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You are called to see another patient Melissa Wong, MD Richmond University Medical Center 30 April 2015
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Case Presentation
51F, progressive abdominal pain x 1d +flatus, +BM Last colonoscopy 2013 (hyperplastic polyps x3)
PMHx: chronic EtOH use, pancreatitis x4 prior episodes (last 5 mos ago), HTN, CKD, asthma PSHx: TAH BSO (fibroids) 2000, VHR x2 (2007, 2008) SHx: 20 pack-year smoker, 5 beers/d
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Case Presentation Afebrile, HR 80s-100s, BP 110s-130s/70s-80s NAD, A&O x3, Obese RRR s1 s2 Abd distended, right-sided rebound tenderness and guarding Well-healed midline scar, no recurrent hernia Guaiac + Labs: WBC 10.8 Cr 2.2 Lactate 1.7
Amylase 150 Lipase 877 HCO3 17 EKG: NSR @ 87 bpm
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OR Procedure: Exploratory laparotomy, LOA, appendectomy, colonic decompression Findings: • dilated colon (cecum to transverse) • no ischemia or pneumatosis of colon or mesentery • adhesive band of omentum across distal transverse
colon → partial LBO • colon decompressed via appendicotomy (2L nonbloody
stool) Pathology: Appendix with normal mucosa, acute serositis
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PresenterPresentation NotesNo inflammation, ischemia or pneumatosis. Descending and sigmoid colon collapsed.After releasing omental adhesion, some air & distension passed distally. Took down splenic flexure.
Post-Operative Course
POD 1-3.5: • extubated • tolerated clears • abdominal exam benign • WBC 12k (plateau) POD 4: tachycardia, tachypnea → intubated • CTA chest, CT Abd/Pel done
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PresenterPresentation NotesCTA neg for PEAbd: new free fluid, fat-stranding and pneumatosis of cecum new, PVG resolved
Post-op Course
POD 1 - 3.5: • extubated • tolerated clears • abdominal exam benign • WBC 12k (plateau) POD 4: tachycardia, tachypnea → intubated • CTA chest, CT Abd/Pel done • febrile 102˚F • OR
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OR
Procedure: Re-exploration laparotomy, R hemicolectomy, peritoneal lavage, end ileostomy Findings: ● cecum normal ● hepatic flexure mobilized → free perforation of
gangrenous retroperitoneal colon Pathology: colon with acute and chronic inflammation and necrosis
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2nd Post-Op Course
POD 1-5: overall improvement ● extubated ● low NGT output, no abdominal distension ● ileostomy function >1L on POD 1 POD 2: no ileostomy output POD 6: new dyspnea ● CT abd/pel done → new intra-abdominal fluid collection
→ IR drainage ○ initial output 1L, purulent ○ current output 60 mL/d
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Pneumatosis Intestinalis & Portal Venous Gas
Melissa Wong, MD Richmond University Medical Center 30 April 2015
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Outline
● pneumatosis intestinalis ○ a brief history ○ etiology ○ clinical significance
● portal venous gas ○ history ○ clinical significance ○ fun quiz
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History of Pneumatosis Intestinalis
● 1730: described by Du Vernoi in cadavers ● 1946: 1st described as a radiographic finding
by Lerner & Gazin
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PresenterPresentation NotesDu Vernoi, pathologist: described primary pneumatosis, aka pneumatosis cystoides intestinalis (multiple thin-walled cysts in submucosa or subserosa of colon)cystic/bubbly vs linear/curvilinear85% of pneumatosis will be secondary (what we’re talking about today)
Gazin: 1st case diagnosed before operation by XR, confirmed by surgery & histology
Where does the gas come from?
● 3 theories:
intraluminal
mucosal or immune defect (or both)
bacterial
bacteria invade wall, or alter intraluminal gas
content
pulmonary
alveolar rupture → air tracks via RP to bowel
mesentery
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PresenterPresentation Notes2 theories:intraluminal gas: defect in mucosa or immune barrier or both
bacterial gas: bacteria invade wall, or alter intraluminal gas contentbacterially-produced hydrogen tension exceeds nitrogen tension in blood → hydrogen diffusion gradient toward submucosal vesselsmay explain penumatosis observed near blood vessels along mesenteric borderpulmonary gas: alveolar rupture → air tracks caudally via RP to bowel mesenteryreduced barrier function from steroid txincreased intraabdominal pressure from pulmonary obstruction
Causes of Pneumatosis
#1 - bowel ischemia IBD diverticulitis Celiac disease bowel obstruction volvulus pyloric stenosis peptic ulcer enteritis, colitis pseudoobstruction
autoimmune (Lupus, scleroderma, PAN) cystic fibrosis HIV, AIDS GvHD COPD, asthma jejunal feeding tubes recent endoscopy BE medications, esp steroids, chemo
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PresenterPresentation Noteswide clinical spectrum, from insignificant to life-threatening → how do you tell where on this spectrum the patient in front of you is
irinotecan, cisplatin
Bani Hani M, J Surg Res 2013.
