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Pseudo-pneumatosis of the gastrointestinal tract: its incidence and the accuracy of a checklist supported by artificial intelligence (AI) techniques to reduce the misinterpretation of pneumatosis

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Abstract

Purpose

To assess the incidence of erroneous diagnosis of pneumatosis (pseudo-pneumatosis) in patients who underwent an emergency abdominal CT and to verify the performance of imaging features, supported by artificial intelligence (AI) techniques, to reduce this misinterpretation.

Methods

We selected 71 radiological reports where the presence of pneumatosis was considered definitive or suspected. Surgical findings, clinical outcomes, and reevaluation of the CT scans were used to assess the correct diagnosis of pneumatosis. We identified four imaging signs from literature, to differentiate pneumatosis from pseudo-pneumatosis: gas location, dissecting gas in the bowel wall, a circumferential gas pattern, and intramural gas beyond a gas-fluid/faecal level. Two radiologists reevaluated in consensus all the CT scans, assessing the four above-mentioned variables. Variable discriminative importance was assessed using the Fisher exact test. Accurate and statistically significant variables (p-value < 0.05, accuracy > 75%) were pooled using boosted Random Forests (RFs) executed using a Leave-One-Out cross-validation (LOO cv) strategy to obtain unbiased estimates of individual variable importance by permutation analysis. After the LOO cv, the comparison of the variable importance distribution was validated by one-sided Wilcoxon test.

Results

Twenty-seven patients proved to have pseudo-pneumatosis (error: 38%). The most significant features to diagnose pneumatosis were presence of dissecting gas in the bowel wall (accuracy: 94%), presence of intramural gas beyond a gas-fluid/faecal level (accuracy: 86%), and a circumferential gas pattern (accuracy: 78%).

Conclusion

The incidence of pseudo-pneumatosis can be high. The use of a checklist which includes three imaging signs can be useful to reduce this overestimation.

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Data availability

Data for this study were obtained through PubMed search. Original material and data from the presented research support our claim and comply with field standards.

Code availability

Matlab code was used in this research.

References

  1. Muhammad MN, Sadough M, King R et al (2017) Pneumatosis of the esophagus and intestines with portal venous air: a rare presentation. J Community Hosp Intern Med Perspect 7:255–257. https://doi.org/10.1080/20009666.2017.1356188

    Article  PubMed  PubMed Central  Google Scholar 

  2. Wada K, Takeuchi N, Emori M et al (2017) Two cases of pneumatosiscystoides intestinalis with intraperitoneal free air. Gastroenterol Res 10:208–211. https://doi.org/10.14740/gr834w

    Article  Google Scholar 

  3. Gray EJ, Darvishzadeh A, Ankush Sharma A et al (2016) Cancer therapy-related complications in the bowel and mesentery: an imaging perspective. Abdom Radiol 41:2031–2047. https://doi.org/10.1007/s00261-016-0799-3

    Article  Google Scholar 

  4. Pear BL (1998) Pneumatosis intestinalis: a review. Radiology 207:13–19. https://doi.org/10.1148/radiology.207.1.9530294

    Article  CAS  PubMed  Google Scholar 

  5. Wu LL, Yang YS, Dou Y et al (2013) A systematic analysis of pneumatosis cystoids intestinalis. World J Gastroenterol 19:4973–4978. https://doi.org/10.3748/wjg.v19.i30.4973

    Article  PubMed  PubMed Central  Google Scholar 

  6. Feczko PJ, Mezwa DG, Farah MC et al (1992) Clinical significance of pneumatosis of the bowel wall. Radiographics 12:1069–1078. https://doi.org/10.1148/radiographics.12.6.1439012

    Article  CAS  PubMed  Google Scholar 

  7. Ho LM, Paulson EK, Thompson WM (2007) Pneumatosis intestinalis in the adult: benign to life-threatening causes. Am J Roentgenol 188:1604–1613. https://doi.org/10.2214/AJR.06.1309

