Pneumatosis Intestinalis Associated with Pulmonary Disorders

Youngsun Ko; Sung Shine Shim; Yookyung Kim; Jung Hyun Chang

doi:10.3348/jksr.2019.80.2.274

Journal List > J Korean Soc Radiol > v.80(2) > 1138889

Go to TopGo to Top Go to BottomGo to Bottom

TOOLS

Ko, Shim, Kim, and Chang: Pneumatosis Intestinalis Associated with Pulmonary Disorders

Original Article

J Korean Soc Radiol 2019;80(2):274-282.

Published online: 20 January 2019

DOI: https://doi.org/10.3348/jksr.2019.80.2.274

Pneumatosis Intestinalis Associated with Pulmonary Disorders

Youngsun Ko, MD¹, Sung Shine Shim, MD^1,^∗, Yookyung Kim, MD¹, Jung Hyun Chang, MD²

¹Department of Radiology, Mokdong Hospital, Ewha Womans University School of Medicine, Seoul, Korea

²Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Ewha Womans University School of Medicine, Seoul, Korea

^∗Corresponding author Sung Shine Shim, MD Department of Radiology, Mokdong Hospital, Ewha Womans University School of Medicine, 1071 Anyangcheon-ro, Yangcheon-gu, Seoul 07985, Korea. Tel 82-2-2650-5380 Fax 82-2-2650-5302 E-mail sinisim@ewha.ac.kr

Received 9 May 2018 Revised 13 June 2018 Accepted 25 July 2018

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Purpose

To determine the clinical features, imaging findings and possible causes of pneumatosis intestinalis (PI) in thoracic disorder patients.

Materials and Methods

From 2005 to 2017, Among 62 PI patients, four of PI related with thoracic disease (6%) were identified. Medical records were reviewed to determine the clinical presentation, laboratory findings and treatment at the time of presentation of PI. Two experienced chest radiologists reviewed all imaging studies and recorded specific findings for each patient.

Results

The causative thoracic diseases for each four patient were severe asthma, emphysema and airway obstruction. The imaging appearance of PI, including the involved bowel segment and pattern of the air, were divided into two mesenteric vascular territories; three of our cases showed linear pattern of PI located in the ascending & proximal transverse colon and the fourth case (lung cancer) had bubbly and cystic PI in the distal transverse and descending colon. All of the remaining 3 patients, except one patient who had not been followed up, improved within 1 month by conservative treatment.

Conclusion

Thoracic disorder with obstructive lung disease may result in the development of benign PI. Such PI in thoracic disease patients has a similar linear and cystic appearance with ischemic bowel disease, but can nevertheless be managed by conservative treatment.

References

1. Keene JG. Pneumatosis cystoides intestinalis and intramural intestinal gas.J Emerg Med. 1989; 7:645–650.

2. Thompson WM, Ho L, Marroquin C. Pneumatosis intestinalis and pneumoperitoneum after bilateral lung transplantation in adults.AJR Am J Roentgenol. 2011; 196:W273–W279.

3. Greenstein AJ, Nguyen SQ, Berlin A, Corona J, Lee J, Wong E, et al. Pneumatosis intestinalis in adults: management, surgical indications, and risk factors for mortality.J Gastrointest Surg. 2007; 11:1268–1274.

4. Hawn MT, Canon CL, Lockhart ME, Gonzalez QH, Shore G, Bondora A, et al. Serum lactic acid determines the outcomes of CT diagnosis of pneumatosis of the gastrointestinal tract.Am Surg. 2004; 70:19–23. ; discussion 23–24.

5. Doumit M, Saloojee N, Seppala R. Pneumatosis intestinalis in a patient with chronic bronchiectasis.Can J Gastroenterol. 2008; 22:847–850.

6. Pear BL. Pneumatosis intestinalis: a review.Radiology. 1998; 207:13–19.

7. Choi JY, Cho SB, Kim HH, Lee IH, Lee HY, Kang HS, et al. Pneumatosis intestinalis complicated by pneumoperitoneum in a patient with asthma.Tuberc Respir Dis (Seoul). 2014; 77:219–222.

8. Ling FY, Zafar AM, Angel LF, Mumbower AL. Benign pneumatosis intestinalis after bilateral lung transplantation. BMJ Case Rep. 2015; 2015:bcr2015210701.

9. Faria LD, Anjos CH, Fernandes GD, Carvalho IF. Pneumatosis intestinalis after etoposide-based chemotherapy in a patient with metastatic small cell lung cancer: successful conservative management of a rare condition. Einstein (Sao Paulo). 2016; 14:420–422.

10. Iwasaku M, Yoshioka H, Korogi Y, Kunimasa K, Nishiyama A, Nagai H, et al. Pneumatosis cystoides intestinalis after gefitinib therapy for pulmonary adenocarcinoma.J Thorac Oncol. 2012; 7:257.

11. Maeda A, Nakata M, Shimizu K, Yukawa T, Saisho S, Okita R. Pneumatosis intestinalis after gefitinib therapy for pulmonary adenocarcinoma: a case report. World J Surg Oncol. 2016; 14:175.

