Download Slide 1 - Baylor College of Medicine

GI Grand Rounds
Johanna Chan
Gastroenterology Fellow
Baylor College of Medicine
12/13/2012
No conflicts of interest
No financial disclosures
HPI
• RFC: nausea, vomiting, abdominal pain
• 61yo WM with HCV/EtOH cirrhosis, admitted
with nausea and nonbloody emesis x 3 wks
• Dull, diffuse abdominal pain, no radiation
• Worse with eating and drinking
• Early satiety
• Poor PO intake x 3 weeks
• No fever, chills, constipation, diarrhea, dysuria,
edema
Past Medical History
• HCV genotype 3a
▫ Nonresponder to pegylated interferon and
ribavirin in 2004
• HCV/EtOH cirrhosis, Child Class A
• Bladder carcinoma s/p TURBT 1999
• BPH
Medications
• Omeprazole 20mg PO daily (recently prescribed
at urgent care)
• No other OTC medications, including NSAID or
aspirin use
Other history
• Family history negative for GI malignancy, liver
disease
• Social history
▫ Current 1 pack/day smoker since teen years
▫ Prior h/o IVDA, none since 1990s
▫ Prior heavy EtOH since teen years, quit in 1980s
Exam
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T 98, BP 108/75, HR 78, RR 12, O2 sat 98% RA
Gen: uncomfortable but nontoxic, NAD, AAOx4
HEENT: PERRL, EOMI, dry MM, OP clear
Neck: supple, no LAD, flat neck veins
CV: RRR no m/r/g
Lungs: CTAB, no wheeze/crackles
Abd: markedly distended, diffusely tender, no
guarding, +BS, dull to percussion
• Ext: WWP no c/c/e
Labs
125
55
94
147
4.4
45
5.6
11.1
17.6
52.3
77% PMNs
Total protein 7.4
Albumin 3.6
Total bili 3.1
ALT 109
AST 123
Alk phos 39
187
INR 1.1
PTT 32
MCV 99
Imaging
Initial thoughts?
Differential diagnosis?
Next steps in management?
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A) NPO +/- NG tube decompression
B) Broad-spectrum antibiotics
C) Consult surgery
D) Endoscopy (and timing?)
Clinical course
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NPO, IV ceftriaxone and flagyl
General surgery consult
Negative blood and urine cultures
Remained clinically well and nontoxic
Symptoms improved
Tolerated clear liquids for 2-3 days
Clinical course
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Return of nausea and vomiting
NG tube decompression: >3L nonbloody output
Saline load test markedly positive
Repeat KUB
Endoscopy
Gastric emphysema
• Diagnosis: gastric emphysema due to gastric
outlet obstruction
• Pneumatosis intestinalis
▫ Gastric pneumatosis
 Gastric emphysema
 Emphysematous gastritis
▫ Pneumatosis coli
Clinical questions
• What is pneumatosis intestinalis (PI)?
• Differential diagnosis of PI?
• Management of PI?
▫ Indications for surgery?
▫ Role for endoscopy?
• Relation to gastric outlet obstruction?
What is pneumatosis intestinalis?
• First described in 1754 by Du Vernoy
• Presence of extraluminal bowel gas within bowel
wall
• Breakdown of mucosal and immunological
barrier of intestine, especially in the setting of
increased intraluminal pressure
Galundiuk S et al. DCR. 1986; (29)5: 358-363.
Heng Y et al. Am J of Gastroenterol. 1995; (90)10: 1747-1758.
Koss LG. Arch Pathol. 1952; (53): 523-549.
What is pneumatosis intestinalis?
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0.03% in general population (autopsy series)
Incidence rising with increasing CT use
Most asymptomatic, incidentally detected
Complications occur in up to 3% of patients
▫ Pneumoperitoneum, bowel obstruction, volvulus,
intussusceptions, hemorrhage
Galundiuk S et al. DCR. 1986; (29)5: 358-363.
Heng Y et al. Am J of Gastroenterol. 1995; (90)10: 1747-1758.
Differential diagnosis for PI
• Idiopathic (rare) – 10-15% by review of 213 cases
• Secondary
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Bowel necrosis
Mucosal disruption
Increased mucosal permeability
Pulmonary disease
Koss LG. Arch Pathol. 1952; (53): 523-549.
Pear BL. Radiology. 1998; 207(1):13-19.