    Article  Google Scholar 

  8. Umapathi BA, Friel CM, Stukenborg GJ et al (2016) Estimating the risk of bowel ischemia requiring surgery in patients with tomographic evidence of pneumatosis intestinalis. Am J Surg 212:762–768. https://doi.org/10.1016/j.amjsurg.2015.09.010

    Article  PubMed  Google Scholar 

  9. Wang JH, Furlan A, Kaya D et al (2011) Pneumatosis intestinalis versus pseudo-pneumatosis: review of CT findings and differentiation. Insights Imaging 2:85–92. https://doi.org/10.1007/s13244-010-0055-2

    Article  PubMed  Google Scholar 

  10. Wittenberg J, Harisinghani MG, Jhaveri K et al (2002) Algorithmic approach to CT diagnosis of the abnormal bowel wall. Radiographics 22:1093–1107. https://doi.org/10.1148/radiographics.22.5.g02se20109

    Article  PubMed  Google Scholar 

  11. Macari M, Balthazar EJ (2001) CT of bowel wall thickening: significance and pitfalls of interpretation. Am J Roentgenol 176:1105–1116. https://doi.org/10.2214/ajr.176.5.1761105

    Article  CAS  Google Scholar 

  12. Taourel P, Garibaldi F, Arrigoni J et al (2004) Cecal pneumatosis in patients with obstructive colon cancer: correlation of CT findings with bowel viability. Am J Roentgenol 183:1667–1671. https://doi.org/10.2214/ajr.183.6.01831667

    Article  Google Scholar 

  13. Coakley F (2010) Pseudo-pneumatosis. Pearls and pitfalls in abdominal imaging: pseudotumors, variants and other difficult diagnoses, 1st edn. Cambridge University Press, Cambridge, pp 202–203

    Chapter  Google Scholar 

  14. Fisher RA (1922) On the interpretation of χ 2 from contingency tables, and the calculation of P. J Roy Stat Soc 85(1):87–94. https://doi.org/10.2307/2340521

    Article  Google Scholar 

  15. Pearson K (1895) Notes on regression and inheritance in the case of two parents. Proc R Soc Lond 58:240–242

    Article  Google Scholar 

  16. Breiman L (2001) Random forests. Mach Learn 45:5–32. https://doi.org/10.1023/A:1010933404324

    Article  Google Scholar 

  17. Altmann A, Tolosi L, Sander O, Lengauer T (2010) Permutation importance: a corrected feature importance measure. Bioinformatics 26(10):1340–1347. https://doi.org/10.1093/bioinformatics/btq134

    Article  CAS  PubMed  Google Scholar 

  18. Jenkins M, Courtney H, Pope E et al (2017) A case report and approach to management in pneumatosis intestinalis. Ann Med Surg 23:25–27. https://doi.org/10.1016/j.amsu.2017.09.010

    Article  Google Scholar 

  19. Hawn MT, Canon CL, Lockhart ME et al (2004) Serum lactic acid determines the outcomes of CT diagnosis of pneumatosis of the gastrointestinal tract. Am Surg 70:19–23

    PubMed  Google Scholar 

  20. Mora-Guzmán I, Muñoz de Nova JL, Del Campo Del Val L et al (2017) Diffuse pneumatosis intestinalis and pneumoperitoneum. Dig Liver Dis 49:938. https://doi.org/10.1016/j.dld.2017.03.016

    Article  PubMed  Google Scholar 

  21. Duron VP, Rutigliano S, Machan JT et al (2011) Computed tomographic diagnosis of pneumatosis intestinalis. Arch Surg 146:506–510. https://doi.org/10.1001/archsurg.2011.95

    Article  PubMed  Google Scholar 

  22. Lee KS, Hwang S, Rúa SMH et al (2013) Distinguishing benign and life-threatening pneumatosis intestinalis in patients with cancer by CT imaging features. Am J Roentgenol 200:1042–1047. https://doi.org/10.2214/AJR.12.8942

