should there be air there? elizabeth m. regan november 22, 2013 dr. cameron; dr. p.smith, dr....

Should there be air there?

Elizabeth M. Regan

November 22, 2013

Dr. Cameron; Dr. P.Smith, Dr. Ebersole

• CC: abdominal pain, N/V, T101.3• HPI: Patient is a 42 y/o female who originally presented to the

ED on 10/26 with 1 month history of cough and markedly elevated WBC of 200. Patient was diagnosed with ALL and admitted for workup and initiation of chemotherapy. Her hospital stay became complicated by an UE DVT, large left-sided pleural effusion and retroperitoneal hematoma s/p BM biopsy. On 11/11 patient developed mid-epigastric abdominal pain, N/V and became febrile to 101.3 F.

• PMH: HTN, UE DVT, left-sided pleural effusion, hematoma• PSH: nill• Allergies: NKA• Social: never smoker, denies alcohol and drug use

CASE: OS (MR:6605248)

2

• Physical Exam:– Vitals: T99.3, BP 136/70, HR 112, RR 20, O2 97%– CONSTITUTIONAL: NAD– LUNGS: CTAB  – CARDIOVASCULAR: NSR normal S1 and S2, no S3 or S4, no

murmur– ABDOMEN: Normal bowel sounds, soft, mildly distended, TTP over

epigastric and RUQ  – EXTREMITIES: no LE edema, Left upper extremity - no longer

edematous surrounding PICC, not TTP– NEURO: A&Ox3, CNII-XII grossly intact  – SKIN: no rashes

• Labs:– Neutropenic– Normal lactate

CASE

• Acute Abdominal Pain, Fever– Ulcer– Pancreatitis– Infectious (Viral, Abscess)– Biliary Obstruction (cholecystitis, cholangitis, malignancy)– Tumor Lysis

• Imaging Modalities to consider– Ultrasound vs CT vs MRI?– Contrast?– Decision: CT abdomen and pelvis with IV contrast

Working Clinical Diagnoses

Appropriateness Criteria

Normal CT Abdomen (Level of Stomach)

Axial CT (with PO contrast)

OS CT Abdomen (Stomach)

CT Abdomen (Small Bowel)

CT Abdomen (Small Bowel)

CT Abdomen (Small Bowel)

• Pneumatosis intestinalis seen in posterior gastric wall, small bowel, as well as air within draining gastric vein

• What’s next?– Investigate for pneumoperitoneum

OS KUB- 1 view

OS CXR-No pneumoperitoneum

Abnormal CXR: Free Air under Diaphragm

• Pneumatosis Intestinalis– Gas within the wall of the bowel; Can occur anywhere

between esophagus and rectum– Symptom of multiple disease states, both GI and non-GI

related– Can be benign or an emergency • Emergencies include pneumoperitoneum, bowel

ischemia/infarction • Most presentations are benign; most patients are

actually asymptomatic– Most Common in adults ages 40-70 as well as in the

neonate population (associated with Necrotizing enterocolitis). Equal prevalence in males and females

Working Diagnosis/ Pathology

– Most commonly associated disease states:• COPD• Immunocompromised states• Inflammatory or infectious causes of GI tract• Recent surgical or endoscopic procedures• Diabetes• Ischemia

– Clinical Presentation usually includes: N/V, abdominal pain, mucus or blood in stools, weight loss

• Plain Films:– Intramural gas can be linear, curvilinear, or circular in

appearance– Linear pneumatosis tends to be more ominous, but can be

benign– If pneumoperiotoneum is also present, look for: free air

under the diaphragm, Rigler’s sign, falciform ligament sign• CT:– More sensitive– Circumferential collections of air adjacent to lumen of

bowel

Characteristic Findings

• Patient was non-peritonitic, complaining only of mild pain

• No pneumoperitoneum• Surgery consulted, no evidence for bowel

infarction/ischemia• Serial abdominal exams, prontonix, and fluid

resuscitation• Patient improved within 36 hours. No surgical

intervention needed.

Outcome/Treatment