Article

Pneumatosis cystoides intestinalis: A single center experience

Department of Surgery, Diyarbakir Education and Research Hospital, 21400 Diyarbakir, Turkey.
World Journal of Gastroenterology (Impact Factor: 2.37). 02/2012; 18(5):453-7. DOI: 10.3748/wjg.v18.i5.453
Source: PubMed

ABSTRACT

To share our experience of the management and outcomes of patients with pneumatosis cystoides intestinalis (PCI).
The charts of seven patients who underwent surgery for PCI between 2001 and 2009 were reviewed retrospectively. Clinical features, diagnoses and surgical interventions of patients with PCI are discussed.
Seven patients with PCI (3 males, 4 females; mean age, 50 ± 16.1 years; range, 29-74 years) were analyzed. In three of the patients, abdominal pain was the only complaint, whereas additional vomiting and/or constipation occurred in four. Leukocytosis was detected in four patients, whereas it was within normal limits in three. Subdiaphragmatic free air was observed radiologically in four patients but not in three. Six of the patients underwent an applied laparotomy, whereas one underwent an applied explorative laparoscopy. PCI localized to the small intestine only was detected in four patients, whereas it was localized to the small intestine and the colon in three. Three patients underwent a partial small intestine resection and four did not after PCI was diagnosed. Five patients were diagnosed with secondary PCI and two with primary PCI when the surgical findings and medical history were assessed together. Gastric atony developed in one case only, as a complication during a postoperative follow-up of 5-14 d.
Although rare, PCI should be considered in the differential diagnosis of acute abdomen. Diagnostic laparoscopy and preoperative radiological tests, including computed tomography, play an important role in confirming the diagnosis.

Full-text

Available from: Sami Akbulut
BRIEF ARTICLE
Pneumatosis cystoides intestinalis: A single center experience
Zulfu Arikanoglu, Erhan Aygen, Cemalettin Camci, Sami Akbulut, Murat Basbug, Osman Dogru, Ziya Cetinkaya,
Cuneyt Kirkil
Zulfu Arikanoglu, Sami Akbulut,
Murat Basbug,
Department
of Surgery, Diyarbakir Education and Research Hospital, 21400
Diyarbakir, Turkey
Erhan Aygen, Cemalettin Camci, Osman Dogru, Ziya Ce-
tinkaya, Cuneyt Kirkil,
Department of Surgery, Faculty of
Medicine, Firat University, 23119 Elazig, Turkey
Author contributions:
Arikanoglu Z, Basbug M, Aygen E and
Kirkil C performed the surgical procedure; Akbulut S, Dogru O,
Camci C, Arikanoglu Z and Cetinkaya Z contributed to writing
the article and reviewing the literature, as well as undertaking a
comprehensive literature search.
Correspondence to: Sami Akbulut, MD,Sami Akbulut, MD,
Department of Sur-
gery, Diyarbakir Education and Research Hospital, 21400 Di-
yarbakir, Turkey. akbulutsami@gmail.com
Telephone:
+90-412-2580052
Fax:
+90-412-2580050
Received:
April 25, 2011
Revised:
August 25, 2011
Accepted:
August 31, 2011
Published online:
February 7, 2012
Abstract
AIM:
To share our experience of the management and
outcomes of patients with pneumatosis cystoides in-
testinalis (PCI).
METHODS:
The charts of seven patients who under-
went surgery for PCI between 2001 and 2009 were re-
viewed retrospectively. Clinical features, diagnoses and
surgical interventions of patients with PCI are discussed.
RESULTS:
Seven patients with PCI (3 males, 4 fe-
males; mean age, 50 ± 16.1 years; range, 29-74 years)
were analyzed. In three of the patients, abdominal
pain was the only complaint, whereas additional vomit-
ing and/or constipation occurred in four. Leukocytosis
was detected in four patients, whereas it was within
normal limits in three. Subdiaphragmatic free air was
observed radiologically in four patients but not in
three. Six of the patients underwent an applied lapa-
rotomy, whereas one underwent an applied explorative
laparoscopy. PCI localized to the small intestine only
was detected in four patients, whereas it was localized
to the small intestine and the colon in three. Three
patients underwent a partial small intestine resection
and four did not after PCI was diagnosed. Five patients
were diagnosed with secondary PCI and two with pri-
mary PCI when the surgical ndings and medical his-
tory were assessed together. Gastric atony developed
in one case only, as a complication during a postopera-
tive follow-up of 5-14 d.
