Erosive Gastritis
Pneumatosis Cystoides Intestinalis

Video Endoscopic Sequence 1 of 27.

Pneumatosis Cystoides Intestinalis

A 42-year-old male, admitted to the hospital due to hepatic encephalopathy due to alcoholic cirrhosis of the liver. There is generalized jaundice with total bilirubin in 31 with direct predominance, two years prior to endoscopy, we found esophageal varices grade I, patient did not return to any subsequent control, was hospitalized to manage the encephalopathy and general condition, improving with laxatives and antibiotics, a computerized axial tomography of the abdomen was indicated, where gastric and colonic thickening was observed as well as ascites, (see images below).

In the upper endoscopy there are varices of the esophagus grade II with icteric mucosa and a large varix of the fundus also with icteric mucosa. In addition, the patient suffers from vitiligo.

Pneumatosis Cystoides Intestinalis

Video Endoscopic Sequence 2 of 27.

Pneumatosis Cystoides Intestinalis

The colonoscopy, which was performed, because the tomography had generalized thickening of the walls os the colon.

Colonoscopy found multiple submucosal lesions of cystic appearance. In different segments from the sigmoid to ascending colon.

Pneumatosis cystoides intestinalis (PCI) is a rare condition that may be associated with a variety of diseases. The presenting clinical picture may be very heterogeneous and represent a challenge for the clinician.

Diagnosis might be suggested by a simple X-ray of the digestive tract showing a change in the characteristics of the intestinal wall in two-thirds of these patients. However, one third of the patients do not have a suggestive X-ray and require a computed tomography (CT) scan/nuclear magnetic resonance that may reveal a thickened bowel wall containing gas to confirm the diagnosis and distinguish PCI from intraluminal air or submucosal fat. CT also allows the detection of additional findings that may suggest an underlying, potentially worrisome cause of PCI such as bowel wall thickening, altered contrast mucosal enhancement, dilated bowel, soft tissue stranding, ascites and the presence of portal air. Our results also point out that clinicians and endoscopists should be aware of the possible presentations of PCI in order to correctly manage the patients affected with this disease and avoid unnecessary surgeries. The increasing number of colonoscopies performed for colon cancer screening makes PCI more frequently casually encountered and/or provoked, therefore the possible endoscopic appearances of this disease should be well known by endoscopists.

 

Pneumatosis Cystoides Intestinalis

Video Endoscopic Sequence 3 of 27.

Pneumatosis Cystoides Intestinalis

The ileocecal valve with jaundice

Primary versus secondary pneumatosis intestinalis

Pneumatosis intestinalis occurs in 2 forms. Primary pneumatosis intestinalis (15% of cases) is a benign idiopathic condition in which multiple thin-walled cysts develop in the submucosa or subserosa of the colon. Usually, this form has no associated symptoms, and the cysts may be found incidentally through radiography or endoscopy. When the cysts protrude into the lumen, they may mimic polyps or carcinomas, as shown on barium enema studies. This primary form is often termed pneumatosis cystoides intestinalis.

The secondary form (85% of cases) is associated with obstructive pulmonary disease, as well as with obstructive and necrotic gastrointestinal disease.
Microvesicular gas collections, defined as 10-100 mm cysts or bubbles within the lamina propria, are predominantly associated with primary (benign) pneumatosis intestinalis, whereas linear or curvilinear gas collections seen parallel to the bowel wall are found in secondary pneumatosis. Therefore, linear gas collections are usually an ominous sign.

Pneumatosis intestinalis is usually identified on plain radiographs of the abdomen. Occasionally, submucosal cysts may be identified during endoscopy. The cysts, which may appear similar to polyps, may be examined at biopsy for signs of inflammation. Gas may collect peripherally in the lumen of the bowel, around fecal or contrast material. This gas can simulate pneumatosis and is usually depicted on CT scans. Rarely, emphysematous ureteritis may simulate pneumatosis of the descending or sigmoid colon on plain radiographs. Colitis cystica profunda is an extremely rare disease in which mucin-filled cysts form in the wall of the rectum.

