SUCCESSFUL CONSERVATIVE TREATMENT OF PNEUMATOSIS INTESTINALIS AND PORTOMESENTERIC VENOUS GAS IN A PATIENT WITH SEPTIC SHOCK

Chen-Te Chou,1,3 Wei-Wen Su,2 and Ran-Chou Chen3,4 1Department of Radiology, Changhua Christian Hospital, Er-Lin branch, 2Department of Gastroenterology, Changhua Christian Hospital, 3Department of Biomedical Imaging and Radiological Science, National Yang-Ming University, and 4Department of Radiology, Taipei City Hospital, Taipei, Taiwan.

Pneumatosis intestinalis (PI) and portomesenteric venous gas (PMVG) are alarming radiological findings that signify bowel ischemia. The management of PI and PMVG remain a challenging task because clinicians must balance the potential morbidity associated with unnecessary sur- gery with inevitable mortality if the necrotic bowel is not resected. The combination of PI, portal venous gas, and acidosis typically indicates bowel ischemia and, inevitably, necrosis. We report a patient with PI and PMVG caused by septic shock who completely recovered after conservative treatment.

Key Words: bowel ischemia, computed tomography, pneumatosis intestinalis, portal venous gas, portomesenteric venous gas (Kaohsiung J Med Sci 2010;26:105–8)

Pneumatosis intestinalis (PI) and portomesenteric CASE PRESENTATION venous gas (PMVG) are alarming radiologic findings that signify bowel ischemia [1]. PI and PMVG are A 78-year-old woman who presented with intermittent often described as an advanced sign of bowel injury, fever for 3 days was referred to the emergency depart- indicating irreversible injury caused by transmural ment of our hospital. The patient had a history of ischemia [2]. Bowel ischemia may be associated with type 2 diabetes mellitus, congestive heart failure, and perforation and has a high mortality rate. Many au- prior cerebral infarct. He had undergone right nephrec- thorities advocate an aggressive surgical approach to tomy due to renal cell carcinoma. Other symptoms of treat PI [3,4]. We report a patient with PI and PMVG the patient included shortness of breath, drowsy con- caused by septic shock who completely recovered sciousness, abdominal fullness, and epigastric pain. after conservative treatment. Physical examination revealed fever (38.5°C), diffuse abdominal tenderness, and icteric sclera. Laboratory studies revealed leukocytosis (white Received: Apr 23, 2009 Accepted: Jun 15, 2009 blood cells, 19,200 cells/mm3), slight hypoglycemia Address correspondence and reprint requests to: Dr Ran Chou Chen, Department of Radiology, (58 mg/dL), elevated blood urea nitrogen (43 mg/dL), Taipei City Hospital Renai branch, 10 Section 4, creatinine (3.3 mg/dL) and γ-glutamyl transpeptidase Renai Road, Taipei 106, Taiwan. (201 U/L) levels, an electrolyte imbalance (sodium/ E-mail: [email protected] potassium, 132/3.2 mmol/L), mild bleeding tendency

Kaohsiung J Med Sci February 2010 • Vol 26 • No 2 105 © 2010 Elsevier. All rights reserved. C.T. Chou, W.W. Su, and R.C. Chen

