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

Transcription

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

2 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

3 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 HCO 3 17 EKG: 87 bpm

4

5

6

7 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

8 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

9

10 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

11 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

12 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

13

14 Pneumatosis Intestinalis & Portal Venous Gas Melissa Wong, MD Richmond University Medical Center 30 April 2015

15 Outline pneumatosis intestinalis a brief history etiology clinical significance portal venous gas history clinical significance fun quiz

16 History of Pneumatosis Intestinalis 1730: described by Du Vernoi in cadavers 1946: 1st described as a radiographic finding by Lerner & Gazin

17 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

18 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

19 Bani Hani M, J Surg Res 2013.

20 Greenstein A, J Gastrointest Surg Wayne E, J Gastrointest Surg 2010 Clinical Significance of Pneumatosis Greenstein et al., 2007: 40 pts, need for laparotomy h/o emesis age >60 leukocytosis >12 mortality risk: sepsis Wayne et al., 2010: 74 pts, vascular risk factor score: h/o smoking HTN, HLD, CAD DM, PVD, vasculitis abnormal abdominal exam lactic acidosis

21 Bani Hani M, J Surg Res pts, outcome: clinically significant ischemia/necrosis

22 Bani Hani M, J Surg Res 2013.

23 Bani Hani M, J Surg Res pts, outcome: clinically significant ischemia/necrosis best model: sensitivity 73%, specificity 67%, accuracy <80% age, peritonitis, BUN, both together Conclusion: No.

24 Portal Venous Gas

25 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

26 Portal Venous Gas #1 cause: bowel ischemia mortality: 25-75% alone vs with pneumatosis early experience vs recent series

27 A B

28

29

30

31 Summary wide range of clinical significance your clinical judgement matters don t miss bowel ischemia

32 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: 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: 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: 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: 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.