseases or their treatment related with pneumatosis intestinalis. The decision for the management of pneumatosis intestinalis should be based on combined patients’ history, physical, clinical, radiological and laboratory findings. Although some of the patients with PI have moderate course, occasionally they need surgical intervention to reduce morbidity and mortality. Therefore it is essential to distinguish the patients who need surgery and those who should be treated by nonsurgical methods.

ACCEPTED MANUSCRIPT Lee et al. developed a radiological scoring system to predict mortality in patients with the diagnosis of PI [2]. In fact it would be more helpful to develop a preoperative scoring system for distinguishing the patients who needs surgery from those who

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should be treated by non-operative observation. Despite all findings, in suspicion of complicated PI and when the benefits outweigh the risks, with patients’ constent, the clinician should not be avoid to perform a

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diagnostic laparoscopy to rule out bowel perforation and ischemia.

Figure Legends

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Figure 1. Reformatted MPR images of the coronal contrast enhanced computed tomography revealed pneumatosis intestinalis in mesocolon and extraluminal area of

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the sigmoid and descending colon.

Figure 2. Intraoperative image of PI affecting especially sigmoid and descending colon and the mesocolon. There is no sign of ischemia and perforation in the affected

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colonic segments.

ACCEPTED MANUSCRIPT References 1. Adar T, Paz K. Images in clinical medicine. Pneumatosis intestinalis. N Engl J Med 2013; 368:19

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2. Lee HS, Cho YW, Kim KJ, Lee JS, Lee SS, Yang SK. A simple score for predicting mortality in patients with pneumatosis intestinalis. Eur J Radiol 2014; 83 (4): 639-45

3. Ellis BW. Symptomatic treatment of primary pneumatosis coli with metronidazole.

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Br Med J 1980; 280(6216): 763–4.

4.
 Tak PP, Van Duinen CM, Bun P, Eulderink F, Kreuning J, Gooszen HG, Lamers

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CB. Pneumatosis cystoides intestinalis in intestinal pseudoobstruction. Resolution after therapy with metronidazole. Dig Dis Sci 1992;37(6):949–54.


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5. Miralbes M, Hinojosa J, Alonso J, Berenguer J. Oxygen therapy in pneumatosis coli. What is the minimum oxygen requirement? Dis Colon Rectum 1983;26(7):458– 60.

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6. Shemen LJ, Stern H, Sidlofsky S, Myers ED. Treatment of pneumatosis cystoides intestinalis with high FIO2: report of two cases. Dis Colon Rectum1979;22(4):245–7. 7. Glandiuk S, Fazio VW. Pneumatosis cystoides intestinalis. A review of the literature. Dis Colon Rectum 1986;29(5):358-63

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8. Read NW, Al-Janabi MN, Cann PA. Is raised breath hydrogen related to the pathogenesis of pneumatosis coli. Gut 1984;25(8):839-45

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9. Yale CE, Balish E, Wu JP. The bacterial etiology of pneumatosis cystoides intestinalis. Arch Surg 1974;109(1):89-94 10. Pai HJ, Wang CS, Hsieh CC, Wang WK, Yang BY. Pneumatosis intestinalis: a rare manifestation of acute appendicitis. Journal of Emergency Medicine 2009 ; 37 : 127-30 11. Firetto MC, Lemos AA, Marini A, Avesani EC, Biondetti PR. Acute bowel ischemia: analysis of diagnostic error by overlooked findings at MDCT. Emergency Radiology 2013;20:139-47 12. Coriat R, Ropert S, Mir O, Billemont B, Chaussade S, Massault PP, Blanchet B, Vignaux O, Goldwasser F. Pneumatosis intestinalis associated with treatment of cancer patients with the vascular growth factor receptor tyrosine kinase inhibitors sorefanib and sunitinib. Invest New Drugs 2011;29:1090-93

ACCEPTED MANUSCRIPT 13. Shingare AB, Howard SA, Krajewski KM, Zukotynski KA, Jagannathan JP, Ramaiya NH. Pneumatosis inestinalis and bowel perforation associated with molecular targeted therapy:an emerging problem and the role of radiologists in its

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management. Am J Roentgenol 2012;199:1259-65 14. Viswanathan C, Bhosale P, Ganeshan DM, Truong MT, Silverman P, Balachandran A. Imaging of complications of oncological therapy in the gastrointestinal systemç Cancer Imaging 2012;12:163-172

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15. Vijayakanthan N, Dhamanaskar K, Stewart L, Conolly J, Leber B, Walker I, Trus M. A review of pneumatosis intestinalis in the setting of systemic cancer treatments,

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including tyrosine kinase inhibitors. Can Assoc Radiol J 2012;63:312-17 16. Nakajima N, Ueda M, Yamamoto K, Katayama Y. Pneumatosis intestinalis in a

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patient with Myastenia Gravis. Intern Med 2013;52:2835-36 17. Bareggi E, Tonolini M, Ardizzone S. Pneumatosis intestinalis and perforation in Crohn’s disease: Worrisome or not? J Crohns Colitis 2014;8(4):338-9

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18. Fong KY, Siao FY, Yen HH. Cecal pneumatosis intestinalis in obstructing sigmoid cancer: Emergency metallic stenting. Am J Emerg Med 2014;32(4):395 19. Lemos AA, Cioffi U, Ossola MW, Conte D. Appendicitis related pneumatosis

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intestinalis and portal venous gas in a pregnant woman. Dig Liver Dis. 2014 Feb 5

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Fig. 1

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Fig. 2