12. Hsueh KC, Tsou SS, Tan KT. Pneumatosis intestinalis and pneumoperitoneum on computed tomography: beware of non-therapeutic laparotomy. World J Gastrointest Surg. 2011; 3:86–88.

13. St Peter SD, Abbas MA, Kelly KA. The spectrum of pneumatosis intestinalis.Arch Surg. 2003; 138:68–75.

14. Gagliardi G, Thompson IW, Hershman MJ, Forbes A, Hawley PR, Talbot IC. Pneumatosis coli: a proposed pathogenesis based on study of 25 cases and review of the literature. Int J Colorectal Dis. 1996; 11:111–118.

15. Ezuka A, Kawana K, Nagase H, Takahashi H, Nakajima A. Improvement of pneumatosis cystoides intestinalis after steroid tapering in a patient with bronchial asthma: a case report. J Med Case Rep. 2013; 7:163.

Fig. 1.

A 43-year-old woman with severe asthma. A. Chest X-ray posterior-anterior views shows pneumomediastinum (arrows) with PI (arrowheads) on initial chest radiography. B. These lesions are completely resolved after 1 month with conservative treatment. C, D. Transverse and coronal abdomen CT scans (2.0-mm slice thickness) obtained with lung and wide window show linear patterns of PI involving from the cecum to proximal transverse colon.

Fig. 2.

A 79-year-old man with lung cancer. A. Chest X-ray posterior-anterior views shows decreased volume of left lung with mass and a nodule in right lower lung zone. B. Transverse contrast-enhanced CT scan obtained with mediastinal window shows a large necrotic mass causing nearly complete stenosis of left main bronchus (arrow). C. Coronal chest CT scan obtained with lung setting shows cystic and bubbly appearance of pneumatosis intestinalis involving distal trans-

Fig. 3.

A 71-year-old man with choking by food material and aspiration pneumonia. with residual food and mucoid impaction in the left main bronchus. B, C. Transverse and coronal abdomen CT scan with bone window shows a linear pattern of pneumatosis intestinalis in the ascending colon. A. Transverse chest CT scan obtained with lung window taken after removal of aspirated food material shows atelectasis of left lower lobe

Table 1.

Clinical Findings in Four Patients with Pneumatosis

Patients		Presenting Symptoms			Underlying Disease	Initial Department	Initial Diagnostic Study	PaO²	Final Diagnosis	Medication	Outcome of Pneumatosis Intestinalis
No.	Sex/Age	Initial Chief Complaint	Duration	Abdomen Symptom	Underlying Disease	Initial Department	Initial Diagnostic Study	PaO²	Final Diagnosis	Medication	Outcome of Pneumatosis Intestinalis
1	F/43	Dyspnea	4 days	Indigestion	Asthma	Emergency room	Chest PA Chest CT	81.7	Asthma exacerbation	Methylon	Resolved in 1 month
2	M/79	Dyspnea	7 days	Poor oral intake	Pulmonary emphysema	Respiratory medicine	Chest PA Chest CT	–	Lung cancer (left main bronchus obstruction)	–	Follow up loss
3	F/53	Dyspnea	3 days	–	AML	Hematologic medicine	Abdomen CT	51.2	GVHD and pneumonia	Methylon Antibiotics	Resolved in 17 days
4	M/71	Dyspnea & mental change	Abrupt	Abdomen distension	–	Emergency room	Chest PA Brain CT Chest CT	33.1	Airway obstruction by food impaction and aspiration pneumonia	Endoscopic removal of food material	Resolved in 7 days

AML = acute myeloid leukemia, GVHD = graft-versus-host disease, PA = posteroanterior, PaO2 = partial pressure of oxygen

Table 2.

Radiologic Findings in Four Patients with PI

No.	Chest				Abdomen CT
	Chest X-Ray	CT			Pneumoperitoneum	PI	Distribution	Pattern	Extra-Luminal Gas Distribution
	Chest X-Ray	Thorax	Pneumoperitoneum	PI	Pneumoperitoneum	PI	Distribution	Pattern	Extra-Luminal Gas Distribution
1	Pneumomediastinum PI	Pneumomediastinum Asthma	Y	Y	Y	Y	Cecum to proximal transverse colon	Linear	Retroperitoneum, liver bare area
2	Lung mass PI	Lung cancer in left lung Pulmonary emphysema	N	Y	N^∗	Y^∗	Distal transverse colon to descending colon^∗	Bubbly and cystic^∗	N^∗
3	–PI	Stable TB Pulmonary emphysema	Y	Y	Y	Y	Cecum to hepatic flexure of colon	Linear	Paracolic gutter
4	Atelectasis in BLLZ PI	Atelectasis in LLL Partial atelectasis in RLL	L N	Y	Y	Y	Cecum to hepatic flexure of colon	Linear	Small bowel mesentery around right psoas muscle, anterior aspect of aorta and IVC

^∗ Scanned abdominal images on chest CT.

PI = pneumatosis intestinalis, BLLZ = both lower lung zones, IVC = inferior vena cava, LLL = left lower lobe, RLL = right lower lobe, TB = tuberculosis

TOOLS

Similar articles