 

Pneumatosis Cystoides Intestinalis

Video Endoscopic Sequence 4 of 27.

There is a long path of the terminal ileum with jaundice

Pneumatosis cystoides intestinalis (PCI) is a rare disease characterized by the presence of gaseous cysts containing nitrogen, hydrogen and carbon dioxide in the intestinal wall that may be iatrogenic or associated with a wide variety of conditions.

In particular, the cysts are located beneath the serosa and mucosa of the intestine with an increase, in recent years, of cases of colonic localization due to an increase in the number of examinations with barium and colonoscopies.

The exact etiology of the disease is still unknown. PCI may appear in association with ileal surgery[, colonoscopies, chronic pulmonary disease, connective tissue disorders and ingestion of sorbitol or lactulose.

 

Pneumatosis Cystoides Intestinalis

Video Endoscopic Sequence 5 of 27.

Pneumatosis Cystoides Intestinalis

Various theories have been proposed: mechanical, bacterial and pulmonary. According to the mechanical theory, the bowel gas is pushed through a mucosal defect into lymphatic channels and is then distributed distally by peristalsis[. This may happen secondarily to a bowel obstruction that may be caused by trauma, surgery and colonoscopy leading to increased intraluminal pressure and this could explain the association between these maneuvers and PCI. However this theory does not explain the high content of hydrogen present in the cysts.

 

Pneumatosis Cystoides Intestinalis

Video Endoscopic Sequence 6 of 27.

Pneumatosis Cystoides Intestinalis

In this video clip displays abundant air that emerges when the biopsy forceps breaks one of the cysts.

The bacterial theory proposes that submucosal localization of fermenting Clostridia and Escherichia Coli leads to the production of gas which is retained by the submucosa and lymphatic channels. In fact, in animal experiments the introduction of bacteria in the gut wall by injection causes the pneumatosis and these cysts have a high content of hydrogen. This theory is also supported by the resolution of pneumatosis with the use of metronidazole for bacterial overgrowth.

The pulmonary theory is demonstrated in patients with asthma and chronic bronchitis and argues that the gas freed by the rupture of the alveoli, travels through the mediastinum into the retroperitoneal space and then comes through the perivascular spaces in the intestinal wall.

Some recent reports[ show an association between PCI and treatment with alpha-glucosidase inhibitor. The explanation would be the fermentation of carbohydrates by the intestinal bacterial flora with production of intestinal gas. The absorption of these carbohydrates is inhibited by α GI.

 

Pneumatosis Cystoides Intestinalis

Video Endoscopic Sequence 7 of 27.

Pneumatosis Cystoides Intestinalis

This sign may be a harbinger of life-threatening pathologies such as bowel ischemia, obstruction, or toxic megacolon. On barium studies and endoscopy, it may appear similar to polyps; therefore, recognition of this condition is very important in order to avoid inadvertent resection that can potentially lead to complications such as frank perforation.

 

 

 

Pneumatosis Cystoides Intestinalis

Video Endoscopic Sequence 8 of 27.

Pneumatosis Cystoides Intestinalis

 


Rectal varices

Video Endoscopic Sequence 9 of 27.

Rectal varices and Pneumatosis Cystoides Intestinalis

As part of its portal hypertension varices of the rectum and rectal mucosa with jaundice are displayed.

 

 

Pneumatosis Cystoides Intestinalis

Video Endoscopic Sequence 10 of 27.

Pneumatosis Cystoides Intestinalis

Computed tomography shows aimage of the colon with thickening of the walls.

Abdominal CT scanning can depict small amounts of intramural gas not shown on routine radiographs. Depending on the morphology, distention, and thickness of the bowel loops, CT scanning helps to provide clues to the cause of pneumatosis intestinalis. With contrast enhancement, thickened bowel wall may suggest ischemia in the setting of pneumatosis. Dilated bowel loops and abnormal fluid levels suggest an obstructive cause of pneumatosis.

