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An Approach to Pneumatosis Intestinalis: Factors Affecting Your Management

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An Approach to Pneumatosis Intestinalis: Factors Affecting Your Management CASE REPORT – OPEN ACCESS International Journal of Surgery Case Reports 6 (2015) 133–137 Contents lists available at ScienceDirect International Journal of Surgery Case Reports journal homepage: www.casereports.com An approach to pneumatosis intestinalis: Factors affecting your management Mehdi Tahiri a,b,∗, Jordan Levy a, Saud Alzaid a, Dawn Anderson a a Saint Mary’s Hospital, Division of General Surgery, McGill University, Montreal, Quebec, Canada b Lady Davis Institute for Medical Research, Jewish General Hospital, Canada article info abstract Article history: Pneumatosis Intestinalis (PI) is defined as the presence of extra-luminal gas confined to the bowel wall. PI Received 16 September 2014 is an ominous condition often requiring emergent surgery. The management can be challenging in some Received in revised form 31 October 2014 circumstances, as the choice of surgery versus medical treatment can be difficult. Accepted 6 December 2014 In this study, we first report the case of a seventy-seven year old woman presenting to the emergency Available online 12 December 2014 department with the presence of PI on computed tomography of the abdomen. Secondly, we review the existing literature regarding the management of PI and we suggest a treatment algorithm based on Keywords: clinical, laboratory and radiological findings. Pneumatosis intestinalis Management © 2014 The Authors. Published by Elsevier Ltd. on behalf of Surgical Associates Ltd. This is an open Treatment access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/3.0/). Algorithm 1. Introduction tomography of the abdomen. Secondly, we review the existing liter- ature regarding the management of PI and we suggest a treatment In 1730, Pneumatosis Intestinalis (PI) was first described in the algorithm based on clinical, laboratory and radiological findings. literature by Du Vernoi as the presence of gas within the wall of the small or large bowel [1]. The exact prevalence of this pathology in 2. Presentation of case the general population is not known. One autopsy series reported the prevalence of PI as 0.03% in the general population [2]. However, Mrs. M is a 77 year-old woman who presented to the emergency most clinicians believe this to be an underestimate as a proportion department (ED) because of longstanding abdominal pain with of cases are asymptomatic and thus go unreported. PI can be sub- intermittent vomiting, which had worsened that day. On history, divided into two distinct groups: Primary PI, representing 15% of she is known for panhypopituitarism secondary to Sheehan Syn- cases, and secondary PI, representing 85% of cases [3]. In Primary drome, hypertension and a recent diagnosis of gastro-esophageal PI, the intramural gas is cystic and benign in nature, in contrast reflux disease (GERD). She had no surgical history. to secondary PI where the gas accumulates as linear collections On arrival to the ED, the patient was hemodinamycally stable and reflects a pathological condition [4]. Secondary PI has been and afebrile. Abdominal exam showed a distended and tym- attributed to endoscopic procedures, immunological disturbances, panic abdomen without tenderness or guarding. Her laboratory bowel mucosal disruptions and intra-abdominal pathologies. tests were unremarkable except for an elevated serum lactate, of It is often difficult to differentiate primary from secondary PI, as 2.1 mmol/L. To further investigate this pain, an abdominal series they can present with similar symptoms. However, management was requested to rule out an abdominal obstruction. The X-rays of primary and secondary PI differ; primary PI requires medical showed several air-fluid levels with slightly dilated small bowel treatment while secondary PI requires surgical intervention. In this (Fig. 1). A computed tomography (CT) of the abdomen with intra- study, we evaluate factors that affect management of PI. We first venous (IV) contrast was then requested in order to identify the report the case of a seventy-seven year old woman presenting to cause of this possible small bowel obstruction. The CT scan showed the emergency department with the presence of PI on computed the presence of mild to moderate small bowel obstruction with a transition point toward the mid bowel. There was extensive pneu- matosis intestinalis involving small bowel distal to the transition point. The CT scan confirmed patent arterial vascularity and a small ∗ Corresponding author at: McGill University, Division of General Surgery, Lady amount of gas was noted in the portal venous system (Fig. 2). Of Davis Institute Research Center, Jewish General Hospital, 3755 Côte Ste Catherine, note, a CT abdomen with IV contrast taken 15 months prior to Pavillon A-631, Montréal, Quebec H3T 1E2, Canada. Tel.: +1 514 340 8222x6738/6524808; fax: +1 514 340 8617. rule out obstruction was unremarkable. Given the patient’s pain, E-mail address: [email protected] (M. Tahiri). the new findings on her CT and her slightly elevated lactate, the http://dx.doi.org/10.1016/j.ijscr.2014.12.007 2210-2612/© 2014 The Authors. Published by Elsevier Ltd. on behalf of Surgical Associates Ltd. