Pneumatosis intestinalis in the pediatric oncology population: An 11-year retrospective review at Memorial Sloan Kettering Cancer Center

Abstract

Background: Pneumatosis intestinalis (PI) is characterized by the presence of intramural gas in the gastrointestinal (GI) tract. The overall aim of this study was to review risk factors and outcome of pediatric oncology patients at our institution who developed PI.

Procedure: Patients diagnosed with PI between 2007 and 2018 were identified from ICD-10 coding of radiology reports at Memorial Sloan Kettering Kids, a tertiary pediatric oncology center. Outcomes of interest were (a) resolution and time to resolution of PI, (b) surgical intervention within 2 weeks of diagnosis of PI, or (c) death secondary to PI. To capture the resolution of PI, we defined the "time to recovery (TTR)" as the time elapsed between date of PI diagnosis and the date of recovery.

Results: Forty-two patients were identified. Within 30 days of diagnosis of PI, three patients had surgical intervention for PI (7%) and two patients died (5%) due to non-PI causes. Median TTR of PI was 4.5 days (95% CI: 3-7 days). In univariable and multivariable analyses, only steroid use in the prior 30 days was significantly associated with a faster TTR of PI (HR = 2.27 [95% CI: 1.17-4.41], p = .02).

Conclusions: This is the largest case series of patients with PI in the pediatric oncology population, which reveals significantly lower surgical and mortality rates than other published PI series. For the majority of patients, conservative medical management is indicated. A prospective study is warranted to define diagnosis and management guidelines for PI in the pediatric oncology population in a cooperative group setting.

Keywords: general; hematology/oncology; intensive care; pain; pediatric oncology; pneumatosis intestinalis; support care.

FIGURE 1.

A 3-year-old girl with high risk pre-B cell acute lymphoblastic leukemia. A. Extensive pneumatosis is shown on KUB (arrows). B. Abdominal CT scan confirmed severe pneumatosis of entire right colon (arrows). C. CT abdomen demonstrated intraperitoneal free air (arrows). D. Cross-table lateral x-ray demonstrates small volume free air (arrows). E. CT abdomen with air seen in the portal vein on cross-sectional views (arrows). F. Area of colon with pneumatosis appears distended. G. Air in the bowel wall (red arrow) and omentum (black arrow) over the transverse colon (black arrow). H. Transverse colon shows pneumatosis (red arrow) next to healthy bowel (black arrow).

FIGURE 2.

Cumulative Incidence curve of patients with pneumatosis intestinalis (PI) representing time to first sign of recovery (TTR), defined as advancement of diet, resolution of PI on imaging, or de-escalation of antibiotics. N=40 of N=42 patients had a recovery. Patients who died before resolution were treated as competing events. (PI = pneumatosis intestinalis)

FIGURE 3.

Time to any form of recovery of the N=40 patients who had a recovery of their PI, regardless of which recovery occurred first. Any (first) resolution N=40, Imaging N=26, Advanced diet N=31, Discontinued Antibiotics N=12, De-escalated Antibiotics N=10. There were 7 extreme variables (>30 days) excluded from the figure for the following modalities: Any resolution (64 days), Imaging (39, 47, 64, 103 and 142 days) and Deescalated AB (1097 days). (AB=antibiotics)