Sensitivity in detecting small, gaseous inclusions in the mesenteric vein or intrahepatic branches of the portal vein is increased with abdominal CT scanning. In this circumstance, pneumatosis is one of the signs of mesenteric ischemia.
CT scans provide additional details, such as various morphologic changes (including mural wall thickening, dilatation, abnormal or absent wall enhancement), mesenteric stranding, edema or hemorrhage, vascular engorgement, ascites, and portomesenteric gas.

 

 

 

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Pneumatosis Cystoides Intestinalis

Video Endoscopic Sequence 11 of 27.

Pneumatosis Cystoides Intestinalis

Computed tomography shows aimage of the colon with thickening of the walls.

CT scanning is often helpful in determining the primary cause of pneumatosis intestinalis, and it can demonstrate important coexistent findings or complications. The use of multidetector-row CT scans, thin sections, and high-quality portal venous phase scans are advantageous for providing greater accuracy in the detection of ischemia, as well as for diagnosing other causes of acute abdomen, such as perforation, abscess formation, and peritonitis.
The sensitivity of CT scanning (82%) for the diagnosis of acute bowel ischemia is comparable to that of angiography (87.5%).

 

 

 

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Pneumatosis Cystoides Intestinalis

Video Endoscopic Sequence 12 of 27.

Pneumatosis Cystoides Intestinalis

Computed tomography shows aimage of the colon with thickening of the walls.

 

 

 

 

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Pneumatosis Cystoides Intestinalis

Video Endoscopic Sequence 13 of 27.

Pneumatosis Cystoides Intestinalis

Computed tomography shows aimage of the colon with thickening of the walls.

 

 

 

 

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Pneumatosis Cystoides Intestinalis

Video Endoscopic Sequence 14 of 27.

Pneumatosis Cystoides Intestinalis

Video clip of Computerized axial tomography

 

Pneumatosis Cystoides Intestinalis

Video Endoscopic Sequence 15 of 27.

Pneumatosis Cystoides Intestinalis

Video clip of Computerized axial tomography

 

Pneumatosis Cystoides Intestinalis

Video Endoscopic Sequence 16 of 27.

The oropharynx with marked jaundice


 

 

 

 

 

Pneumatosis Cystoides Intestinalis

Video Endoscopic Sequence 17 of 27.

Esophageal Varices grade II and mucosa with jaundice are observed. Which were banding 4 days later.

 

Pneumatosis Cystoides Intestinalis

Video Endoscopic Sequence 18 of 27.

A varix of the gastric fundus is observed also with marked jaundice.

 

 

 

Palatine tonsils

Video Endoscopic Sequence 19 of 27.

A Palatine tonsils with marked jaundice

 

Vitiligo ictericia

Video Endoscopic Sequence 20 of 27.

The patient suffers of vitiligo, in this video clip: the contrast of vitiligo with marked jaundice is observed.

 

 

Vitiligo ictericia

Video Endoscopic Sequence 21 of 27.

The marked jaundice and the contrast with vitiligo spots are shown.

 

 

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Vitiligo ictericia

Video Endoscopic Sequence 22 of 27.

Another image of jaundice with vitiligo

 

 

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Vitiligo ictericia

Video Endoscopic Sequence 23 of 27.

Another image of jaundice with vitiligo

 

 

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Vitiligo ictericia

Video Endoscopic Sequence 24 of 27.

Another image of jaundice with vitiligo

 

 

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Vitiligo ictericia

Video Endoscopic Sequence 25 of 27.

Another image of jaundice with vitiligo

 

 

 

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Vitiligo ictericia

Video Endoscopic Sequence 26 of 27.

Another image of jaundice with vitiligo

 

 

 

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Vitiligo ictericia

Video Endoscopic Sequence 27 of 27.

Another image of jaundice with vitiligo

 

 

 

 

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