    Article  Google Scholar 

  23. Khalil PN, Huber-Wagner S, Ladurner R et al (2009) Natural history, clinical pattern, and surgical considerations of pneumatosis intestinalis. Eur J Med Res 14:231–239. https://doi.org/10.1186/2047-783x-14-6-231

    Article  PubMed  PubMed Central  Google Scholar 

  24. Morris MS, Gee AC, Cho SD et al (2008) Management and outcome of pneumatosis intestinalis. Am J Surg 195:679–683. https://doi.org/10.1016/j.amjsurg.2008.01.011

    Article  PubMed  Google Scholar 

  25. Treyaud MO, Duran R, Zins M et al (2017) Clinical significance of pneumatosis intestinalis– correlation of MDCT-findings with treatment and outcome. Eur Radiol 27:70–79. https://doi.org/10.1007/s00330-016-4348-9

    Article  PubMed  Google Scholar 

  26. Goyal R, Lee HK, Akerman M et al (2017) Clinical and imaging features indicative of clinically worrisome pneumatosis: key components to identifying proper medical intervention. Emerg Radiol 24:341–346. https://doi.org/10.1007/s10140-017-1484-8

    Article  PubMed  Google Scholar 

  27. Kunishi Y, Ota M, Kato Y et al (2017) Pneumatosis cystoides intestinalis: lung window setting on CT. Clin Case Rep 5:1896–1897. https://doi.org/10.1002/ccr3.1151

    Article  PubMed  PubMed Central  Google Scholar 

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Authors and Affiliations

  1. Department of Radiology, Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via Sforza 35, 20122, Milan, Italy

    Andrea Alessandro Esposito & Gianpaolo Carrafiello

  2. Post-Graduate School in Radiodiagnostics, Università Degli Studi Di Milano, Via Festa del Perdono 7, 20122, Milan, Italy

    Stefania Zannoni & Emanuele Avola

  3. Department of Surgical Emergency, Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Via Sforza 35, 20122, Milan, Italy

    Laura Castoldi

  4. Department of Radiology, Istituto Clinico Humanitas, Via Manzoni 56, 20089, Rozzano, MI, Italy

    Caterina Giannitto

  5. Department of Computer Science, University of Milan, Via Celoria 18, 20133, Milan, Italy

    Elena Casiraghi

  6. Department of Radiology, Massachusetts General Hospital, 55 Fruit St, Boston, MA, 02114, USA

    Onofrio Catalano

Authors
  1. Andrea Alessandro Esposito
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  2. Stefania Zannoni
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Contributions

A.A.E, L.C., S.Z., and C.G. contributed to the study conception and design, and literature search and data analysis were performed by E.C., S.Z., C.G., E.A., O.C.

First draft of the manuscript was written by A.A.E., S.Z., E.C., L.C., C.G., and E.A. and was critically reviewed and edited by A.A.E, E.C., E.A., L.C., O.C, and G.C. All authors read and approved the final manuscript.

Corresponding author

Correspondence to Andrea Alessandro Esposito.

Ethics declarations

Ethics approval

The study was approved by the Ethics Committee of Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico and the patient’s informed consent was waived for its retrospective nature.

Consent to participate

The patient’s informed consent was waived by the Ethics Committee of Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico for the retrospective nature of the study.

Conflict of interest

The authors declare that they have no conflict of interest.

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Esposito, A.A., Zannoni, S., Castoldi, L. et al. Pseudo-pneumatosis of the gastrointestinal tract: its incidence and the accuracy of a checklist supported by artificial intelligence (AI) techniques to reduce the misinterpretation of pneumatosis. Emerg Radiol 28, 911–919 (2021). https://doi.org/10.1007/s10140-021-01932-3

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  • DOI: https://doi.org/10.1007/s10140-021-01932-3

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