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Pneumomediastinum and Pneumoperitoneum Secondary to Cystic Intestinal Pneumatosis After Percutaneous Endoscopic Gastrostomy Placement
Neumomediastino y neumoperitoneo secundario a neumatosis quística intestinal tras colocación de gastrostomía endoscópica percutánea
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Paz Garcia Pravia, Rosa María del Campo Ugidos, Carmen Garcia Álvarez, María Concepción Fernández Fernández" "autores" => array:5 [ 0 => array:4 [ "nombre" => "Esther" "apellidos" => "Barbon Remis" "email" => array:1 [ 0 => "estherbarbon@gmail.com" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "M. Paz" "apellidos" => "Garcia Pravia" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "Rosa María" "apellidos" => "del Campo Ugidos" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "Carmen" "apellidos" => "Garcia Álvarez" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 4 => array:3 [ "nombre" => "María Concepción" "apellidos" => "Fernández Fernández" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] ] "afiliaciones" => array:4 [ 0 => array:3 [ "entidad" => "Departamento de Cirugía General, Fundación Hospital de Jove, Gijón, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Departamento de Radiología, Fundación Hospital de Jove, Gijón, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Departamento de Urgencias, Fundación Hospital de Jove, Gijón, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Departamento de Medicina Interna, Fundación Hospital de Jove, Gijón, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "<span class="elsevierStyleItalic">Corresponding author</span>." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Neumomediastino y neumoperitoneo secundario a neumatosis quística intestinal tras colocación de gastrostomía endoscópica percutánea" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 800 "Ancho" => 744 "Tamanyo" => 73771 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Coronal CT image: presence of pneumomediastinum, pneumoperitoneum, retropneumoperitoneum and gas in the wall of the right colon.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Pneumatosis cystoides intestinalis (PCI) is a rare disease. First described in 1730 by Du Vernoy, it has been defined as the presence of gas within the submucosa or subserosa of the wall of the small intestine and colon, and it has received different names in the literature. The detection of PCI has increased due to the greater use of computed tomography (CT) studies.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> Its clinical presentation can be varied, from accidental findings in asymptomatic patients to life-threatening situations.</p><p id="par0010" class="elsevierStylePara elsevierViewall">We present the case of a 77-year-old female patient with a history of lacunar stroke with left hemiparesis and Parkinson's disease, associated with multisystemic atrophy and dysphagia, requiring a percutaneous endoscopic gastrostomy (PEG) for enteral tube feeding. Two months later, she was evaluated in the outpatient consultation because of abdominal pain and altered bowel transit, with palpation of an abdominal mass in the left iliac fossa and a soft, non-painful abdomen, no peritonism and preserved peristalsis. Lab work was normal. An abdominal Rx was requested, in which the feeding tube and gas were seen in the wall of the right colon, followed by a CT scan that demonstrated the presence of pneumoperitoneum, retropneumoperitoneum and pneumomediastinum; meanwhile, the right colon presented gas in the wall and small parietal air formations in the left and transverse colon, with no mesentery edema or free intra-abdominal fluid. No gas was identified in the vascular structures. The findings described could be compatible with intestinal ischemia, although the patient did not present an acuteabdomen, so it appeared to be a progressive process that could be secondary to PCI (<a class="elsevierStyleCrossRefs" href="#fig0005">Figs. 1 and 2</a>). We decided to hospitalize the patient for medical treatment with oxygen therapy, antibiotic therapy with ciprofloxacin and metronidazole, fluid therapy and <span class="elsevierStyleItalic">nil per os</span>. The patient progressed favorably, and a control CT showed significant radiological improvement of the pneumatosis intestinalis, with a minimal residual lesion in the hepatic angle of the colon. Stool culture was compatible with dysbiosis. The patient was discharged 14 days later with enteral and oral feeding.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The pathogenesis of PCI is unknown and probably multifactorial. Although older studies show more frequent involvement in the small intestine, more recent studies indicate a greater involvement of the colon.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> This is more common in patients over 50 years of age, idiopathic in 15% and secondary to a wide variety of diseases in 85%, including the association between enteral tube feeding and PCI.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> Disease progression is variable, with a high mortality rate when associated with intestinal necrosis and perforation. Several hypotheses have been suggested in the pathogenesis of PCI, including the mechanical theory in which gas dissects the intestinal wall from its lumen through perforations in the mucosa or through the serous side along the blood vessels.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">4</span></a> The bacterial theory has also been considered, in which the gas produced by the bacteria accesses the submucosa through mucosal lesions.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> The argument against this theory is that the cysts are sterile and their rupture results in pneumoperitoneum with no development of peritonitis.