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CT Predictors For Differentiating Benign And Clinically

Worrisome Pneumatosis Intestinalis In


Children Beyond The Neonatal Period

Sony Sutrisno
INTRODUCTION

• Pneumatosis intestinalis (PI)  presence of gas in the bowel


wall

• Diagnostic entities benign conditions -- high morbidity

• Benign and clinically worrisome pathologic causes


INTRODUCTION

Benign Clinically worrisome


• Selflimited • Requires specific medical therapy

• Resolves without specific therapy • Intestinal ischemia

• Asthma or bronchitis • Bowel obstruction


• Scleroderma, systemic lupus • Enteritis
erythematosus,
• Colitis
• Acquired immunodeficiency
syndrome • Trauma

• Postsurgical anastomoses or
endoscopy

• Organ transplantation
INTRODUCTION
CT imaging findings

• Linear pattern vs bubblelike or cystic pattern (benign)

• Portal venous gas

• Bowel wall thickening

• Abnormal mucosal enhancement that is either absent or intense

• Bowel dilatation

• Arterial occlusion

• Ascites

• Hepatic portomesenteric venous gas


MATERIALS AND METHODS
PATIENTS
• CT reports from an 8-year period (July 2000–July 2008)

• Categories for underlying medical diagnosis

• Immunosuppression, bowel disorders, postsurgical operation, neurologic


impairment, cystic fibrosis
• Grouped into one of two final diagnosis categories
• Benign and clinically worrisome pathologic causes of PI
• Benign PI was a diagnosis of exclusion
PATIENTS

• Criteria for a final diagnosis of benign PI included

• PI at serial imaging without targeted therapeutic intervention


and lack of pathologic or laboratory evidence of a specific
underlying bowel disease

• Patients undergoing diagnostic laparoscopy that did not


demonstrate findings other than PI
PATIENTS

• Pathologic or laboratory evidence of a bowel disease with


potential associated morbidity or mortality

• Resultant specific medical or surgical intervention

• Patients who did not meet the criteria for benign PI and were
suspected of having underlying disease but without definitive
diagnosis were considered in a subgroup of clinically worrisome
PI, labeled suspected rather than definitive
CT EXAMINATION TECHNIQUE

• Low-dose technique

• Standard 120 kilovolt, thickness 5 mm

• IV Contrast : volume 2 mL/kg, for a volume of up to 120 mL

• Enteric contrast
CT IMAGE EVALUATION
Categorized

• Mild PI  fewer than five “bubbles”

• Moderate PI  as between five low-attenuation areas and too numerous to


count

• Extensive PI  as too numerous to count low-attenuation areas over a large


distribution

Morphology  Linear, cystic, mixed


CT IMAGE EVALUATION
• Soft-tissue thickness of bowel wall 2 mm

• Periintestinal soft-tissue stranding (linear areas of soft-tissue attenuation in


the fat adjacent to bowel)

• Free peritoneal air

• Free peritoneal fluid

• Portal venous gas

• Bowel dilatation (more than three segments 2.5 cm in diameter)

• Small-bowel obstruction
RESULTS
RESULTS

• Abdominal CT depicted PI in 44 patients

• Mean age, 8.45 years; range, 6 months to 18 years

• 27 male (mean age, 7.84 years; range, 7 months to 18 years)

• 17 female (mean age, 8.42 years; range, 6 months to 18 years)


UNDERLYING MEDICAL DIAGNOSES

• Immunosuppression in 24 patients

• Bowel disorders in seven patients

• Postsurgical operation in five patients

• Neurologic mpairment in four patients

• Cystic fibrosis in one patients

• Three healthy children


TYPE OF PI

• Benign PI in 15 patients

• 29 had associated underlying boweldisease

• Definitive  n 26

• Suspected butnot defined  n 3


CT FINDINGS AND RELATIONSHIP TO BENIGN
VERSUS CLINICALLY WORRISOME PI
Clinically worrisome vs benign

• Soft-tissue bowel wall thickening (51.2% vs 13.3%, p .0167)

• Free peritoneal fluid (82.8% vs 33.3%, p .002)

• Extent of PI (extensive 17.2% vs 69%, p .001)

• Peribowel soft-tissue stranding (55.2% vs 20.0%, p .0228)

• Other CT findings evaluated PI distribution, free peritoneal air, and


morphology (linear vs cystic) were not good discriminators (all P .05)
DISCUSSION
• CT findings that were significantly different in patients with clinically worrisome compared
with those with benign causes of PI

• Free peritoneal fluid

• Softt issue bowel wall thickening

• Extent of PI

• Peri intenstinal soft-tissue stranding

• Free peritoneal fluid

• Since the clinically worrisome causes of PI are related to either ischemia or inflammation

 CT findings associated with inflammation such as bowel wall thickening, peribowel


softtissue stranding, or free peritoneal fluid
DISCUSSION
• The extent (mild, moderate, extensive) of PI (P .001)

 with more extensive PI more commonly associated with benign disease

• Characterization of PI as linear or cystic, free peritoneal air and portal


venous gas was not useful
DISCUSSION
• PI can be seen in children beyond the neonatal period due to a wide variety of
underlying medical conditions

• The most common underlying causes were

• Related to immunosuppressive therapy

• Underlying bowel disorders

• Postsurgical status

• Neurologic impairment

• Previous study  portal venous gas was considered indicative of clinically


worrisome

• In this study  portal venous gas in both benign and clinically worrisome
DISCUSSION
• One of the final conclusions of the McCarville et al study (13) was that male
children may be at increased risk of benign PI

• This conclusion is in agreement with findings in a previous study

• In our study, male patients were also disproportionately represented,


compared with female patients, twenty-seven (61%) of the 44 patients
identified were male
LIMITATIONS
• Change in the approach to the treatment of these children

• Through experience  extensive PI even with associated free intra


peritoneal air was often a benign self-limited condition

• Laparoscopic evaluation  no peritoneal soiling or need for intervention,


the patients were increasingly treated conservatively over time

• Early in the study period, an asymptomatic patient with PI and free


peritoneal air would probably be examined  now, probably would not
CONCLUSION
• CT predictors for differentiating benign versus clinically worrisome causes of PI :

• Soft-tissue thickening of the bowel wall

• Free intraperitoneal fluid

• Extent of PI

• Periintestinal soft-tissue stranding

• More extensive PI correlated with increase in the frequency of benign PI

• Characterization of PI as cystic or linear is not an accurate parameter

• The presence of free intraperitoneal air or portal venous gas does not necessarily
imply a clinically worrisome cause of PI
THANK YOU