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    "titulo" => "Abdominal pain&#44; <span class="elsevierStyleItalic">pneumatosis intestinalis</span> and <span class="elsevierStyleItalic">aeroportia</span> in a hemodialyzed patient"
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          "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Abdominal contrast-enhanced computed tomography showing large areas of hepatic portal venous gas &#8211; <span class="elsevierStyleItalic">aeroportia</span> &#40;white arrows&#41;&#46;</p>"
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Hemodialyzed patients frequently experience various symptoms intrinsic to the dialysis session&#44; some reflecting acute complications of the procedure&#46; Hypotension is the most common complication&#44; affecting 25&#8211;55&#37; of patients&#44;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> and is not infrequently accompanied by nausea&#44; vomiting&#44; headache&#44; and chest and&#47;or abdominal pain&#46; We present a 51-year-old man with end-stage renal disease receiving hemodialysis&#44; that presented with abdominal pain due to non-occlusive mesenteric ischemia&#44; with <span class="elsevierStyleItalic">aeroportia</span> and <span class="elsevierStyleItalic">pneumatosis intestinalis</span>&#44; unusual findings&#44; but increasingly found in dialysis patients&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Case report</span><p id="par0010" class="elsevierStylePara elsevierViewall">A 51-year-old man with diabetic nephropathy on hemodialysis for the past four years presented to our emergency department because of sudden onset of excruciating abdominal pain&#44; with bilateral dorsal irradiation&#44; nausea and vomiting&#46; He was otherwise asymptomatic until one hour after beginning his regular hemodialysis session&#44; when the pain suddenly began&#46; The dialysis session was interrupted and he was brought to our hospital&#46; Physical examination revealed arterial hypotension &#40;blood pressure 80&#47;64<span class="elsevierStyleHsp" style=""></span>mmHg&#41;&#44; tachycardia &#40;130&#47;min&#41;&#44; painful abdominal palpation with signs of peritoneal irritation&#44; and absence of bowel sounds&#46; The patient was afebrile and had a normal pulmonary auscultation&#46; The rectal touch was negative for bloody stools or melena&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The results of laboratory examinations were unremarkable&#44; except for a mildly elevated C-reactive protein &#40;3&#46;43<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#41; and elevations in plasma creatinine and urea &#40;6&#46;3<span class="elsevierStyleHsp" style=""></span>mg&#47;dL and 61<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#44; respectively&#41;&#46; Both chest X-ray and plain radiography of the abdomen were normal&#46; The electrocardiogram revealed sinusal tachycardia&#44; and no signs of ischemic myocardial disease&#46; A computed tomography revealed large amounts of air within the portal venous system along its extension&#44; from the colic veins to the distal branches of the intra-hepatic portal vein &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; We also found areas of <span class="elsevierStyleItalic">pneumatosis intestinalis</span> in terminal ileum and ascending colon&#44; suggesting intestinal ischemia &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; Computed tomography multiplan and volumetric reconstructions of mesenteric arteries were performed&#44; and were negative for significant local atherosclerotic disease or thrombosis&#44; suggesting that the pathophysiological process underlying the intestinal ischemia was non-occlusive intestinal hypoperfusion &#40;probably secondary to intradialytic hypotension&#41;&#46; The patient was hemodynamically stabilized&#46; An exploratory laparotomy evidenced necrosis of ileum&#44; ascending&#44; transverse and descending colon&#46; A diagnosis of mesenteric ischemia and necrosis was established&#46; Subtotal colectomy was performed with removal of all colonic segments and the distal 20<span class="elsevierStyleHsp" style=""></span>cm of small intestine&#46; There were no signs of perforation or peritonitis&#46; The surgery had no complications and the hospitalization was held with no intercurrences&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0020" class="elsevierStylePara elsevierViewall">The presence of <span class="elsevierStyleItalic">pneumatosis intestinalis</span> is a rare finding in clinical medicine&#44; and gas accumulation in portomesenteric vessels&#44; or <span class="elsevierStyleItalic">aeroportia</span>&#44; is an even rarer finding&#46; They are both consequence of serious conditions and carry high mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The primary cause is mesenteric ischemia&#44; accounting for about 70&#37; of all cases&#46; Other causes of <span class="elsevierStyleItalic">pneumatosis intestinalis</span> and <span class="elsevierStyleItalic">aeroportia</span> are ulcerative colitis&#44; gastric ulcers&#44; diverticulitis&#44; acute pancreatitis and following invasive procedures&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a><span class="elsevierStyleItalic">Pneumatosis intestinalis</span> can also arise in the context of less serious conditions like asthma or emphysema&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">In