Case-Based Discussion

PGY 林佩嫻
Dr.陳建翰

Jun 12, 2020

  Name: 蔡O榮
 Gender: Male
Patient  Age: 68 years old
Profile  Date of Admission: Jun 1, 2020
 Chief Complaint:
 Progressive bowel distension with diarrhea
for one week
 3

Past History
1. Rectosigmoid cancer with bladder invasion and
multiple lung and liver meta
 s/p HAR, partial cystectomy, L’t hepatectomy,
RUL/RLL/LUL wedge resection
 concurrent target therapy, C/T and palliative R/T
2. ESRD
 s/p R’t renal transplantation
 Sirolimus, Tacrolimus
3. HTN
Present Illness
Jun 1, 2020
 EDA ER

Progressive abdominal fullness with

diarrhea for one week
Physical Examination
BP: 121/76 mmHg, HR: 108, BT: 36.2 C
General Appearance: not in acute
distress
Consciousness: E4V5M6
HEENT: Abdomen:
conjunctiva: not pale, distended,
sclera: not icteric no muscle guarding,
Neck: no jugular vein engorgement no tenderness, no rebound tenderness
Chest: bil. clear breath sounds
Heart: regular beat, no murmur Extremities: freely movable
Lab
KUB
CT
CT
Problem 1 Pneumatosis Instestinalis
suspect bowel ischemia
List
2 Diarrhea

3 Electrolyte Imbalance

4
Plan
 Conservative Treatment
 NPO
 IVF and electrolyte
 NG decompression
 Abx with Flumarin
Clinical Course
Jun 1, 2020
 Admission to GS Ward

6/1 6/2 6/3 6/4

WBC 3450 2900 /μI
CRP 28.44 54.37
Vein gas
pH 7.346 7.267 7.282
pCO2 32.2 39.8 39.7
HCO3 17.2 17.7 18.3
Lactate 7.91 14.69 6.72 mg/dL
Clinical Course
Jun 3, 2020 Jun 6, 2020
 Discharge

 AGE
 Flumarin-> Ciprofloxacin
Pneumatosis Intestinalis
Introduction
 Refers to the presence of gas within the wall of the
small or large intestine
 The pathogenesis of is poorly understood, and probably
multifactorial
 Mechanical
 Bacterial
 Biochemical
 Incidental finding associated with a benign etiology,
whereas in others, it portends a life-threatening intra-
abdominal condition
Clinical Features
 Most are
asymptomatic
and probably never
come to clinical
attention
Evaluation
 History and PE
 CT:
 Decreased mural enhancement and the presence of
associated portal venous gas in patients with PI are
suggestive of intestinal ischemia
 But, 30 percent of patients with PI and PVG have a
benign idiopathic cause
Evaluation
 History and PE
 CT
 Lab:
 marked leukocytosis, immature WBC, an elevated Ht, and
metabolic acidosis
 Retrospectively reviewed all 104 CT scan diagnoses
of pneumatosis from Jan 2000~Feb 2007
A. OP group
B. Non-OP group
C. Futile group

 Mortality rate
 Lab values, APACHE II
 Location of pneumatosis
 Lab values should not be used alone to guide therapy

 APACHE II scores are predictive of mortality and

may guide management
 Concomitant PI and PVG are more likely to have bowel
ischemia
A single institution over 5 years
 Acute mesenteric ischemia were associated with
 abdominal pain (p=0.01)
 elevated lactate (≥27.0 mg/dL; p=0.006)
 small bowel PI (p=0.04)
 calculated vascular disease score (p<0.0005)

 Sensitivity of 89%, specificity of 100%, and positive

predictive value of 100%
27 mg/dL
 Here, analysis has been expanded in a large, multicenter
study
 developed five ad hoc models (scoring systems)
 area of ROC: none of these models was able to accurately
diagnose the outcome
 Older age (≥60 y), peritoneal signs, and high BUN
(> 25mg/dL) are associated with I/N
 ability to predict which patients need OP

CT findings traditionally suggestive of ischemic PN/PVG,

 do not diagnose I/N accurately enough to reliably identify
patients needing OP
 Suggest that the presence of a
peritoneal irritation sign on PE
and decreased or absent
contrast enhancement on CT
associate with a significantly
increased risk of mortality
 Pathologic PI is associated most strongly with a
decreased Hb, elevated INR, and lactate ≥18mg/dL
even in patients presenting without peritonitis

 Recommend a high index of suspicion of disease requiring

OP especially when radiographic findings include small
bowel PI and ascites
 Concomitant PMVG, decreased bowel wall
enhancement, and severe atherosclerosis highly
significantly correlate with an ischemic origin of PI

 Diagnosing the aetiology of PI remains a challenging

situation
 Number of gas-containing PV
regions was associated with
bowel necrosis
 Presence of gas in the EPV was
associated with bowel necrosis
 indicative of a large quantity of gas

 Air-type PI was not associated

with bowel necrosis
Conclusion
 PE: peritoneal sign?
 CT: PI location? characteristics?
 small bowel
 decreased wall enhancement
 bubble type
 CT: PVG present? others?
 number of regions & EPV
 ascites
 severe atherosclerosis
 Lab
 Lactate ≥18mg/dL
 BUN > 25mg/dL
 Hb, INR
Back to Our Patient
 68-year-old male
 s/p renal transplantation under immunosuppressant rx,
rectosigmoid CA with meta under CCRT, target therapy
 CT:
 Pneumoporta and air within the SMV, as well as
← non-contrast
pneumatosis intestinalis CT
 PE: no peritoneal sign
 Lab:
 metabolic acidosis (pH 7.346, pCO2 32.2, HCO3 17.2) ← ” V”BG
 normal lactate (7.91mg/dL) INR?
 initial elevation of BUN (39 mg/dL)
THE.END