CONCLUSION:
Although rare, PCI should be consid-
ered in the differential diagnosis of acute abdomen.
Diagnostic laparoscopy and preoperative radiological
tests, including computed tomography, play an impor-
tant role in conrming the diagnosis.
© 2012 Baishideng. All rights reserved.
Key words:
Pneumatosis cystoides intestinalis; Perito-
neal free air; Radiological tools; Diagnosis
Peer reviewer: Kjetil Soreide, MD, PhD, Associate Professor,
Department of Surgery, Stavanger University Hospital, Armauer
Hansensvei 20, PO Box 8100, N-4068 Stavanger, Norway
Arikanoglu Z, Aygen E, Camci C, Akbulut S, Basbug M,
Dogru O, Cetinkaya Z, Kirkil C. Pneumatosis cystoidesPneumatosis cystoides
intestinalis: A single center experience.World J Gastroenterol
2012; 18(5): 453-457 Available from: URL: http://www.
wjgnet.com/1007-9327/full/v18/i5/453.htm DOI: http://dx.doi.
org/10.3748/wjg.v18.i5.453
INTRODUCTION
Pneumatosis cystoides intestinalis (PCI) is a relatively
uncommon condition, characterized by the presence of
multiple gas-filled cysts within the wall of the gastro-
intestinal tract
[1-12]
. The term “pneumatosis intestinalis”
was first used by Duo Vernoi while observing autopsy
specimens in 1730. The entity defined by Duo Vernoi is
what we now know as primary PCI. The term “second-
World J Gastroenterol 2012 February 7; 18(5): 453-457
ISSN 1007-9327 (print) ISSN 2219-2840 (online)
© 2012 Baishideng. All rights reserved.
Online Submissions: http://www.wjgnet.com/1007-9327ofce
wjg@wjgnet.com
doi:10.3748/wjg.v18.i5.453
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Arikanoglu Z
et al.
Approach to PCI
ary PCI” was termed by Koss in 1952, who analyzed 213
pathological specimens and attributed 85% of the cases
to a secondary disease
[1,2]
.
One of the patho�nomonic features of PCI is pneu-patho�nomonic features of PCI is pneu-features of PCI is pneu-
moperitoneum without peritoneal irritation as a result of
a cyst rupture. In contrast, air retention leadin� to acute
abdominal findings may be seen in some cases
[3]
.
PCI is a radiolo�ical or exploratory entity, not a dis-
ease, and the underlyin� causes are numerous. PCI may
develop either after a beni�n procedure, such as endos-
copy, or from an unknown cause (primary or idiopathic).
In some cases, a more serious disease, such as second-
ary necrotizin� enterocolitis, may be the cause. No clear
consensus has yet been established, althou�h many me-
chanical, bacterial, and pulmonary hypotheses have been
proposed re�ardin� the etiopatho�enesis of PCI
[4]
. PCI
usually does not lead to clinical findings and may disap-
pear spontaneously in cases in which the primary disease
is treated. Steroids, an elemental diet, hyperbaric oxy�en,
antibiotics, and sur�ery have been used as treatments. In
this study, we describe seven PCI cases, which were diag-
nosed and treated at our clinic.
MATERIALS AND METHODS
Seven patients were admitted to Firat University Faculty
of Medicine, Department of Surgery, Emergency Unit,
between January 2001 and August 2009. Their medical
records were evaluated retrospectively to obtain follow-
up and clinical data, includin� a�e, sex, initial complaints,
medical histories, white blood cell, abdominal and tho-
racic radioraphy, intraoperative findins, surical in-
tervention, duration of hospital stay, complications and
follow-up time (Table 1). Preoperative tests were per-
formed, includin� routine biochemistry and thoracic and
abdominal radiography. Five of the patients had findings
consistent with an acute abdomen and were operated on.
Contrast-enhanced abdominal computed tomo�raphy
(CT) was performed in one case due to vague abdominal
findings. The CT findings were consistent with a rectal
perforation. Abdominal ultrasonography (USG) was also
used in one patient who had marked tenderness in the
right upper quadrant. All patients operated on under-
went emergent surgery, and all patients were diagnosed
with PCI intraoperatively. Surgical team consensus was
used to determine which patients would be resected af-
ter a laparotomy and/or laparoscopic exploration. The
affected segment was resected in cases with suspicion of
bowel perforation and ischemia, whereas no additional
surgical intervention was performed in cases in which
only PCI was detected. The primary or secondary nature
of the PCI was determined by considering the medical
history and preoperative findings. Cases with no underly-
ing predisposing disease were considered primary or id-
iopathic PCI, whereas those accompanying some disease,
such as appendicitis, Crohn’s disease, pyloric stenosis,
necrotizing enterocolitis, peptic ulcers, cystic fibrosis, or
chronic obstructive lung disease, were regarded as sec-
ondary PCI. Follow-up time was determined from the
time of sur�ery to the last visit to our outpatient clinic.