patients on chronic hemodialysis there have been some case reports of <span class="elsevierStyleItalic">pneumatosis intestinalis</span> with <span class="elsevierStyleItalic">aeroportia</span>&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#8211;6</span></a> In these patients the pathophysiological mechanism is prolonged central hypoperfusion during dialysis&#44; leading to non-occlusive intestinal necrosis&#46; In addition to this&#44; hemodialyzed patients frequently have membrane changes in enterocytes&#44; with greater predisposition to bacterial translocation into bloodstream&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> In this particular group of patients the microbial flora is heterogeneous&#44; comprising not only aerobial agents&#44; but also anaerobial agents&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Other factors contributing to intestinal ischemia in the hemodialyzed patient appear to be the early and aggressive erythropoietin therapy and vascular calcifications in mesenteric vessels&#44; resulting from deregulated phosphocalcic metabolism&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In those patients in which mesenteric ischemia coexists with <span class="elsevierStyleItalic">aeroportia</span>&#44; the clinician should expect probabilities of transmural necrosis and mortality of&#44; respectively&#44; 91 and 75&#37;&#44;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> reason why the clinical suspicion&#44; early diagnosis and precocious treatment are fundamental&#46; Nonocclusive mesenteric ischemia is thus a recognized and often lethal complication in hemodialysis patients&#44; and its frequency is increasing in this group of patients&#44;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> being about 1&#46;9&#37; per patient-year&#44; compared to 0&#46;09&#8211;0&#46;2&#37; per patient-year in the general population&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;11</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Portal venous gas and <span class="elsevierStyleItalic">pneumatosis intestinalis</span> are rare entities&#44; with increasing incidence in hemodialyzed patients&#46; The pathogenic pathways and risk factors are known&#44; and are almost always preventable with simple measures such as avoiding prolonged periods of intradialytic hypotension and controlling inter-dialytic weight gain&#46; They often cause significant morbidity and mortality&#44; and should always be suspected in patients suffering abdominal pain during or after dialysis sessions&#44; since prompt diagnosis and treatment are key factors for a good outcome&#46;</p></span></span>"
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Clinical communications
Abdominal pain, pneumatosis intestinalis and aeroportia in a hemodialyzed patient
Dolor abdominal, pneumatosis intestinalis y aeroportia en un paciente en hemodiálisis
E. Oliveira
Corresponding author
Eurico.oliveira@gmail.com

Corresponding author.
, P. Manuel, J. Alexandre, I. Coelho, F. Girão
Internal Medicine Department, Centro Hospitalar Tondela-Viseu, King D. Duarte Avenue, 3504-509 Viseu, Portugal
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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Hemodialyzed patients frequently experience various symptoms intrinsic to the dialysis session&#44; some reflecting acute complications of the procedure&#46; Hypotension is the most common complication&#44; affecting 25&#8211;55&#37; of patients&#44;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> and is not infrequently accompanied by nausea&#44; vomiting&#44; headache&#44; and chest and&#47;or abdominal pain&#46; We present a 51-year-old man with end-stage renal disease receiving hemodialysis&#44; that presented with abdominal pain due to non-occlusive mesenteric ischemia&#44; with <span class="elsevierStyleItalic">aeroportia</span> and <span class="elsevierStyleItalic">pneumatosis intestinalis</span>&#44; unusual findings&#44; but increasingly found in dialysis patients&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Case report</span><p id="par0010" class="elsevierStylePara elsevierViewall">A 51-year-old man with diabetic nephropathy on hemodialysis for the past four years presented to our emergency department because of sudden onset of excruciating abdominal pain&#44; with bilateral dorsal irradiation&#44; nausea and vomiting&#46; He was otherwise asymptomatic until one hour after beginning his regular hemodialysis session&#44; when the pain suddenly began&#46; The dialysis session was interrupted and he was brought to our hospital&#46; Physical examination revealed arterial hypotension &#40;blood pressure 80&#47;64<span class="elsevierStyleHsp" style=""></span>mmHg&#41;&#44; tachycardia &#40;130&#47;min&#41;&#44; painful abdominal palpation with signs of peritoneal irritation&#44; and absence of bowel sounds&#46; The patient was afebrile and had a normal pulmonary auscultation&#46; The rectal touch was negative for bloody stools or melena&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The results of laboratory examinations were unremarkable&#44; except for a mildly elevated C-reactive protein &#40;3&#46;43<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#41; and elevations in plasma creatinine and urea &#40;6&#46;3<span class="elsevierStyleHsp" style=""></span>mg&#47;dL and 61<span