pneumatosis sistoides intestinalis ( psi ) a rare condition that is characterized by gas - filled cysts in the intestinal submucosa and subserosa .
psi may occur as primary or secondary and often seen terminal ileum in the gastrointestinal tract .
respiratory infections , tumor or collagen disease , traumas , immunosuppression and the use of steroids are associated with psi .
imaging tools , endoscopy , surgery and sometimes pathological examinations are used in the diagnosis .
although psi is usually benign disease , sometimes high mortality is observed . in asymptomatic patients
are used hyperbaric oxygen treatment , antibiotics and rest to bowel ; in patients with signs of peritonitis are recommended to surgical treatment .
we want to discuss 3 case of with psi that followed - up and treated in our clinic .
a male patient aged 62 was hospitalized for emergency treatment of previously diagnosed free air under the diaphragm . at the time of arrival the patient reported supraumbilical pain , nausea and vomiting in the past two weeks .
the problems of abdominal discomfort and pain connected with taking food had started 21 years earlier , with intermittent remissions and there was a history of stomach bleeded before 15 years . a few months before , the intensity of the symptoms had increased and continued with nausea , vomiting and weight loss ( 15  kg in a year ) and his body mass index ( bmi ) was 17  kg / m .
he often received proton pomp inhibitors and there was not history of gastroscopy . on physical examination
the abdomen was tenderness and defense at palpation in the epigastrium . in laboratory analysis hemoglobin was 10.3 
contrast - enhanced abdominal ct was detected free - air in the abdomen ( fig .
2 ) . the patient was admitted and prepared for the operating theatre where the operation was started .
after opening the abdominal cavity and exploration , the following finding was present : stenotic pylorus with an abnormally increased stomach and gas - filled cysts were seen in the terminal ileum ( figs .
after that we decided to make the first resection of that antrectomy and were performed retrocolic , isoperistaltic gastrojejunostomy .
specimens were sent to the pathology department . at first , when the specimen sections from the ileum and proximal colon ; macroscopic findings were noted that cystic lesions were filled with air and in greatest diameter 2  cm . under the microscope ,
additionally , the cysts were not communicated with each other and in different sizes which means that the finding at the terminal ileum was pneumatosis cystoides intestinalis ( figs .
at second , operative material of stomach with increased dimensions , decreased elasticity , tall and prominent mucosal folds without macroscopic erosions and ulcerations , astenotic place on the pylorus with the lumen passable for 0.6  cm ( fig .
3 ) . microscopic finding , there was seen chronic inflammatory infiltration with lymphocytes and intestinal metaplasia into the antrum with bleeding erosions focus and an oedematic edge of the pylorus .
he resumed normal activity in the follow- up visit 1 month after the second surgery .
a male patient aged 70 was admitted with abdominal pain and vomiting in emergency room .
he has received proton pump inhibitor therapy for long years and weight loss ( bmi  =  17  kg / m ) .
the abdomen was tenderness and defense at palpation in the epigastrium and upper right quadrant .
x - ray showed to free - air under diaphragm . in the laboratory white blood cell was 9 10/l and amylase was 220 
intraperitoneal free air and millimetric contrast agent leakage in curvature minor of the stomach has been detected with contrast - enhanced abdominal ct .
were seen gas - filled cysts in the terminal ileum and pyloric stenosis that 2    1  cm diameter and permitting passage .
he was discharged on postoperative day 8 and performed upper gastrointestinal endoscopy a month later .
we detected pyloric stenoses that did not allow of endoscop passage in to the duodenum .
pathology reports were benign and determined diffuse intestinal metaplasia and widespread involvement of helicobacter pylor .
the patient resumed normal activity in the follow - up visit 20 day after the surgery .
a male patient aged 81 was admitted with abdominal pain from internal medicine of clinics .
the patient had been operated before 4 years and had congestive heart failure , chronic lung disease and prostate disease .
was detected median incision scar and only tenderness at palpation in the epigastrium and there was no acute abdomen .
the patients had gas or stool output and white blood cell was 5.6    10/l .
free - air was determined under diaphragm and intraperitoneal in x - ray and abdomen ct , respectively .
upper gastrointestinal endoscopy and colonoscopy were performed and detected hiatus hernia , erythematous pangastritis and grade 2 internal hemorrhoids .
the 2 - 4  lt / dk oxygen and antibiotic therapy were given to patients .
a male patient aged 62 was hospitalized for emergency treatment of previously diagnosed free air under the diaphragm . at the time of arrival the patient reported supraumbilical pain , nausea and vomiting in the past two weeks .
the problems of abdominal discomfort and pain connected with taking food had started 21 years earlier , with intermittent remissions and there was a history of stomach bleeded before 15 years .
a few months before , the intensity of the symptoms had increased and continued with nausea , vomiting and weight loss ( 15  kg in a year ) and his body mass index ( bmi ) was 17  kg / m .
he often received proton pomp inhibitors and there was not history of gastroscopy . on physical examination
the abdomen was tenderness and defense at palpation in the epigastrium . in laboratory analysis hemoglobin was 10.3 
contrast - enhanced abdominal ct was detected free - air in the abdomen ( fig .
