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Electronic Clinical Challenges and Images in GI
Electronic Clinical Challenges and Images in GI David A. Katzka and David L. Jaffe, Section Editors
Image 2
Question: A 48-year-old patient with colorectal cancer and peritoneal carcinomatosis underwent right hemicolectomy and resection of parts of the tumor that infiltrated the small bowel. Postoperative parenteral nutrition had to be initiated in addition to enteral nutrition. There was no measurable disease (liver metastasis), but peritoneal carcinomatosis with massive ascites required palliative chemotherapy. The patient received oxaliplatin, 5-FU, and folinic acid according to the FOLFOX6 regime. After initiation of chemotherapy, ascites was regressing and the patient reduced parenteral and increased enteral nutrition, which was clinically tolerated. Seven weeks after initiation of FOLFOX6, we performed a multislice computed tomography (CT) scan (16-row CT) for restaging. The patient was in a good clinical condition (ECOG 0) and did not report abdominal pain. What is the most likely diagnosis of Figure A?
GASTROENTEROLOGY 2008;135:e4 – e5
See the GASTROENTEROLOGY website (www. gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. VOLKER KAECHELE, MD THOMAS SEUFFERLEIN, MD Department of Internal Medicine I SANDRA PAULS, MD Department of Diagnostic and Interventional Radiology Ulm University Ulm, Germany
© 2008 by the AGA Institute
0016-5085/08/$34.00 doi:10.1053/j.gastro.2008.06.059
August 2008
Answer to the Clinical Challenges and Images in GI Question: Image 2: Pneumatosis Cystoides Intestinalis Figure A (arrows) shows air-filled cysts within the bowel wall of the left colon as a manifestation of a pneumatosis cystoides intestinalis (PCI). In our patient, who had undergone resection of parts of the small bowel, a rise in enteric gas production upon increasing enteral nutrition owing to fermentation of carbohydrates by anaerobic bacteria is the most likely cause of this condition. In addition to total parenteral nutrition, oral antibiotic therapy with metronidazole was initiated to reduce the colonization with anaerobic bacteria. CT images 2 weeks later showed a normal gas accumulation in the colon without signs of PCI. Upon continuation of chemotherapy, there was no more sign of PCI in follow-up CT scans. PCI is an imaging sign that does not reflect a distinct disease.1 Most of the cases of PCI are so-called secondary PCI and are associated with a wide spectrum of diseases. PCI is also described in patients with immunosuppression or those receiving systemic chemotherapy. Multiple factors can contribute to the development of pneumatosis intestinalis.2 According to the mechanical theory, the mucosa is injured and intraluminal air enters the intestinal wall. The biochemical theory of PCI postulates an invasion of gas-producing bacteria (e.g., Clostridium perfringens) into the bowel wall. Because PCI cysts contain elevated levels of hydrogen, a secondary progression owing to gas production by colonic bacteria is suspected. The clinical manifestation of PCI often depends on the underlying disease. Usually, patients are free of symptoms and PCI is diagnosed by chance. The most common forms of treatment are antibiotics (with metronidazole),3 parenteral nutrition, elementary diet, or inhalation of oxygen.4 Upon inhalation of oxygen, the partial pressure of the non-oxygen gases in the blood is decreased and the diffusion from the gas-containing cysts into the blood is supposedly facilitated. References 1. Pear BL. Pneumatosis intestinalis. A review. Radiology 1998;207:13–19. 2. Gagliardi G, Thompson IW, Hershman MJ, et al. Pneumatosis coli: a proposed pathogenesis based on study of 25 cases and review of the literature. Int J Colorect Dis 1996;11:111–118. 3. Jauhonnen P, Lethola J, Karttunene T. Treatment of pneumatosis coli with metronidazole. Dis Colon Rectum 1987;30:800 – 801. 4. Forgacs P, Wright PH, Wyatt AP. Treatment with intestinal gas cysts by oxygen breathing. Lancet 1973;1: 579 –582. For submission instructions, please see the GASTROENTEROLOGY website (www.gastrojournal.org).