class="elsevierStyleHsp" style=""></span>mg&#47;dL&#44; respectively&#41;&#46; Both chest X-ray and plain radiography of the abdomen were normal&#46; The electrocardiogram revealed sinusal tachycardia&#44; and no signs of ischemic myocardial disease&#46; A computed tomography revealed large amounts of air within the portal venous system along its extension&#44; from the colic veins to the distal branches of the intra-hepatic portal vein &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46; We also found areas of <span class="elsevierStyleItalic">pneumatosis intestinalis</span> in terminal ileum and ascending colon&#44; suggesting intestinal ischemia &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46; Computed tomography multiplan and volumetric reconstructions of mesenteric arteries were performed&#44; and were negative for significant local atherosclerotic disease or thrombosis&#44; suggesting that the pathophysiological process underlying the intestinal ischemia was non-occlusive intestinal hypoperfusion &#40;probably secondary to intradialytic hypotension&#41;&#46; The patient was hemodynamically stabilized&#46; An exploratory laparotomy evidenced necrosis of ileum&#44; ascending&#44; transverse and descending colon&#46; A diagnosis of mesenteric ischemia and necrosis was established&#46; Subtotal colectomy was performed with removal of all colonic segments and the distal 20<span class="elsevierStyleHsp" style=""></span>cm of small intestine&#46; There were no signs of perforation or peritonitis&#46; The surgery had no complications and the hospitalization was held with no intercurrences&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0020" class="elsevierStylePara elsevierViewall">The presence of <span class="elsevierStyleItalic">pneumatosis intestinalis</span> is a rare finding in clinical medicine&#44; and gas accumulation in portomesenteric vessels&#44; or <span class="elsevierStyleItalic">aeroportia</span>&#44; is an even rarer finding&#46; They are both consequence of serious conditions and carry high mortality&#46;<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The primary cause is mesenteric ischemia&#44; accounting for about 70&#37; of all cases&#46; Other causes of <span class="elsevierStyleItalic">pneumatosis intestinalis</span> and <span class="elsevierStyleItalic">aeroportia</span> are ulcerative colitis&#44; gastric ulcers&#44; diverticulitis&#44; acute pancreatitis and following invasive procedures&#46;<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a><span class="elsevierStyleItalic">Pneumatosis intestinalis</span> can also arise in the context of less serious conditions like asthma or emphysema&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">In patients on chronic hemodialysis there have been some case reports of <span class="elsevierStyleItalic">pneumatosis intestinalis</span> with <span class="elsevierStyleItalic">aeroportia</span>&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#8211;6</span></a> In these patients the pathophysiological mechanism is prolonged central hypoperfusion during dialysis&#44; leading to non-occlusive intestinal necrosis&#46; In addition to this&#44; hemodialyzed patients frequently have membrane changes in enterocytes&#44; with greater predisposition to bacterial translocation into bloodstream&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> In this particular group of patients the microbial flora is heterogeneous&#44; comprising not only aerobial agents&#44; but also anaerobial agents&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Other factors contributing to intestinal ischemia in the hemodialyzed patient appear to be the early and aggressive erythropoietin therapy and vascular calcifications in mesenteric vessels&#44; resulting from deregulated phosphocalcic metabolism&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In those patients in which mesenteric ischemia coexists with <span class="elsevierStyleItalic">aeroportia</span>&#44; the clinician should expect probabilities of transmural necrosis and mortality of&#44; respectively&#44; 91 and 75&#37;&#44;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> reason why the clinical suspicion&#44; early diagnosis and precocious treatment are fundamental&#46; Nonocclusive mesenteric ischemia is thus a recognized and often lethal complication in hemodialysis patients&#44; and its frequency is increasing in this group of patients&#44;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> being about 1&#46;9&#37; per patient-year&#44; compared to 0&#46;09&#8211;0&#46;2&#37; per patient-year in the general population&#46;<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10&#44;11</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Portal venous gas and <span class="elsevierStyleItalic">pneumatosis intestinalis</span> are rare entities&#44; with increasing incidence in hemodialyzed patients&#46; The pathogenic pathways and risk factors are known&#44; and are almost always preventable with simple measures such as avoiding prolonged periods of intradialytic hypotension and controlling inter-dialytic weight gain&#46; They often cause significant morbidity and mortality&#44; and should always be suspected in patients suffering abdominal pain during or after dialysis sessions&#44; since prompt diagnosis and treatment are key factors for a good outcome&#46;</p></span></span>"
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