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 Constipation 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

REFERENCES1. 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: 62–643. 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

REFERENCES8. Hwang, J. Pneumatosis Cystoides Intestinalis with Free Intraperitoneal Air:

A Case Report. American Surgeon; Apr2003, Vol. 69 Issue 4, p346-499. 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 Attar, A. Pneumatosis Cystoides Intestinalis in Primary Intestinal Pseudo-

obstruction: A nonsurgical cause of Pneumoperitoneum. Clinical gastroenterology and Hepatology, 2005;3:xxi

Braumann, C. Pneumatosis intesyinalis- A Pitfall for Surgeons?Scandinavian Journal of Surgery 2005, 94:47-50

Brill, S. Conservative Management of Pneumatosis Intestinalis and Massive Pneumoperitoneum in the Acute Abdomen: A Case Report. Ann R CollSurg Engl. 2008 March; 90(2): 103

Cammarota, G. Free Peritoneal Gas Accumulation Caused by Pneumatosis Coli After Diagnostic Gastrointestinal Endoscopy. Clinical Gastroenterology and Hepatology. August 2009 (Vol. 7, Issue 8, Page A18)

Davila, M. Neutropenic Enterocolitis: Current Issues in Diagnosis and Management. Current Infectious Disease Reports. 2007, 9:116-120

Davila, M. Neutropenic Enterocolitis. Current Treatment Options in Gastroenterology. 2006, 9: 249-55.

Hokama, A. Pneumatosis Cystoides Intestinalis: Radiographic and Endoscopic Features. Clin Gastroenterol Hepatol. Aug 2009;7(8):A32

Hoover, E "Avoiding laparotomy in nonsurgical pneumoperitoneum". The American journal of surgery, 1992, 164 (2), p. 99

BIBLIOGRAPHY Ito M, Horiguchi A, Miyakawa S. Pneumatosis intestinalis and hepatic portal

venous gas. J Hepatobiliary Pancreat Surg 2008; 15: 334-337 Schulenburg, S. Pneumocystis cystoides intestinalis with

pneumoperitoneum and pneumoretroperitoneum in a patient with extensive chronic graftversus- host disease. Bone Marrow Transplantation, (1999) 24, 331–333

Togawa, S. Evaluation of HBO2 therapy in pneumatosis cystoidesintestinalis. Undersea Hyperb Med. 2004;31(4):387-93

Wu, B et al. An avoidable abdominal surgery: pneumatosis coli. The American Journal of Emergency Medicine, 2008, Volume 26, Issue 4, Pages 517.e1-517.e2

THANK YOU

extras

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