2 ) . the patient was admitted and prepared for the operating theatre where the operation was started .
after opening the abdominal cavity and exploration , the following finding was present : stenotic pylorus with an abnormally increased stomach and gas - filled cysts were seen in the terminal ileum ( figs .
after that we decided to make the first resection of that antrectomy and were performed retrocolic , isoperistaltic gastrojejunostomy .
specimens were sent to the pathology department . at first , when the specimen sections from the ileum and proximal colon ; macroscopic findings were noted that cystic lesions were filled with air and in greatest diameter 2  cm . under the microscope ,
additionally , the cysts were not communicated with each other and in different sizes which means that the finding at the terminal ileum was pneumatosis cystoides intestinalis ( figs .
at second , operative material of stomach with increased dimensions , decreased elasticity , tall and prominent mucosal folds without macroscopic erosions and ulcerations , astenotic place on the pylorus with the lumen passable for 0.6  cm ( fig .
3 ) . microscopic finding , there was seen chronic inflammatory infiltration with lymphocytes and intestinal metaplasia into the antrum with bleeding erosions focus and an oedematic edge of the pylorus .
he resumed normal activity in the follow- up visit 1 month after the second surgery .
a male patient aged 70 was admitted with abdominal pain and vomiting in emergency room .
he has received proton pump inhibitor therapy for long years and weight loss ( bmi  =  17  kg / m ) .
the abdomen was tenderness and defense at palpation in the epigastrium and upper right quadrant .
x - ray showed to free - air under diaphragm . in the laboratory white blood cell was 9 10/l and amylase was 220  u / l .
intraperitoneal free air and millimetric contrast agent leakage in curvature minor of the stomach has been detected with contrast - enhanced abdominal ct .
were seen gas - filled cysts in the terminal ileum and pyloric stenosis that 2    1  cm diameter and permitting passage .
he was discharged on postoperative day 8 and performed upper gastrointestinal endoscopy a month later .
we detected pyloric stenoses that did not allow of endoscop passage in to the duodenum .
pathology reports were benign and determined diffuse intestinal metaplasia and widespread involvement of helicobacter pylor .
the patient resumed normal activity in the follow - up visit 20 day after the surgery .
a male patient aged 81 was admitted with abdominal pain from internal medicine of clinics .
the patient had been operated before 4 years and had congestive heart failure , chronic lung disease and prostate disease .
was detected median incision scar and only tenderness at palpation in the epigastrium and there was no acute abdomen .
the patients had gas or stool output and white blood cell was 5.6    10/l .
free - air was determined under diaphragm and intraperitoneal in x - ray and abdomen ct , respectively .
upper gastrointestinal endoscopy and colonoscopy were performed and detected hiatus hernia , erythematous pangastritis and grade 2 internal hemorrhoids .
the 2 - 4  lt / dk oxygen and antibiotic therapy were given to patients .
pneumatosis sistoides intestinalis ( psi ) a rare condition that is characterized by gas - filled cysts in the intestinal submucosa and subserosa , is most frequently observed in the terminal ileum of gastrointestinal tract .
psi is more frequently seen in the first days of life and 60 years of age and its estimated prevalence is 0.03% .
its etiology is unclear and there are plenty of theories about the pathogenesis of pnemautosis intestinalis , including mechanical , bacterial , pulmonary , and caused by the increase in the mucosa permeability .
our 3 patients were over the age of 60 and gas - filled cystic lesions were localized in the ileum .
h. pylori can be considered in etiology of psi that identified in the biopsy of 3 patients ( figs .
pneumatosis cyistoides intestinalis is classified as primary disease ( 15% ) of unknown cause and secondary ( 85% ) associated to gastrointestinal diseases , as intestinal obstruction , cystic fibrosis , peptic ulcer , diverticula , inflammatory bowel disease , mesenteric infarction , chronic intestinal pseudo - obstruction , respiratory infections , tumor or collagen disease , traumas , immunosuppression and the use of steroids .
we believe that psi develops in our three patients which secondary to gastrointestinal obstruction or pyloric stenosis . the history of patient , symptoms and physical examination are important for diagnosis of psi .
diarrhea , constipation , rectal bleeding , tenesmus , nonspecific symptoms such as weight loss and abdominal pain may occur in symptomatic patients .
volvulus , intestinal obstruction , blood pressure pneumoperitoneum , rectal bleeding , intussusception and intestinal perforation can be seen by 3% .
there was rectal bleeding in a patient and in three of our patients had abdominal pain and weight loss ( table 1 ) .
