You are called to see another patient• dilated colon (cecum to transverse) • no ischemia or pneumatosis of colon or mesentery • adhesive band of omentum across distal transverse

You are called to see another patient Melissa Wong, MD Richmond University Medical Center 30 April 2015

www.downstatesurgery.org

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


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


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


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



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


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


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


Pneumatosis Intestinalis & Portal Venous Gas

Melissa Wong, MD Richmond University Medical Center 30 April 2015


Outline

● pneumatosis intestinalis ○ a brief history ○ etiology ○ clinical significance

● portal venous gas ○ history ○ clinical significance ○ fun quiz


History of Pneumatosis Intestinalis

● 1730: described by Du Vernoi in cadavers ● 1946: 1st described as a radiographic finding

by Lerner & Gazin


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


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


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.


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


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



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



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


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


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


A B www.downstatesurgery.org

PresenterPresentation NotesPVG vs pneumobilia

Summary

● wide range of clinical significance ● your clinical judgement matters ● don’t miss bowel ischemia


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.


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

Documents

You are called to see another patient• dilated colon (cecum to transverse) • no ischemia or pneumatosis of colon or mesentery • adhesive band of omentum across distal transverse