Holly Foote, DO1, Amanda Chiu2, Itnia Pramanik, MBBS1, William Buniak2, Sharique Nazir, MDFACSFICS1. 1St Barnabas Hospital,Bronx ,New York, 2New York Institute Of Technology College Of Osteopathic Medicine, Old Westbury, NY
Introduction: Pneumatosis intestinalis (PI), or gas in the bowel wall, can be seen on various imaging modalities. The pathophysiology behind PI is unclear. One theory proposes a mechanical cause (e.g. small bowel obstruction) while another proposes a bacterial etiology . Management of PI in adults is difficult as often there is a benign clinical course. However, when paired with specific clinical features such as hepatic portal venous gas (HPVG) on imaging, the course of management changes as the suspicion of bowel ischemia increases . HPVG alone has been associated with a high mortality rate and a poor prognosis . Management in this case becomes surgical.
Case Presentation: We present a case of 59-year-old Latino male who presented to the emergency room with abdominal pain and altered mental status. Focused physical examination revealed a non-rigid abdomen, no rebound tenderness, no guarding, and diffuse tenderness only to deep palpation. CT scan of the abdomen and pelvis demonstrated moderate portal venous gas in the right and left hepatic lobes, an upper midline dilated small bowel loop with pneumatosis intestinalis, and a moderately distended stomach with gas and fluid. Laboratory studies revealed metabolic acidosis and a lactic acid level of 2.9 mmol/L. Due to these findings, bowel ischemia was suspected, and the patient was taken to the operating room for a diagnostic laparoscopy. The laparoscopy was converted to an exploratory laparotomy due to extensive adhesions. Intraoperatively, there was no small bowel compromise and no identifiable transition point. Extensive lysis of adhesions and repair of iatrogenic enterotomy were performed. Patient tolerated the procedure well, clinically improved, and was discharged from the hospital.
Discussion: This case illustrates the difficulty in management of a patient with pneumatosis intestinalis and, specifically, hepatic portal vein gas seen on CT imaging. HPVG has traditionally been a harbinger of morbidity and mortality, but exploratory laparotomy revealed only diffuse abdominal adhesions and the absence of bowel ischemia despite high clinical suspicion.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 88398
Program Number: P055
Presentation Session: iPoster Session (Non CME)
Presentation Type: Poster
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