(prothrombin time/activated partial thromboplastin initially prescribed for her intra-abdominal infection. time, 14.4/44.1 seconds) and hyperbilirubinemia Ceftriaxone was then changed to ceftaxime (200 mg (total/direct, 4.95/4.31 mg/dL). She was mildly aci- every 12 hours) due to persistent fever on day 3 of demic upon examination, with an arterial pH of 7.33 admission. Escherichia coli, Morganella morganii, and and a partial CO2 of 26 mmHg. Progressive shortness Pseudomonas aeruginosa were isolated from the blood of breath and unstable hemodynamics with a decrease culture 6 days later. in blood pressure to 70/38 mmHg developed the same The general condition of the patient improved after day, and the patient was transferred to our intensive conservative treatment and the jaundice subsided. A care unit. follow-up CT scan was done 4 days after the conserva- Endotracheal intubation was done due to respira- tive treatment and depicted no obvious PI and PMVG tory distress because the chest X-ray film revealed mild together with normal enhancement of the intestine pulmonary edema. An emergency abdominal com- wall (Figure C). Endoscopic retrograde cholangiopan- puted tomography (CT) scan was arranged following creatography was scheduled after her hemodynam- the development of progressive abdominal pain, ab- ics had stabilized and revealed stenosis of the distal dominal distention and peritoneal signs. The CT scan common bile duct. Subsequent sphinterectomy with revealed PI with poor mucosal enhancement of the biliary stent placement was done. The patient was ileum, in addition to PMVG (Figures A and B). No discharged in good condition after 3 weeks. occlusion of the main trunk or ileal branches of the superior mesenteric artery was noted. There was also mild dilatation of the common bile duct and intrahe- DISCUSSION patic ducts. Because we suspected bowel ischemia with transmural necrosis, an emergency operation was rec- Bowel ischemia or infarction caused by insufficient ommended for the patient. However, because of her blood flow to the intestine has various causes, age and the high mortality rate associated with surgery including thromboembolism, non-occlusive causes, for this condition, the patient’s family chose conser- bowel obstruction, neoplasms, vasculitis, abdominal vative treatment instead of surgery. The patient was inflammatory conditions, trauma, drugs, radiation, given supportive therapy, which included fasting and corrosive injury. The presence of PMVG and PI is with fluid replacement and total parenteral nutrition. predictive of bowel infarction. Mortality rates have Empiric antibiotics with metronidazole (500 mg every been reported to exceed 75% in patients in whom PI 8 hours) and ceftriaxone (200 mg every day) were and PMVG are both seen on plain films [5,6]. PI and

A B C

Figure. A 78-year-old woman with septic shock and peritoneal signs. (A) Axial computed tomography (CT) scan showed pneumato- sis intestinalis (black arrow) and air collection in the mesenteric vein (white arrow). Dilatation of the ileum with poor enhancement of the mucosal layer was also noted. (B) A coronal reformatted CT scan revealed PI (black arrow), portomesenteric venous air (white arrow), and portal air in the liver (arrowhead). (C) A follow-up CT scan was done 4 days after the conservative treatment. The coronal reformatted CT showed no air collection in the bowel wall or the portomesenteric vein. Normal enhancement of the small intestine, without obvious dilatation was noted.