RESULTS
Data for seven patients with PCI (3 males, 4 females;
age, 50 ± 16.1 years (mean ± SD); range, 29-74 years)
were analyzed retrospectively. Of the patients who pre-
sented at the Emergency Unit, three had severe abdomi-
nal pain, two had abdominal pain and vomiting, and two
had abdominal pain, vomitin�, and constipation. Liver
and renal function tests as well as electrolyte values were
normal in all patients, while marked leukocytosis was de-
tected in four. Exam findings in six of the patients were
consistent with acute peritonitis, whereas no findings
other than minimal tenderness were noted in one patient
(female, aged 29 years). Subdiaphragmatic free air was
detected on plain thoracic and abdominal radio�raphs in
four patients. Abdominal USG used in one patient (fe-
male, aged 74 years), who had marked tenderness in the
right upper quadrant, revealed cholecystitis together with
an image consistent with a stone in the lower tip of the
choledoch. An abdominal CT of a 29-year-old female
patient with vague findings revealed free air extending
into the retroperitoneum, indicatin� a rectal perforation.
This patient was diagnosed with acute abdomen and
was scheduled for urgent surgery. A PCI diagnosis was
established in seven patients after a laparotomy in six
and a laparoscopic exploration in one. An appearance
consistent with PCI was observed in the small intestine
of four patients and in the small intestine and colon of
three (Figure 1A). A small intestinal perforation was ob-
served in only one (female, a�ed 34 years) of these cases
(Figure 1B). PCI was detected incidentally in a 74-year-
old female patient who was scheduled for bile duct
surery (cholecystectomy and choledoch exploration
only). Three patients underwent a partial small intestinal
resection and anastomosis, while four had no additional
surgical procedures after PCI was diagnosed. All patients
were given 3 L/min oxygen during the first 3 postopera-
tive days. During the 5-14 d clinical follow-up, a 48-year-
old male developed gastric atony, whereas the remaining
six patients were discharged with no complications. No
additional complications were observed in any of the
patients during the 15 ± 5.4 mo (range, 8-23 mo) follow-
up. After considering the surgical findings and medical
and surgical histories, five of these patients had second-
ary PCI and two had primary PCI.
DISCUSSION
PCI is a rare condition characterized by multilocular �as-
filled cysts localized in the submucosa and subserosa
of the astrointestinal tract
[5,13-17]
. The term “pneuma-
tosis intestinalis” was first used by Duo Vernoi during
postmortem observations. A PCI diagnosis in surviving
patients was first established by Hahn in 1899. A PCI
dia�nosis
via
preoperative radiological findings was first
454
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Page 2
described by Baumann-Schender in 1939. The condi-
tion originally described by Duo Vernoi is what we now
consider primary PCI. The term “secondary PCI” was
coined by Koss in 1952, who analyzed 213 pathological
specimens and attributed 85% of the cases to a second-
ary disease
[1-3]
.
Several hypotheses have been proposed re�ardin� the
development of PCI, althou�h its patho�enesis is still
controversial. Two main hypotheses regarding the fun-
damental patho�enesis of PCI are mechanical and bacte-
rial
[17]
. The mechanical hypothesis postulates that PCI
develops when defects in the mucosa, in combination
with increased intraluminal pressure, allow gas to infil-
trate the gastrointestinal (GI) tract wall. A subgroup of
patients with severe pulmonary conditions may present
with PCI arising from pulmonary causes, such as cough
and rapid chan�es in intra-abdominal pressure. The bac-
terial hypothesis proposes that PCI develops when gas-
producing bacteria gain entry into the GI tract wall and
produce gas pockets. Much of the supporting evidence
for these two hypotheses is derived from observational
studies, and mechanical and bacterial mechanisms may
occur simultaneously
[4,6,7]
.
