Treatment of Pneumatosis Coli by Oxygen Therapy Bijan Kumar Basak, M.D

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TREATMENT OF PNEUMATOSIS COLI BY OXYGEN THERAPY BIJAN KUMAR BASAK, M.D. Director of Anesthesiology and Respiratory Medicine Charles Cole Memorial Hospital Coudersport, Pennsylvania

JAMES F. GUTHRIE, M.D., JACK W. MCELWAIN, M.D., AND M. DOUGLAS MACLEAN, M.D. Attending Surgeons Mid-Island Hospital Bethpage, New York

TNEUMATOSIS coli is a rare condition of unknown etiology, manifested lby gas-filled cysts in the submucosa of the colon and rectum. Cysts vary from a few millimeters to one or two centimeters in size, and may obliterate the bowel lumen. The condition is termed pneumatosis cystoides intestinalis if the small bowel is involved. Recent reports in the literature1"4 describe the successful treatment of pneumatosis coli using oxygen. We report a patient with incapacitating pneumatosis coli affecting the entire colon who was successfully treated by high oxygen concentrations using a closed mask. An 83-year-old man entered the Mid-Island Hospital, Bethpage, N.Y., because he was incontinent of large quantities of mucus and flatus, and had lost 40 lbs. over the previous year. He had been previously treated with courses of tetracycline hydrochloride and cephalexin with no decrease in the amount of mucus. The diagnosis of pneumatosis coli was confirmed by a sigmoidoscopy, plain abdominal roentgenogram, and barium enema (Figure 1). He had previously undergone a left inguinal herniorraphy. He denied any history of chest pain, dyspnea, hypertension, or myocardial infarction. Physical examination revealed a well-developed man, blood pressure 140/66 mm.Hg, pulse rate 88/minute. Lungs were clear and heart tones of good quality. Stool cultures yielded no enteric pathogens. The hemoglobin was 12 gm.% and hematocrit was 33.3 vol.%. Electrocardio- gram was interpreted as bundle branch block with nonspecific ST-T wave

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Fig. 1. Roentgenogram before treatment of lesion with oxygen therapy changes. Chest roentgenogram was consistent with pulmonary em- physema. Oxygen therapy was begun, utilizing a Hudson mask with a reservoir bag. Humidified oxygen, flowing at 8 liters per minute, resulted in an inspired oxygen concentration of 75% to 78%, and the PaO2 level varied from 277.5 to 210 Torr. Interruptions in oxygen therapy were made for 30 minutes daily for meals and other necessities. Four four-hourly periods of unbroken oxygen administration were rigorously followed and the mask was worn at night. Determination of arterial blood gas was done twice daily and flat abdominal and chest roentgenograms were taken daily. On the third day of treatment the bowel pattern became normal by roentgenographic examination and on the fourth day no abnormality was seen. The oxygen tension (PaO2) on the first day was 277.5, the second day 261.2, the third day

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Fig. 2. Roentgenogram after treatment of lesion with oxygen therapy

223.2, and the fourth day 261 Torr. Aggressive treatment should continue at least 48 hours after complete radiological disappearance of all the cysts. Hence, our patient continued with oxygen therapy 48 hours after radiological disappearance of the irregular radiolucencies. Oxygen administration was discontinued on the sixth day, after which barium enema examination was reported as unremarkable except for an occasional diverticulum (Fig- ure 2). Follow-up a month later showed no recurrence on sigmoidoscopy. Symptoms of pneumatosis coli include excessive mucus, diarrhea, and flatus, which gradually progress to fecal incontinence. The diagnosis is usually confirmed by a barium enema, sigmoidoscopy, or colonoscopy. In 1973, however, Forgacs et al.2 predicted that the cysts, which contain variable proportions of nitrogen, carbon dioxide, hydrogen, and oxygen, could be deflated if the total pressure of gases in the venous blood were lowered by prolonged breathing of high concentrations of oxygen. This

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alters the balance of diffusion of gases inside the cysts and suggests that cysts are created and maintained by a fastidious anaerobic gas-forming organism.1 The high tissue oxygen concentration6 achieved by this therapy destroys the organism, and the gas is then reabsorbed in the same way as gas contained within any artificially created space in the body. It has been emphasized by Simon et al.,3 Van der Linden,4 and Wyatt5 that long-term follow-up investigation is important because of possible recurrence. Ablative surgery was the main treatment in the past, but oxygen therapy now appears to be a safe, simple, and effective treatment.

REFERENCES 1. Down, R. H. L. and Castleden, W. H.: intestinal gas cysts after oxygen treatment. Oxygen therapy for pneumatosis coli. Br. Lancet 2:1388, 1974. Med. J. 1:493, 1975. 5. Wyatt, A. P.: Prolonged symptomatic and 2. Forgacs, P., Wright, P.H., and Wyatt, radiological remission of colonic gas cysts A. P.: Treatment of intestinal gas cysts afteroxygen therapy. Br. J. Surg. 62:837, of oxygen breathing. Lancet 1:579, 1975. 1973. 6. Wylie, W. D. and Churchill-Davidson, 3. Simon, N. M., Nyman, K. E., Divertie, H. C.: A Practice of Anesthesia. Chicago, M. B., et al.: Pneumatosis cystoides in- Year Book Medical Publishers, 1960, p. testinalis. J.A.M.A. 231:1354, 1975. 138. 4. Van der Linden, W.: Reappearance of

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