these include plain radiographs , usg , barium series , ct , ct - colonoscopy , magnetic resonance imaging and mri - colonography , endoscopy , colonoscopy . x - ray can show intraperitoneal free - air and abdominal ct can detect pneumoperitoneum , portomesenteric venous air , bowel wall thickening , bowel dilatation .
reported in their work of eighty - four patients that importance of ct in the diagnosis of psi .
a definitive diagnosis is difficult with the upper gastrointestinal endoscopy and colonoscopy , because of submucosal cysts can be mixed with polyps .
a laparoscopic exploration is quite useful to confirm a pci diagnosis , if the physical examination findings are suspicious , and particularly in cases that are not preoperatively diagnosed clearly using the above - mentioned radiological methods .
diagnostic laparoscopy provides the convenience of converting to open surgery as well as confirming the diagnosis .
treatment of psi depends on the underlying cause , so that include elemental diet , antibiotics , steroids , hyperbaric oxygen therapy and surgery
. in asymptomatic patients with free - air at x - ray and abdominal ct reporting gastrointestinal perforation direction , is a great handicap for the surgeon .
so we should be careful in the diagnosis of disease . because of spontaneous remission can see rate of 50% in treating the disease and may occur gas - filled cysts again after surgery .
conservative approaches , including nasogastric 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 . in asymptomatic patients
can be given hyperbaric oxygen ( hbo ) or absolute atmospheres ( non - hbo ) therapy may be given .
oxygen therapy has long been recognized as an effective therapy for pi , leading to cyst regression on imaging and symptom resolution .
applying 250  mmhg po2 pressure or 70% oxygen inhalation for 5  days or 2.5 atmospheres of hyperbaric oxygen pressure for 150  min / day for 3 consecutive days can lead to resolution of gas collection within a cyst .
. gave hbo therapy to seven patients and atmospheres absolute ( ata , non - hbo ) to 20 patients in asymptomatic patients with psi .
hbo therapy was given mean of 4.7 days , ata treatment was given mean of 14.6 days and have found lower recurrence rates . in asymptomatic patients with psi is not necessary surgery treatment .
early surgical intervention should be considered in any patient with signs of perforation , peritonitis , sespsis or predictors of poor outcomes .
emergency surgery should be considered in psi patients with the ph is less than 7.3 , actual bicarbonate level is less than 20 , amylase is higher than 200 
similarly , patients who are immunosuppressed with underlying liver disease , sepsis , and hypotension are all at a higher risk of mortality from pi .
radiologically , the presence of portal venous gas is highly indicative of severe disease , and when present , mortality rates range from 37% to 75% ( 7 , 22 ) . in patients with symptomatic psi , laparotomy and laparoscopic exploration
arkanolu et al . in a series of seven cases showed that safely performed ileal resection and anastomosis in 3 patients , underwent laparotomy in 2 patients , choledocotomy , drainage and cholecystectomy in a patient , and laparoscopic exploration in a patient .
we performed to 2 patients ileal and cecal resection and anastomosis with antrectomy and gastroentorostomy .
pneumatosis intestinalis is a rare condition that may be occur a sign of an underlying systemic disease . in psi patients with peritonitis
mehmet aziret contributed in study concept , design , data collection and writing the paper .
 introductionpneumatosis sistoides intestinalis ( psi ) is a rare condition with unknown origin , defined as the appearance of gas - filled cysts in the intestinal wall . 
 it usually occurs due to respiratory infections , tumor or collagen disease , traumas , immunosuppression.presentation of casethree patients with psi were examined that followed up and treated in our clinic . 
 the first patient was hospitalized for emergency treatment of previously diagnosed free - air under the diaphragm . 
 he had a defense on physical examination and free - air was detected in x - ray and abdomen ct . 
 we decided to laparatomy and peroperatively , stenotic pylorus with an abnormally increased stomach and gas - filled cysts were seen in the terminal ileum . 
 antrectomy and gastrojejunostomy with partial ileum and cecum resection and end ileostomy were performed . 
 the second patient underwent laparatomy because of intraperitoneal free - air and acute abdomen . 
 partial ileum and cecum resection and ileotransversostomy were performed . 
 the third patient with intraperitoneal free - air was treated with antibiotics , oxygen treatment and bowel rest.discussionpsi is usually asymptomatic . 
 plain radiographs , usg , ct , upper gastrointestinal endoscopy , colonoscopy can use for diagnosis . 
 treatment of psi depends on the underlying cause ; include elemental diet , antibiotics , steroids , hyperbaric oxygen therapy and surgery.conclusionin patients with asymptomatic and symptomatic psi are different treat . 
 symptomatic psi can be safely treated antrectomy and gastrojejunostomy with partial ileum and cecum resection . 
Introduction
Case report 1
Case report 2
Case report 3
Discussion
Conclusion
Conflict of interest
Funding
Ethical approval
Author contributions