Although PCI may occur anywhere in the gastroin-
testinal tract, from the esopha�us to the rectum, it is usu-
ally seen in the intestine. A previous study reported that
20%-51.6% of all PCI cases involve the small intestine,
36%-78% involve the colon, and 2%-22% include both
the small intestine and colon.
The small intestine was
involved in 57.1% of the cases we presented here and
42.9% involved the small intestine and the colon
[1,2,6,8]
.
PCI is not a disease but a clinical entity. The etiolo�y
can be classified by considering factors thought to play a
role in its development. Based on this notion, PCI can be
divided into primary and idiopathic (15%) or secondary
(85%) type
[9]
. No identifiable underlying or predisposing
factor is present in the primary or idiopathic type. How-
ever, numerous �astrointestinal diseases, includin� appen-
dicitis, necrotizin� enterocolitis, Crohns disease, pyloric
stenosis, ulcerative colitis, diverticular disease, necrotiz-
in enterocolitis, astroduodenal ulcer, and simoid
volvulus, may accompany PCI as a secondary cause.
PCI has also been reported as accompanyin� some non-
astrointestinal diseases, such as chronic obstructive
pulmonary disease, colla�en tissue diseases, acquired im-
mune deficiency syndrome, and glucocorticoid use. PCI
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No. Age Sex Complaint Medical history WBC
Radiologic
tools
Loc. Etiology
Surgical
intervention
Length of
hospital stay (d)
Postoperative
complication
Follow-
up (mo)
1 29 F AP + V Endoscopy 11.1 X-ray, CT
4
SB Secondary Ileal resection +
anastomosis
7 No 14
2 48 M AP + V + C
2
Peptic ulcer perforation NR X-ray SB Secondary Ileal resection +
anastomosis
14 Gastric atony 21
3 71 M AP + V + C
2
CLL (CT
3
) 35 X-ray SB Secondary Laparatomy 5 No 8
4 74 F AP Normal NR X-ray, US SB Secondary Cholecystectomy
+ choledocotomy
+ drainage
11 No 23
5 53 F AP Colonoscopy NR X-ray SB + C
1
Secondary Laparatomy 8 No 18
6 34 F AP + V Normal 23 X-ray SB + C
1
Primary Ileal resection +
anastomosis
10 No 12
7 41 M AP Normal 16 X-ray SB + C
1
Primary Laparoscopic
exploration
7 No 9
Table 1 Demographic and clinical characteristics of the seven patients with pneumatosis cystoides intestinalis
WBC: White blood cell; SB: Small bowel;
1
C: Colon; AP: Abdominal pain; V: Vomiting;
2
C: Constipation; CLL: Chronic lymphocytic leukemia;
3
CT: Chemo-
therapy; NR: Normal range;
4
CT: Computed tomography; US: Ultrasonography.
Figure 1 Intraoperative appearance of multiple air sacs in the small intestine. A: Multiple air sacs (white arrow); B: A perforation and multiple air sacs (white arrow).
Arikanoglu Z
et al.
Approach to PCI
Page 3
cases secondary to sur�ical or endoscopic trauma have
also been reported
[10,11]
.
Lesions are usually localized to the left hemicolon
or its mesentery or to the submucosal layer and are fre-
quently characterized by se�mentary involvement in the
primary form of the disease. However, involvement is
usually subserosal in the secondary form, and occurs in
the stomach, small intestine, and ri�ht colon, usually in a
�eneralized or se�mented pattern
[7]
.
The incidence of PCI is unknown, because it is usu-
ally asymptomatic. Symptoms, if any, are usually second-
ary to an underlying disease. Together with non-specific
symptoms, such as abdominal discomfort, diarrhea, con-
stipation, rectal bleeding, tenesmus, or loss of weight,
severe complications, includin� volvulus, intestinal ob-
struction, tension pneumoperitoneum, bleedin�, intus-
susception, and intestinal perforation may be seen in 3%
of patients
[18-23]
.
Radiolo�ical tools are important for dia�nosin� PCI.