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Image 2
Question: A 48-year-old patient with colorectal cancer and peritoneal carcinomatosis underwent right hemicolectomy and resection of parts of the tumor that infiltrated the small bowel. Postoperative parenteral nutrition had to be initiated in addition to enteral nutrition. There was no measurable disease (liver metastasis), but peritoneal carcinomatosis with massive ascites required palliative chemotherapy. The patient received oxaliplatin, 5-FU, and folinic acid according to the FOLFOX6 regime. After initiation of chemotherapy, ascites was regressing and the patient reduced parenteral and increased enteral nutrition, which was clinically tolerated. Seven weeks after initiation of FOLFOX6, we performed a multislice computed tomography (CT) scan (16-row CT) for restaging. The patient was in a good clinical condition (ECOG 0) and did not report abdominal pain. What is the most likely diagnosis of Figure A?
GASTROENTEROLOGY 2008;135:e4 – e5
See the GASTROENTEROLOGY website (www. gastrojournal.org) for more information on submitting your favorite image to Clinical Challenges and Images in GI. VOLKER KAECHELE, MD THOMAS SEUFFERLEIN, MD Department of Internal Medicine I SANDRA PAULS, MD Department of Diagnostic and Interventional Radiology Ulm University Ulm, Germany
© 2008 by the AGA Institute
0016-5085/08/$34.00 doi:10.1053/j.gastro.2008.06.059
August 2008
Answer to the Clinical Challenges and Images in GI Question: Image 2: Pneumatosis Cystoides Intestinalis Figure A (arrows) shows air-filled cysts within the bowel wall of the left colon as a manifestation of a pneumatosis cystoides intestinalis (PCI). In our patient, who had undergone resection of parts of the small bowel, a rise in enteric gas production upon increasing enteral nutrition owing to fermentation of carbohydrates by anaerobic bacteria is the most likely cause of this condition. In addition to total parenteral nutrition, oral antibiotic therapy with metronidazole was initiated to reduce the colonization with anaerobic bacteria. CT images 2 weeks later showed a normal gas accumulation in the colon without signs of PCI. Upon continuation of chemotherapy, there was no more sign of PCI in follow-up CT scans. PCI is an imaging sign that does not reflect a distinct disease.1 Most of the cases of PCI are so-called secondary PCI and are associated with a wide spectrum of diseases. PCI is also described in patients with immunosuppression or those receiving systemic chemotherapy. Multiple factors can contribute to the development of pneumatosis intestinalis.2 According to the mechanical theory, the mucosa is injured and intraluminal air enters the intestinal wall. The biochemical theory of PCI postulates an invasion of gas-producing bacteria (e.g., Clostridium perfringens) into the bowel wall. Because PCI cysts contain elevated levels of hydrogen, a secondary progression owing to gas production by colonic bacteria is suspected. The clinical manifestation of PCI often depends on the underlying disease. Usually, patients are free of symptoms and PCI is diagnosed by chance. The most common forms of treatment are antibiotics (with metronidazole),3 parenteral nutrition, elementary diet, or inhalation of oxygen.4 Upon inhalation of oxygen, the partial pressure of the non-oxygen gases in the blood is decreased and the diffusion from the gas-containing cysts into the blood is supposedly facilitated. References 1. Pear BL. Pneumatosis intestinalis. A review. Radiology 1998;207:13–19. 2. Gagliardi G, Thompson IW, Hershman MJ, et al. Pneumatosis coli: a proposed pathogenesis based on study of 25 cases and review of the literature. Int J Colorect Dis 1996;11:111–118. 3. Jauhonnen P, Lethola J, Karttunene T. Treatment of pneumatosis coli with metronidazole. Dis Colon Rectum 1987;30:800 – 801. 4. Forgacs P, Wright PH, Wyatt AP. Treatment with intestinal gas cysts by oxygen breathing. Lancet 1973;1: 579 –582. For submission instructions, please see the GASTROENTEROLOGY website (www.gastrojournal.org).
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