Chronic intestinal pseudo-obstruction with pneumatosis cysto
A 68-year-old woman, who has been well managed for her SSc condition using 5 mg/d of prednisone as a maintenance dosage for the past 6 years, was admitted to our hospital with mild abdominal fullness for 3 months for the first time. On admission, physical examination showed only mild abdominal fullness without tenderness and rebound tenderness in her entire abdomen. Abdominal X-ray and contrast-enhanced computed tomography (CT) images showed PCI and pneumoperitoneum findings without mechanical obstructions. In spite of the significant imaging findings, there was no critical complaint from the patient, and there were no abnormalities in any of the laboratory results or blood and faecal culture examinations.

According to the image findings, we diagnosed as initial onset of CIPO from SSc accompanied with PCI and pneumoperitoneum and planned further investigations for her bowel peristaltic activity by using cine MRI with observation under fasting state.

This patient underwent cine MRI before initiation of treatment (Fig. 3). All images were acquired on a 3.0-Tesla (3T) Siemens MAGNETOM trio. To make clear visualization of the distended small intestine, the patient drank 500 mL of water before the examination of cine MRI. The each successive scan of cine MRI was gotten within about 1 second. The cine MRI images showed manifest peristaltic malfunction in the right lower small bowel, whereas sufficient intestinal movement with PCI findings could be observed in the left upper small bowel. Intestinal dilatation of the small bowel was noticeably seen in the entire small intestine.

Based on the results of cine MRI, we started multidrug therapy including 15 g/d of Daikenchuto, 750 mg/d of Metronidazole and Sodium Picosulfate for improving the bowel peristaltic movement and decreasing intestinal gas production. After confirming the improvement of abdominal fullness, we re-evaluated her bowel peristaltic activity by using 3T cine MRI and could find the crucial amelioration of peristaltic movement, especially in the right lower small bowel, which had mainly shown the peristaltic malfunction, and the marked reduction of intestinal gas volume. The observation suggests that the peristaltic malfunction of a part of the small intestine might be the origin of her digestive disorder, which occurred from SSc. Finally, the patient was discharged from our hospital and has been able to keep in satisfactory intestinal condition with stable medical status by continual multidrug therapy in our outpatient clinic without any surgical interventions for around 1 year.

Source: Medicine: May 2019 - Volume 98 - Issue 18 - p e15480

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