These include plain radiographs, USG, barium series, CT,
CT-colonoscopy, ma�netic resonance ima�in� and MRI-
colono�raphy, endoscopy, and colonoscopy
[19,20]
. X-ray is
of reat importance, because it is readily available in ev-
ery emer�ency room. Cysts usually appear as radiolucent
shadows, similar to a bunch of grapes, close to the intes-
tinal lumen on radiographs. Free air underneath the dia-
phragm may be seen if these cysts perforate. An appear-
ance of bulging into the lumen as a filling defect is seen
on barium-colon radioraphs
[15,23]
. Linear or spot-like
hyperechoic images may be seen in the intestinal wall on
USG. CT is the most useful method for diagnosing PCI
and is important because it provides data on other ab-
dominal pathologies. However, CT may not provide data
on intestinal ischemia and necrosis
[1,4,7,12]
. The colonosco-The colonosco-
pic findings may be similar to multiple polyposis or col-
lections of submucosal tumors, but subserous pneuma-
tosis may o undetected
[20]
. A laparoscopic explorationA laparoscopic exploration
is quite useful to confirm a PCI diagnosis, if the physical
examination ndings are suspicious, and particularly in
cases that are not preoperatively dia�nosed clearly usin�
the above-mentioned radiological methods. Diagnostic
laparoscopy provides the convenience of convertin� to
open surgery as well as confirming the diagnosis.
When presence of such an entity is confirmed radio-
lo�ically, �astroenterolo�ic sur�eons be�in to feel annoy-
ance. The answer to the question, “What should we do to
these patients?” is correlated with the experience of each
surgeon on that entity. The approach to a patient with PCI
should be determined by evaluatin� the underlyin� causes
and exam findings together. A specific treatment is not
recommended in asymptomatic patients who are detected
as having PCI radiologically and whose examination find-
in�s are ne�ative. Conservative approaches, includin� na-
so�astric decompression, intestinal rest, antibiotic therapy
and oxygen, are recommended for patients with positive
examination findings and normal biochemical parameters
who are confirmed radiologically to have no intestinal
ischemia or perforation
[24]
. Applying 250 mmHg PO
2
pressure or 70% oxygen inhalation for 5 d or 2.5 atmo-
spheres of hyperbaric oxygen pressure for 150 min/d for
3 consecutive days can lead to resolution of �as collec-
tion within a cyst
[10,13,24,25]
. An urgent laparotomy is neces-
sary in cases of intestinal ischemia, obstruction, intestinal
bleedin�, or peritonitis
[14,16]
. Definitive surgery should be
performed durina laparotomy if necrosis, perforation,
or marked ischemia is observed in the intestine. Further-
more, no additional sur�ical procedures should be con-
ducted unless other patholo�y is detected in addition to
serosal or subserosal air cysts.
Consequently, clinical suspicion, physician experi-
ence, radiolo�ical tools, and team spirit are important in
terms of the approach to PCI. When and how to treat
these patients is the main issue to lower mortality and
morbidity.
COMMENTS
Background
Pneumatosis cystoides intestinalis (PCI) is a pathologic condition dened as
inltration of gas into the wall of the gastrointestinal tract
Research frontiers
The authors retrospectively reviewed the diagnosis and management of seven
patients with pneumatosis cystoides intestinalis.neumatosis cystoides intestinalis.
Innovations and breakthroughs
Clinical suspicion, physician experience, radiological tools and team spirit are
important in terms of the approach to PCI. When and how to treat these pa-
tients is the main issue to lower mortality and morbidity.
Applications
According to authorsopinion, specific treatment is not recommended in as-
ymptomatic patients who are detected to have PCI radiologically and whose
examination ndings are negative However, laparotomy is necessary in cases
of intestinal ischemia, obstruction, intestinal bleeding or peritonitis
Terminology
The primary and idiopathic or secondary nature of the PCI is determined by
considering the medical history and by preoperative examination. Cases with
no underlying predisposing disease are considered primary PCI, whereas those
accompanying some disease, such as appendicitis, Crohn’s disease, pyloric
stenosis, necrotizing enterocolitis, peptic ulcers, cystic brosis or chronic ob-
structive lung disease, are regarded as secondary PCI.
Peer review
This is a well written report on a small series of a rare entity. It has some edu-
cational value in the presentation and the gures
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COMMENTS
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Approach to PCI
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S- Editor
Tian L
L- Editor
Logan S
E- Editor
Li JY
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Arikanoglu Z
et al.