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PMVG can be detected early by a CT scan and the con- after conservative treatment may indicate a good prog- current findings are predictive of bowel ischemia [2,7]. nosis for recovery. Careful monitoring and selection of About 91% of patients with both PMVG and PI show patients may help to avoid unnecessary exploratory transmural bowel infarction [7]. Fortunately, the bowel surgery. ischemia associated with PI and PMVG was reversible in this patient and she recovered uneventfully. Non-occlusive bowel ischemia is a condition in REFERENCES which the mesenteric arteries and veins are patent, but the blood flow through is too slow to deliver suffi- 1. Schulze CG, Blum U, Haag K. Hepatic portal venous cient oxygenated blood to the intestine. It is generally gas: imaging modalities and clinical significance. Acta Radiol 1995;36:377–80. a result of vasospasm and vasoconstriction, which typ- 2. Kernagis LY, Levine MS, Jacobs JE. Pneumatosis ically occur in critically ill patients who are in low-flow intestinalis in patients with ischemia: correlation of CT states (e.g. septic shock, cardiac shock, burns, or hypo- findings with viability of the bowel. AJR Am J Roentgenol volemic shock) [8]. The outcomes of surgical manage- 2003;180:733–6. ment of mesenteric ischemic bowel disease are poor 3. Heng Y, Schuffler MD, Haggitt RC, et al. Pneumatosis [9]. The goal of therapy for non-occlusive bowel intestinalis: a review. Am J Gastroenterol 1995;90:1747–58. 4. Knechtle SJ, Davidoff AM, Rice RP. Pneumatosis ischemia is to reduce the spasm and improve the perfu- intestinalis: surgical management and clinical out- sion of the mesenteric artery using vasodilators in the come. Ann Surg 1990;212:160–5. early stage. Surgery is reserved for excision of irre- 5. Liebman PR, Patten MT, Manny J, et al. Hepatic-portal versibly necrotized intestine [10]. venous gas in adults: etiology, pathophysiology and The management of PI and PMVG remains a chal- clinical significance. Ann Surg 1978;187:281–7. lenging task because clinicians must balance the poten- 6. Griffiths DM, Gough MH. Gas in the hepatic portal tial morbidity of unnecessary surgery with inevitable veins. Br J Surg 1986;73:172–6. 7. Wiesner W, Mortele KJ, Glickman JN, et al. Pneumatosis mortality if the necrotic bowel is not resected. Knechtle intestinalis and portomesenteric venous gas in intes- et al reported that asymptomatic patients with PI and tinal ischemia: correlation of CT findings with severity PMVG without metabolic acidosis could be safely of ischemia and clinical outcome. AJR Am J Roentgenol observed, while those with clinical evidence of bowel 2001;77:1319–23. obstruction or ischemia required emergency surgery 8. Taourel PG, Deneuville M, Pradel JA, et al. Acute [4]. Conservative treatment of patients with PI or mesenteric ischemia: diagnosis with contrast-enhanced CT. Radiology 1996;199:632–6. PMVG has been reported by several authors, including 9. Edwards MS, Cherr GS, Craven TE, et al. Acute occlu- PI as a result of cytotoxic or immunosuppressive treat- sive mesenteric ischemia: surgical management and ment [11,12] and as a postoperative condition [13]. outcomes. Ann Vasc Surg 2003;17:72–9. No clinical signs of secondary complications such as 10. Mitsuyoshi A, Obama K, Shinkura N, et al. Survival in peritonitis, ischemia, or perforation were seen in the nonocclusive mesenteric ischemia: early diagnosis by patients in the above reports. To our knowledge, ours multidetector row computed tomography and early treatment with continuous intravenous high-dose is the first case of PI and PMVG associated with peri- prostaglandin E1. Ann Surg 2007;246:229–35. toneal signs, acidemia and sepsis to be successfully 11. Galm O, Fabry U, Adam G, et al. Pneumatosis intesti- treated with conservative therapy. nalis following cytotoxic or immunosuppressive treat- In conclusion, patients with PI and PMVG caused ment. Digestion 2001;64:128–32. by non-occlusive bowel ischemia, even those associ- 12. Kung D, Ruan DT, Chan RK, et al. Pneumatosis intesti- ated with mild acidemia and peritoneal sign, could nalis and portal venous gas without bowel ischemia in a patient treated with irinotecan and cisplatin. Dig Dis be successfully treated with conservative therapy, Sci 2008;53:217–19. although the opportunity for this might be very rare. 13. Tchabo NE, Grobmyer SR, Jarnagin WR, et al. For patients with poor conditions and who are con- Conservative management of pneumatosis intestinalis. sidered to be high risk for surgery, rapid improvement Gynecol Oncol 2005;99:782–4.

Kaohsiung J Med Sci February 2010 • Vol 26 • No 2 107 成功以保守治療醫治腸氣囊腫病合併 門脈腸系靜脈積氣及酸血症的病例報告

1,3 2 3,4 周成德 蘇維文 陳潤秋

1 2 彰化基督教醫院 二林分院 放射診斷 腸胃內科

3 陽明大學 生物醫學影像暨放射科學系

4 台北市聯合醫院 放射診斷科

腸氣囊腫病（pneumatosis intestinalis）和門脈腸系靜脈積氣（ortomesenteric venous gas）在影像診斷學上是缺血性腸道疾病（Ischemic Bowel Disease）非常 重要的表現，當病人的影像出現腸氣囊腫病或是門脈腸系靜脈積氣時，臨床醫師要如 何作最適當的處置，依然是一項富挑戰性任務，因為如果壞死的腸組織沒有被切除， 無可避免的會造成病人死亡，但是多餘的手術亦會有潛在的併發症。由以往的文獻得 知，當病人同時出現腸氣囊腫病、門脈腸系靜脈積氣和酸血症的表現時，腸組織的壞 死幾乎是不可避免的。我們報告一例罕見的病例，病人因為敗血症合併出現腸氣囊腫 病、門脈腸系靜脈積氣及酸血症的表現，但在保守治療之後，病人完全恢復且健康的 出院。

關鍵詞：腸氣囊腫病，電腦斷層，缺血性腸道疾病，門脈積氣，門脈腸系靜脈積氣 （高雄醫誌 2010;26:105–8）

收文日期：98 年 4 月 23 日 接受刊載：98 年 6 月 15 日 通訊作者：陳潤秋醫師 台北市聯合醫院仁愛院區放射診斷科 台北市仁愛路 4 段 10 號

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