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/3.0/). CASE REPORT – OPEN ACCESS 134 M. Tahiri et al. / International Journal of Surgery Case Reports 6 (2015) 133–137 Fig. 1. Abdominal X-ray series. Fig. 2. CT-scan abdomen C+ (axial)–pneumatosis intestinalis. Fig. 3. Intra-operative finding of PI. decision was made to proceed with an exploratory laparotomy. state. After discussion with the family, the treating team decided Our intraoperative findings showed extensive mesenteric emphy- to apply her to a long-term care facility. From the time of the appli- sema in a large part of the small intestine with no small bowel cation she continued to deteriorate; she became increasingly frail, compromise and no identifiable transition point (Fig. 3). and about six weeks post-operatively she passed away. Given there was no sign of bowel compromise, it was decided that small bowel resection was not necessary and the incision was 3. Discussion closed. Post-operatively, the patient failed to improve, complained of abdominal pain and was eating a minimal amount. The gastroen- The pathophysiology of PI remains controversial and as such, its terology service was consulted for their opinion, but no cause was management can be challenging for clinicians. Emergent surgery identified to explain patient’s symptomatology. The patient refused is required in as many as 66% of cases [5]. Hence, for the treating all medical interventions and she was in a decompensated physical team, the most important step in managing a patient with PI is CASE REPORT – OPEN ACCESS M. Tahiri et al. / International Journal of Surgery Case Reports 6 (2015) 133–137 135 Table 1 Clinical & laboratory findings associated with morbidity when PI present. Study Acute abdomen Hypotension Elevated Bicarbonate Age ≥60 Elevated lactate ≤20 mmol/L creatinine Lee [15] 4.73a 3.79a – 2.54a – 2.43a (1.79–12.45) (1.67–8.60) (1.21–5.32) (1.17–5.05) DuBose [6] 4.7b 5.1b 4.3b – – 3.4b (2.2–10.3) (2.0–13.0) (2.2–8.7) (1.5–7.8) Duron [16] 9.35b 4.38a 2.29b – 2.88a – (1.85–47.14) (1.52–12.65) (1.17–4.51) (1.27–6.50) Wayne [17] 9.5a – 13.8a ––– (1.7–52.1) (1.6–122.0) Greenstein [8] – 7.0a 9.0a 6.7a 18.4b – (1.2–40) (1.1–71) (1.2–3.6) (1.3–261) Hawn [18] – – 30.37b – – 3.05a (7.31–126.20) (1.25–7.42) Odds ratios and 95% CI. a Univariate analysis. b Multivariate analysis. the decision to operate. Many studies have investigated the use of vasopressor use, peritonitis, a lactate level >2 mmol/L, acute renal risk factors as predictors of compromised bowel and the need for failure, and active mechanical ventilation [6]. A memorial Sloan- surgery. Kettering cancer center study published in 2013, analyzed risk In 2013, the Eastern Association for the Surgery of Trauma factors classifying oncology patients having PI as “worrisome” or (EAST) pneumatosis study group published the largest retrospec- “benign”. Patients were placed in the worrisome group according tive multicenter study to date involving 500 patients diagnosed to previously studied laboratory and clinical risk factors includ- with PI and explored different risk factors for pathologic PI. In their ing: elevated serum lactate or the presence of guarding or rebound study, they identified risk factors, which best predicted patholog- tenderness on physical exam. Forty four percent of the cohort (37 ical PI. The risk factors included the presence of hypotension or patients) were designated as worrisome according to these fac- Pneumatosis Intestinalis Critically ill or unstable patient? Yes No Severe intra-abdominal process? Resuscitate Age ≥60 and Acute Abdomen or Hypotension Acute Kidney Injury Surgical Intervention Lactate >2 mmol/L Bicarbonate ≤20 mmol/l WBC ≤12 x 109/L CT Findings: Bowel Dilatation, Ascites or PVG Yes No Symptomatic Surgical Intervention Pneumatosis Intestinalis? Yes No Medical Treatment Observation Metronidazole Inhalational or hyperbaric oxygen Elemental diet Fig. 4. Treatment algorithm for PI. CASE REPORT – OPEN ACCESS 136 M. Tahiri et al. / International Journal of Surgery Case Reports 6 (2015) 133–137 Table 2 abdomen, hypotension, elevated serum lactate, white cell count Radiological factors associated with morbidity when PI present. or creatinine, low serum bicarbonate, age above 60 and comple- Study PVG Bowel Ascites mented by radiological findings such as bowel dilatation, ascites or dilatation PVG. In the presence of these factors, surgical exploration is war- Lee [15] 3.71a – 4.80a ranted. In the absence of these red flags, a regimen of antibiotics, (1.78–7.71) (1.67–13.80) elemental diet and oxygen therapy can be attempted to relieve Duron [16] 3.19a 13.19b 2.21a symptoms.
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