SURGERY GRAND ROUNDS: CASE PRESENTATION
Maria B Albuja-Cruz, MD HISTORY PRESENT ILLNESS
04/14/09: Mr. W, 43 y/o M Few weeks of vague complaints: fatigue, malaise, nausea, cough and loss of appetite Symptoms gradually worsen L sided 4/10 crampy abdominal pain Abdominal distention, intermittent BRBR, + diarrhea, weight loss (10 pounds) CXR large amount of free air PAST MEDICAL HISTORY
Non-ischemic cardiomyopathy 2/2 cardiac sarcoidosis Refractory paroxysmal V-tach Complete AV block OSA on positive airway pressure Pulmonary sarcoidosis Amiodarone induced lung toxicity HTN Anal fistula PAST SURGICAL HISTORY
Cardiac ablation
Placement AICD PAST SOCIAL HISTORY/PAST FAMILY HISTORY/ ALLERGIES
Do not smoke
Drinks alcohol socially
Denies
NKDA MEDICATIONS On chronic immunosuppressants: Cellcept 1500mg BID Prednisone 40 mg daily On chronic anticoagulation : Coumadin 5mg daily ASA 81mg daily Lipitor 10mg PO daily Cozaar 25mg PO daily Coreg 50 mg PO BID Lasix 20 mg PO every other day Amiloride/HCTZ 5/50mg PO daily Dapsone Fosamax Citalopram PHYSICAL EXAM
36.5 107/68 87’ 18’ 90% RA NAD Cushingoid Abdomen: no scars, distended, +BS, soft, very minimal TTP. No rebound. No guarding. No peritonitis. LABORATORY
WBC 11.2 (Seg 87%) Hct 36.5 Plt 182 Cr 1.5 (1.1-1.3) Bilirubin 3.9 INR 3.1 ABG 7.42/ 35 / 82 / 23 / 90% / -0.9 CRP 6.2
DIFERENTIAL DIAGNOSIS
Perforated viscus?:
Perforated ulcer?
Perforated diverticulitis?
Perforated colitis? Chilaiditi’s sign/syndrome?5,6 MANAGEMENT
Broad spectrum IV antibiotics (Zosyn) IVF Transfused 2 units FFP & Vitamin K IV OR PROCEDURE
EXPLORATORY LAPAROTOMY FINDINGS:
NO EVIDENCE OF FREE FLUID OR PNEUMOPERITONEUM
Courtesy of Dr. Christopher Raeburn Courtesy of Dr. Christopher Raeburn Courtesy of Dr. Christopher Raeburn Courtesy of Dr. Christopher Raeburn Courtesy of Dr. Christopher Raeburn Courtesy of Dr. Christopher Raeburn Courtesy of Dr. Christopher Raeburn Courtesy of Dr. Christopher Raeburn Courtesy of Dr. Christopher Raeburn Courtesy of Dr. Christopher Raeburn PERITONEAL FLUID CULTURES: Negative for any microorganism
Courtesy of Dr. Christopher Raeburn HISTOPATHOLOGY REPORT PNEUMATOSIS INTESTINALIS
Courtesy of the Department of Pathology UCH HOSPITAL COURSE
Uneventful
Discharge POD# 6
Tolerating regular diet
Good bowel function PNEUMATOSIS CYSTOIDES INTESTINALIS
First described in 1730 by Du Vernoi8 Multiple gas-filled cysts within the wall1,7 Rare disease8 Mostly benign Affects men more commnly7 Peak incidence 30-50 years of age7 PNEUMATOSIS CYSTOIDES INTESTINALIS
33% mortality rate7 75% mortality necrotic bowel8 Primary 15% or secondary 85%8,9 Significance of PI depends on the nature and severity of the underlying condition1 St. Peter, S. D. et al. Arch Surg 2003;138:68-75 ETIOLOGIC FACTORS
St. Peter, S. D. et al. Arch Surg 2003;138:68-75 CLINICAL MANIFESTATION
Most common symptoms1:
Diarrhea
Bloody stools
Abdominal pain
Weight loss
Tenesmus DIAGNOSIS
CT technique of choice9 CT most sensitive9 Distinguish PI from intraluminal air or submucosal fat1,9 Soyer, P. J Radiol. 2008 Dec;89(12):1907-20 Clin Gastroenterol Hepatol. Aug 2009;7(8):A32 DIAGNOSIS
Differentiation of benign from fulminant PCI10
Portal or mesenteric venous gas
PI + PVG have high fatality rate
70% PI + PVG have bowel ischemia13 St. Peter, S. D. et al. Arch Surg 2003;138:68-75 DIAGNOSIS
Differentiation of benign from fulminant10,16
Portal or mesenteric venous gas
Focal or diffusely fluid-filled bowel segments
Thickening of the bowel wall
Thrombosis SMA
Absence or intense mucosal enhancement
Free fluid Pneumatosis Cystoides Intestinalis: Radiographic and Endoscopic Features. Clin Gastroenterol Hepatol. Aug 2009;7(8):A32 MANAGMENT
