should there be air there? elizabeth m. regan november 22, 2013 dr. cameron; dr. p.smith, dr....
TRANSCRIPT
Should there be air there?
Elizabeth M. Regan
November 22, 2013
Dr. Cameron; Dr. P.Smith, Dr. Ebersole
• CC: abdominal pain, N/V, T101.3• HPI: Patient is a 42 y/o female who originally presented to the
ED on 10/26 with 1 month history of cough and markedly elevated WBC of 200. Patient was diagnosed with ALL and admitted for workup and initiation of chemotherapy. Her hospital stay became complicated by an UE DVT, large left-sided pleural effusion and retroperitoneal hematoma s/p BM biopsy. On 11/11 patient developed mid-epigastric abdominal pain, N/V and became febrile to 101.3 F.
• PMH: HTN, UE DVT, left-sided pleural effusion, hematoma• PSH: nill• Allergies: NKA• Social: never smoker, denies alcohol and drug use
CASE: OS (MR:6605248)
2
• Physical Exam:– Vitals: T99.3, BP 136/70, HR 112, RR 20, O2 97%– CONSTITUTIONAL: NAD– LUNGS: CTAB – CARDIOVASCULAR: NSR normal S1 and S2, no S3 or S4, no
murmur– ABDOMEN: Normal bowel sounds, soft, mildly distended, TTP over
epigastric and RUQ – EXTREMITIES: no LE edema, Left upper extremity - no longer
edematous surrounding PICC, not TTP– NEURO: A&Ox3, CNII-XII grossly intact – SKIN: no rashes
• Labs:– Neutropenic– Normal lactate
CASE
• Acute Abdominal Pain, Fever– Ulcer– Pancreatitis– Infectious (Viral, Abscess)– Biliary Obstruction (cholecystitis, cholangitis, malignancy)– Tumor Lysis
• Imaging Modalities to consider– Ultrasound vs CT vs MRI?– Contrast?– Decision: CT abdomen and pelvis with IV contrast
Working Clinical Diagnoses
Appropriateness Criteria
Normal CT Abdomen (Level of Stomach)
Axial CT (with PO contrast)
OS CT Abdomen (Stomach)
CT Abdomen (Small Bowel)
CT Abdomen (Small Bowel)
CT Abdomen (Small Bowel)
• Pneumatosis intestinalis seen in posterior gastric wall, small bowel, as well as air within draining gastric vein
• What’s next?– Investigate for pneumoperitoneum
OS KUB- 1 view
OS CXR-No pneumoperitoneum
Abnormal CXR: Free Air under Diaphragm
• Pneumatosis Intestinalis– Gas within the wall of the bowel; Can occur anywhere
between esophagus and rectum– Symptom of multiple disease states, both GI and non-GI
related– Can be benign or an emergency • Emergencies include pneumoperitoneum, bowel
ischemia/infarction • Most presentations are benign; most patients are
actually asymptomatic– Most Common in adults ages 40-70 as well as in the
neonate population (associated with Necrotizing enterocolitis). Equal prevalence in males and females
Working Diagnosis/ Pathology
– Most commonly associated disease states:• COPD• Immunocompromised states• Inflammatory or infectious causes of GI tract• Recent surgical or endoscopic procedures• Diabetes• Ischemia
– Clinical Presentation usually includes: N/V, abdominal pain, mucus or blood in stools, weight loss
• Plain Films:– Intramural gas can be linear, curvilinear, or circular in
appearance– Linear pneumatosis tends to be more ominous, but can be
benign– If pneumoperiotoneum is also present, look for: free air
under the diaphragm, Rigler’s sign, falciform ligament sign• CT:– More sensitive– Circumferential collections of air adjacent to lumen of
bowel
Characteristic Findings
• Patient was non-peritonitic, complaining only of mild pain
• No pneumoperitoneum• Surgery consulted, no evidence for bowel
infarction/ischemia• Serial abdominal exams, prontonix, and fluid
resuscitation• Patient improved within 36 hours. No surgical
intervention needed.
Outcome/Treatment