Approach to PCI
Page 5
  • Source
    • "As illustrated in our case, PCI can easily mimic pneumoperitoneum on radiological imaging. Intramural air may appear as radiolucent shadows along the bowel lumen on X-ray [9]. Extensive PCI or ruptured cysts may appear like free air under the diaphragm in an erect chest X-ray. "
    [Show abstract] [Hide abstract] ABSTRACT: Aim: The aim of this study is to increase the understanding of pneumatosis cystoides intestinalis (PCI) and its incidents. Method: We report here a case of PCI in an 88-year-old man with a provisional diagnosis of perforated viscus and possible ischaemic bowels based on CT findings of pneumoperitoneum. The patient was found to have extensive PCI on his small bowels. We then systematically search the PubMed database for case reports for articles containing 'pneumatosis intestinalis' in their titles or key words. Results: The study group consisted of 52 cases on PCI from the period of 2010-2014 with the focus on the adult population. The youngest patient was 18 years old and the oldest was 91 years old. The mean age was 60.4 years (range, 18-91 years old). There were 27 (52 %) females and 25 (48 %) males. The most common symptoms were abdominal pain (79 %) followed by nausea/vomiting (27 %) and abdominal distension (19 %). CT imaging was the most common investigation modality used (94 %). Three (6 %) of the patients had laparoscopic treatment while 20 (38 %) had laparotomy. Thirty-six (69 %) of them recovered uneventfully while 9 (17 %) of the patients died. Conclusion: Although there have been more case reports published on PCI in the recent years, the understanding of this condition remains in the infancy stage. PCI can be difficult to diagnose and can be easily misdiagnosed as pneumoperitoneum in an acute abdomen. Often it is identified incidentally during operation. Asymptomatic PCI should be treated conservatively, while emergency laparotomy should be reserved for life threatening abdominal pathology.
    Preview · Article · Dec 2015
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    • "Even nowadays many physicians are not aware of the possibility that nonsurgical pneumoperitoneum could exist, even though it has been described repeatedly in the world literature.5678101112131417,1920212223262728293031323334363738394041424344454647484950) It is mainly due to the lack of knowledge of the attending physicians which leads to unnecessary laparotomy with possible morbidity. "
    [Show abstract] [Hide abstract] ABSTRACT: Not all cases of pneumoperitoneum found on abdominal X-ray or computed tomography (CT) scan are caused by hollow viscus perforation. Non-surgical or spontaneous pneumoperitoneum is a repeatedly described entity. However, not all physicians in emergency departments are aware of it, and in such cases unnecessary laparotomy is often performed which reveals no intra-abdominal pathology. Non-surgical pneumoperitoneum can have thoracic, abdominal, gynecological, or other causes. When we acknowledge the possibility of non-surgical pneumoperitoneum, the primary goal is to discern sur-gical from non-surgical pneumoperitoneum. Identifying cases in which laparotomy can be avoided is important to prevent unnecessary surgery and its associated morbidity and financial costs. In this paper we propose a practical algorithm which may help the attending physicians to distinguish between surgical and non-surgical pneumoperitoneum.
    Full-text · Article · Jun 2014 · Signa Vitae
  • [Show abstract] [Hide abstract] ABSTRACT: To increase the understanding, diagnosis and treatment of pneumatosis cystoides intestinalis (PCI) and to find the characteristics and potential cause of the disease in China. We report here one case of PCI in a 70-year-old male patient who received a variety of treatment methods. Then, we systematically searched the PCI eligible literature published from an available Chinese database from May 2002 to May 2012, including CBM, CBMDisc, CMCC, VIP, Wanfang, and CNKI. The key words were pneumatosis cystoides intestinalis, pneumatosis, pneumatosis intestinalis, pneumatosis coli and mucosal gas. The patients' information, histories, therapies, courses, and outcomes were reviewed. The study group consisted of 239 PCI cases (male:female = 2.4:1) from 77 reported incidents. The mean age was 45.3 ± 15.6 years, and the median illness course was 6 mo. One hundred and sixty patients (66.9%) were in high altitude areas. In addition, 43.5% (104/239) of the patients had potential PCI-related disease, and 16.3% had complications with intestinal obstruction and perforation. The most common symptom was abdominal pain (53.9%), followed by diarrhea (53.0%), distention (42.4%), nausea and vomiting (14.3%), bloody stool (12.9%), mucous stool (12.0%) and constipation (7.8%). Most multiple pneumocysts developed in the submucosa of the colon (69.9%). The efficacy of the treatments by combined modalities, surgery, endoscopic treatment, conservative approach, oxygen, and antibiotics were 100%, 100%, 100%, 93.3%, 68.3% and 26.3%, respectively. PCI can be safely managed by conservative treatments, presents more frequently in males, in the large bowel and submucosa, than in females, in the small intestine and subserosa. High altitude residence maybe associated with the PCI etiology.
    No preview · Article · Aug 2013 · World Journal of Gastroenterology
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