Associated illness inciting PI1 Management: level II-3/III clinical evidence13 Oxygen therapy1,2,3,10 Bowel rest10,11 TPN10,11 Antibiotics - Metronidazole10,11,14 Management and Outcome of Pneumatosis Intestinalis12
Morris, Department of Surgery-OHSU Retrospective review (2000-2007) 97 pts 3 management strategies: 52% non-operative (NGT/bowel rest) Mortality rate= 6% 33% operative. Mortality rate= 16% 13% nontherapeutic exploratory laparotomies 15% futile care. Mortality rate= 87% Overall mortality rate= 22% Patients admitted to GS service lower mortality rate Approx 50% of PI can be managed non-operatively. PI + portal venous gas may confer a higher mortality rate
The American Journal of Surgery, 2008, Volume 195, Issue 5, pp 679-683 Pneumatosis Intestinalis in Adults: Management, Surgical, Indications, and Risk Factors for Mortality13 Greenstein, Department of Surgery-MSMC Retrospective review (1996–2006) Aim of study: identify factors significant for surgery/death 40 pts Factors independently associated with surgical mngt ≥ 60 years (p = 0.03) Emesis (p = 0.01) WBC > 12 c/mm3 (p = 0.03) Sepsis highest risk of death High mortality risk associated lactate ≥ 2 mmol/15
J Gastrointest Surg. 2007 Oct;11(10):1268-74 CONCLUSIONS
Free air is not always an indication for surgery Overall clinical picture of patient mandates the need for further evaluation/management Presence of PI and PVG should rise high concern Need for level I evidence base information regarding management REFERENCES
1. St. Peter SD, Abbas MA, Kelly KA. The spectrum of pneumatosis intestinalis. Arch Surg 2003; 138: 68–75 2. Gruenberg JC, Batra SK, Priest RJ. Treatment of pneumatosis cystoides intestinalis with oxygen. Arch Surg 1977; 112: 62–64 3. Simon NM, Nyman KE, Divertie MB, Rovelstad RA, King JE. Pneumatosis cystoides intestinalis: treatment with oxygen via close-fitting mask. JAMA. 1975;231:1354-1356 4. Rowe NM, Kahn FB, Acinapura AJ, Cunningham JN Jr. Nonsurgical pneumoperitoneum: a case report and a review. Am Surg. 1998;64:313- 322 5. Wong,V. Chilaiditi’s syndrome: A nonemergent cause of “free gas under diaphragm” The American Journal of Surgery, Volume 198, Issue 2, Pages e25-e26 6. Kamiyoshihara, M. Chilaiditi's Sign Mimicking a Traumatic Diaphragmatic Hernia. The Annals of Thoracic Surgery, 2009, Volume 87, Issue 3, pp. 959-961 7. Sakurai, Y. Pneumatosis cystoides intestinalis associated with massive free air mimicking perforated diffuse peritonitis. World J Gastroenterol 2008 November 21; 14(43): 6753-6756 REFERENCES 8. Hwang, J. Pneumatosis Cystoides Intestinalis with Free Intraperitoneal Air: A Case Report. American Surgeon; Apr2003, Vol. 69 Issue 4, p346-49 9. Soyer, P. Linear or bubbly: a pictorial review of CT features of intestinal pneumatosis in adults J Radiol. 2008 Dec;89(12):1907-20 10.Koop, A. Pneumatosis cystoides intestinalis with pneumoperitoneum and pneumoretroperitoneum following chemotherapy Abdom Imaging (1997) 22:395–397 11.Galm, O. Pneumatosis intestinalis following Cytotoxic or Immunosuppressive Treatment Digestion 2001;64:128-132 12.Morris, M. Management and outcome of pneumatosis intestinalis. The American Journal of Surgery, Volume 195, Issue 5, pp 679-683 13.Greenstein, J. Pneumatosis Intestinalis in Adults: Management, Surgical Indications, and Risk Factors for Mortality. J Gastrointest Surg. 2007 Oct;11(10):1268-74 14.Ellis BW, Symptomatic treatment of primary pneumatosis coli with metronidazole. Br Med J. 1980 Mar 15;280(6216):763-4 15.Hawn, T. Serum lactic acid determines the outcomes of CT diagnosis of pneumatosis of the gastrointestinal tract Am Surg. 2004 Jan;70(1):19-23 16.Ho, L. Peumatosis Intestinalis in the Adult: Benign to Life-Threatening Cases. AJR, 2007;188:1604-1613 BIBLIOGRAPHY
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