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Clinical Significance of Pneumatosis
Greenstein et al., 2007: 40 pts, 1996-2006 ○ need for laparotomy
■ h/o emesis ■ age >60 ■ leukocytosis >12
○ mortality risk: sepsis Wayne et al., 2010: 74 pts, 2004-2007
○ vascular risk factor score: ■ h/o smoking ■ HTN, HLD, CAD ■ DM, PVD, vasculitis ■ abnormal abdominal exam ■ lactic acidosis
Greenstein A, J Gastrointest Surg 2007. Wayne E, J Gastrointest Surg 2010
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PresenterPresentation Notesseveral studies have tried to look at clinical, radiologic, lab parameters to differentiate cases of bowel ischemia vs notsmaller, single-institution
209 pts, 1983-2007 outcome: clinically significant ischemia/necrosis
Bani Hani M, J Surg Res 2013.
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PresenterPresentation Notesmost other studies on pneumatosis & PVG are smaller, single-institution4 centers: U Maryland MC, Baltimore VA, Hopkins, U michigan Hospitalage 18+, with CT showing pneumatosis or PVG → 265 pts → only 209 w/ enough data to include in study
in model that maximised probability of correct diagnosis: still not v good at predicting sig ischemia/necrosis→ CT findings (or lack of findings eg bowel wall thickening, mesenteric stranding) should not offer false reassurance over clinical picture
Bani Hani M, J Surg Res 2013.
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PresenterPresentation NotesAge >60, Peritoneal signs, PaCO2, albumin, BUN, both PN & PVG, ascites, HTN, cardiovascular disease, CVA, immunosuppressionwhen only these variables pulled into a single model, only 3 variables remained significant: age, peritonitis, BUN, both PN & PGthese 4 used again in several scoring-system models,
209 pts, 1983-2007 outcome: clinically significant ischemia/necrosis best model: sensitivity 73%, specificity 67%, accuracy
Portal Venous Gas
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PresenterPresentation Notesgas from mesentery coalescing in portal circulation → progressive steps along same spectrumpredeliction for L lobe → more anterior
History of Portal Venous Gas
● 1955: 1st described by Wolfe and Evans in 6 neonates
● 1960: 1st described in adults ● 1965: 1st survivor ● up to 2008: approx 335 cases in literature
○ vs pneumatosis intestinalis (~350 by 1990) ○ ~50% associated w/ pneumatosis
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PresenterPresentation Notes1955: radiologic sign 1st described by Wolfe and Evans in 6 neonates, died of bowel ischemia- 1960: 1st described in adults, Susman and Senturia- 1965: 1st survivor, Lazar- 1978: Liebman et al collected 64 cases in literature, reported 75% mortality- approx 50% of cases in literature a/w pneumatosis intestinalis
Portal Venous Gas
● #1 cause: bowel ischemia ● mortality: 25-75%
○ alone vs with pneumatosis ○ early experience vs recent series
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PresenterPresentation NotesPVG vs pneumobilia
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Summary
● wide range of clinical significance ● your clinical judgement matters ● don’t miss bowel ischemia
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References Bani Hani M, Kamangar F, Goldberg S, Greenspon J, Shah P, Volpe C, Turner DJ, Horton K, Fishman EK, Francis IR, Daly B, and Cummingham SC. Pneumatosis and portal venous gas: do CT findings reassure? J Surg Res 2013;185:581-586. Khalil PN, Huber-Wagner S, Ladurner R, Kleespies A, Siebeck M, Mutschler W, Hallfeldt K, Kanz K-G. Natural History, Clinical Pattern, and Surgical Considerations of Pneumatosis Intestinalis. Eur J Med Res 2009;14:231-239. Lee HS, Cho YW, Kim KJ, Lee JS, Lee SS, Yang SK. A simple score for predicting mortality in patients with pneumatosis intestinalis. Eur J Radiol 2014;83:639-645. Morris MS, Gee AC, Cho SD, Limbaugh K, Underwood S, Ham B, Schreiber MA. Management and outcome of pneumatosis intestinalis. Am J Surg 2008;195:679-683. Naguib N, Mekhail P, Gupta V, Naguib N, Masoud A. Portal Venous Gas and Pneumatosis Intestinalis; Radiologic Signs with Wide Range of Significance in Surgery. J Surg Educ 2012;69(1):47-51.
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You are called to see another patientCase PresentationCase PresentationSlide Number 4Slide Number 5Slide Number 6ORPost-Operative CourseSlide Number 9Post-op CourseOR2nd Post-Op CourseSlide Number 13Pneumatosis Intestinalis & Portal Venous GasOutlineHistory of Pneumatosis IntestinalisWhere does the gas come from?Causes of PneumatosisSlide Number 19Clinical Significance of PneumatosisSlide Number 21Slide Number 22Slide Number 23Portal Venous GasHistory of Portal Venous GasPortal Venous GasSlide Number 27Slide Number 28Slide Number 29Slide Number 30SummaryReferences