DDx PI: Bowel necrosis
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Ischemia/infarction
Necrotizing enterocolitis
Neutropenic colitis
Volvulus
Sepsis
In the stomach, emphysematous gastritis or
ingestion of caustic agents
DDx PI: Mucosal disruption
• Over-distention (peptic ulcer, pyloric stenosis,
annular pancreas, or distal obstruction)
• Ulceration, erosions, trauma
• Iatrogenic (feeding tubes, stent perforation,
sclerotherapy, or surgical or endoscopic trauma)
• Connective tissue disease: scleroderma, SLE
• Medications that cause bowel distention:
sortibol, lactulose
DDx PI: Increased mucosal
permeability
• Mucosal erosions or defects in intestinal crypts
(inflammatory bowel disease)
• Immunocompromise (due to steroids,
chemotherapy, radiation therapy, or AIDS) with
defects in bowel wall lymphoid tissue
• Acute graft vs. host disease
DDx PI: Pulmonary disease
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Chronic obstructive pulmonary disease
Asthma
Cystic fibrosis
Barotrauma
After chest tube placement
Increased intrathoracic pressure (retching,
vomiting, PEEP)
Management of PI
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Exclude acute intra-abdominal emergency
Antibiotics
Elemental diet (for pneumatosis coli)
High-flow oxygen or hyperbaric oxygen therapy
Endoscopic therapy (particularly obstructive
symptoms)
*No randomized controlled data
Indications for surgery
• Clinical indications of bowel ischemia
• Combination of PI and serum lactate >2 mmol/L
associated with >80% mortality (Hawn et al)
• Radiographic signs:
▫ Hepatic portal and portomesenteric venous gas
▫ Vascular distribution suggesting ischemia
▫ Additional abnormal bowel wall findings
• Others: obstruction, ileus, toxic megacolon,
severe collagen vascular disease
Hawn MT et al. Am Surg. 2004; (70)1:19-23.
Wayne E et al. J Gastrointest Surg 2010; 14:437.
Role for endoscopy
• Non-surgical cases
• Diagnosis of underlying etiology
• Gastric emphysema
▫ Submucosal “bubbles” with pale/bluish mucosa
▫ Deflate when biopsied
▫ Edema, erosions
• Emphysematous gastritis
▫ Edematous, friable, ulceration with exudates
▫ Histology: fibrin thrombi, gas-forming organisms,
bacterial infiltration, microabscesses
Cordum NR et al. Am J Gastroenterol 1997; 92:692.
Gastric emphysema in relation to
gastric outlet obstruction
• Well-reported in the pediatric literature
• Most commonly due to pyloric stenosis
▫ Also duodenal stenosis, tumor, protracted
vomiting
• Mortality rate for gastric pneumatosis 41% in
adults, 6% in children
D’Cruz R et al. J Pediatr Surg 2008 ;43:2121-3.
Taylor D et al. Int Pediatr 2000; 15:117-20.
Lim RK et al. CMAJ 2010. 182(5): E227.
Patient case follow-up
• Esophagus, biopsy
▫ Gastric-type mucosa with mild chronic and focally
acute inflammation
▫ Intestinal metaplasia
• Stomach ulcer, biopsy
▫ Reactive gastropathy
• Stomach, random biopsy
▫ Reactive gastropathy with focal chronic inflammation
• Duodenum “mass”, biopsy
▫ Mild chronic focally active duodenitis, suggestive of
Brunner’s gland hyperplasia
References
• Braumann C, Menenakas C, and Jacobi CA. “Pneumatosis intestinalis – a
pitfall for surgeons?” Scandinavian Journal of Surgery. 2005; (94)1: 47-50.
• Cordum NR, Dixon A, Campbell DR. Gastroduodenal pneumatosis:
endoscopic and histologic findings. Am J Gastroenterol 1997; 92:692.
• Galundiuk S and Fazio VW. “Pneumatosis cystoides intestinalis: a review
of the literature.” Diseases of the Colon and Rectum. 1986; (29)5: 358-363.
• Hawn MT, Canon CL, Lockhart ME, et al. “Serum lactic acid determines
the outcomes of CT diagnosis of pneumatosis of the gastrointestinal tract.”
Am Surg. 2004; (70)1:19-23.
• Heng Y, Schuffler MD, Haggitt RC, and Rohrmann CA. “Pneumatosis
intestinalis: a review.” American Journal of Gastroenterology. 1995;
(90)10: 1747-1758.
• Ho LM, Paulson EK, and Thompson WM. “Pneumatosis intestinalis in the
adult: benign to life-threatening causes.” American Journal of
Roentgenology. 2007; (188)6: 1604-1613.
References (con’t)
• Hoer J, Truong S, Virnich N, Fuzesi L, Schumpelick V. “Pneumatosis
cystoides intestinalis: confirmation of diagnosis by endoscopic puncture a
review of pathogenesis, associated disease and therapy and a new theory of
cyst formation. Endoscopy. 1998; (30)9:793-799.
• Koss LG. “Abdominal gas cysts (penumatosis cystoides intestinorum
hominis): an analysis with a report of a case and a critical review of the
literature.” Arch Pathol. 1952; (53): 523-549.
• Pear BL. “Pneumatosis intestinalis: a review.” Radiology. 1998; 207(1):1319.
• Pieterse AS, Leong AS, Rowland R. “The mucosal changes and
pathogenesis of pneumatosis cystoides intestinalis. Hum Pathol 1985;
16:683.
• Wayne E, Ough M, Wu A et al. “Management algorithm for pneumatosis
intestinalis and portal venous gas: treatment and outcome of 88
consecutive cases.” J Gastrointest Surg 2010; 14:437.
Thank you!
Additional slides
Histology
• Histology: pseudocysts (no epithelium) with rim
of histiocytes, multinuclear giant cells,
lymphocytes, neutrophils, eosinophils,
granulomas, fibrosis