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">6</span></a> The chemical or nutritional deficiency theory argues that malnutrition can impede the digestion of carbohydrates and lead to increased bacterial fermentation in the bowel, with the production of large amounts of gas and, subsequently, dissection of the submucosa by the gas. Recently, PCI has been associated with chemotherapy, hormone therapy and connective tissue diseases.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> Finally, the pulmonary theory postulates that the increased intraluminal pressure in the respiratory system would cause alveolar rupture, so that the gas of the alveoli would dissect the mesenteric vessels through the diaphragm and, hence, the intestinal wall.<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">7</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">PCI may be asymptomatic, although the most common symptoms are abdominal pain and diarrhea (53%), followed by abdominal distension, nausea and vomiting, blood or mucus in stools, and constipation. Almost 16% of patients have complications related with PCI, such as intestinal obstruction, intussusception, volvulus, hemorrhage and perforation.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a> The diagnosis of PCI is based on radiology; CT is the most effective imaging method in the detection of pneumatosis, with a cystic pattern along the wall of the intestine.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> Endoscopy is useful to exclude other mucosal lesions and reveal submucosal cysts.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">Appropriate therapy for PCI ranges from conservative treatment to exploratory laparotomy. Asymptomatic patients can be cured without treatment, while symptomatic patients are treated with intestinal decompression, parenteral nutrition and electrolyte replacement. In some cases, response to treatment has been reported with metronidazole and hyperbaric therapy.<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a> Surgery is reserved for cases of bowel obstruction, perforation or cancer.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">This article is of interest because it presents the diagnosis of a rare disease such as PCI after the placement of a PEG tube as a possible etiological factor. Therefore, this possibility should be contemplated in the differential diagnosis of pneumoperitoneum in an asymptomatic patient with PEG.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Barbon Remis E, Garcia Pravia MP, del Campo Ugidos RM, Garcia Álvarez C, Fernández Fernández MC. Neumomediastino y neumoperitoneo secundario a neumatosis quística intestinal tras colocación de gastrostomía endoscópica percutánea. Cir Esp. 2017;95:476–477.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Fig. 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 800 "Ancho" => 957 "Tamanyo" => 80485 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Axial CT scan: presence of pneumoperitoneum and retropneumoperitoneum; right colon is striated in appearance, in layers, with presence of gas in the wall; PEG.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 800 "Ancho" => 744 "Tamanyo" => 73771 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Coronal CT image: presence of pneumomediastinum, pneumoperitoneum, retropneumoperitoneum and gas in the wall of the right colon.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:10 [ 0 => array:3 [ "identificador" => "bib0055" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Natural history, clinical pattern, and surgical considerations of pneumatosis intestinalis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "P.N. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 October | 13 | 3 | 16 |
| 2024 September | 25 | 8 | 33 |
| 2024 August | 15 | 2 | 17 |
| 2024 July | 18 | 5 | 23 |
| 2024 June | 19 | 2 | 21 |
| 2024 May | 19 | 2 | 21 |
| 2024 April | 36 | 9 | 45 |
| 2024 March | 32 | 5 | 37 |
| 2024 February | 21 | 2 | 23 |
| 2024 January | 33 | 3 | 36 |
| 2023 December | 30 | 5 | 35 |
| 2023 November | 25 | 4 | 29 |
| 2023 October | 35 | 4 | 39 |
| 2023 September | 17 | 2 | 19 |
| 2023 August | 16 | 0 | 16 |
| 2023 July | 18 | 3 | 21 |
| 2023 June | 28 | 0 | 28 |
| 2023 May | 58 | 2 | 60 |
| 2023 April | 99 | 1 | 100 |
| 2023 March | 64 | 1 | 65 |
| 2023 February | 36 | 5 | 41 |
| 2023 January | 34 | 3 | 37 |
| 2022 December | 42 | 5 | 47 |
| 2022 November | 36 | 9 | 45 |
| 2022 October | 27 | 8 | 35 |
| 2022 September | 21 | 21 | 42 |
| 2022 August | 29 | 18 | 47 |
| 2022 July | 25 | 10 | 35 |
| 2022 June | 24 | 9 | 33 |
| 2022 May | 30 | 12 | 42 |
| 2022 April | 25 | 7 | 32 |
| 2022 March | 36 | 12 | 48 |
| 2022 February | 34 | 5 | 39 |
| 2022 January | 43 | 7 | 50 |
| 2021 December | 31 | 13 | 44 |
| 2021 November | 30 | 12 | 42 |
| 2021 October | 47 | 8 | 55 |
| 2021 September | 40 | 9 | 49 |
| 2021 August | 51 | 7 | 58 |
| 2021 July | 19 | 13 | 32 |
| 2021 June | 36 | 8 | 44 |
| 2021 May | 32 | 5 | 37 |
| 2021 April | 83 | 9 | 92 |
| 2021 March | 45 | 8 | 53 |
| 2021 February | 40 | 9 | 49 |
| 2021 January | 30 | 7 | 37 |
| 2020 December | 32 | 4 | 36 |
| 2020 November | 47 | 4 | 51 |
| 2020 October | 57 | 4 | 61 |
| 2020 September | 24 | 8 | 32 |
| 2020 August | 23 | 8 | 31 |
| 2020 July | 13 | 9 | 22 |
| 2020 June | 19 | 8 | 27 |
| 2020 May | 37 | 10 | 47 |
| 2020 April | 23 | 10 | 33 |
| 2020 March | 14 | 4 | 18 |
| 2020 February | 16 | 3 | 19 |
| 2020 January | 10 | 5 | 15 |
| 2019 December | 39 | 10 | 49 |
| 2019 November | 15 | 6 | 21 |
| 2019 October | 22 | 0 | 22 |
| 2019 September | 26 | 1 | 27 |
| 2019 August | 18 | 1 | 19 |
| 2019 July | 37 | 11 | 48 |
| 2019 June | 65 | 23 | 88 |
| 2019 May | 159 | 50 | 209 |
| 2019 April | 39 | 32 | 71 |
| 2019 March | 4 | 4 | 8 |
| 2019 February | 21 | 3 | 24 |
| 2019 January | 6 | 1 | 7 |
| 2018 December | 12 | 4 | 16 |
| 2018 November | 15 | 9 | 24 |
| 2018 October | 25 | 6 | 31 |
| 2018 September | 6 | 2 | 8 |
| 2018 August | 10 | 1 | 11 |
| 2018 July | 5 | 0 | 5 |
| 2018 June | 2 | 0 | 2 |
| 2018 May | 2 | 0 | 2 |
| 2018 April | 7 | 0 | 7 |
| 2018 March | 2 | 0 | 2 |
| 2018 February | 8 | 0 | 8 |
| 2018 January | 5 | 0 | 5 |
| 2017 November | 1 | 1 | 2 |
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