American Journal of Emergency Medicine xxx (2014) xxx–xxx
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
An unusual etiology of abdominal pain and spontaneous pneumomediastinum in a young adult☆,☆☆,★ Abstract Among numerous manifestations of diabetic ketoacidosis (DKA), spontaneous pneumomediastinum (SPM) has seldom been described. It usually has a benign character and usually is a self-limited condition. Recently, we encountered a young adult complained of abdominal pain with interesting radiologic findings of SPM, a complication of DKA. We describe our case and review the previous literature. A 24-year-old man was admitted to our hospital with a 4-hour history of abdominal pain and 1 month thirsty. The patient also complained of weakness and nausea. He denied any previous history of abdominal trauma or diabetes mellitus in both himself and his family. His physical examination was remarkable for hyperventilation with characteristic of Kussmaul respiration. Respiratory rate was 32 breaths per minute, temperature of 36.0°C, pulse of 110 beats per minute, and blood pressure of 145/86 mm Hg. The mucous membranes were dry. There was no subcutaneous emphysema. The chest was clear. Cardiac examination showed a regular heartbeat, with no presence of heart murmur. The abdomen was flat, bowel sounds were low, and there was no guarding or rebound tenderness. Laboratory results were blood cell count, leukocyte, 24,390/mm3 (70.5% neutrophils). Plasma glucose was 20.9 mmol/L. The urinalysis was significant for 4+ glucose and 2+ ketones. It also revealed a metabolic acidosis with arterial blood pH 7.021, plasma bicarbonate 2.9 mmol/L, PCO2 1.50 kPa, PO2 20.16 kPa, and base excess −27.4 mmol/L. A computed tomography (CT) study on admission showed an unexpected finding of pneumomediastinum. The diagnosis of severe metabolic acidosis was retained, and he was treated medically for diabetic ketoacidosis (DKA). Treatment consisted in strict bed rest with oxygen therapy, fluid replacement, and insulin. Abdominal symptoms resolved after correction of metabolic, fluid, and electrolyte disturbances. Pneumomediastinum resolved spontaneously and had completely resolved 7 days later. He was discharged with the prescription of multiple daily insulin injection and followed up for 3 months without recurrence of any symptoms. Diabetic ketoacidosis is an acute and serious metabolic complication of diabetes millitus. Although it develops most commonly in patients with type 1 diabetes mellitus, it can be seen in type 2 diabetes mellitus adults and children, especially during acute disease or omission of treatment. Abdominal pain, sometimes mimicking an acute abdomen, is a frequent manifestation in patients with DKA and usually associated with a more severe metabolic acidosis. It may lead the clinicians into diagnostic error. ☆ The paper has not been presented in any meetings. ☆☆ Grant or other financial support: None ★ Conflicts of interest: The authors declared that they have no conflicts of interest to this work.
The exact pathophysiology of abdominal pain in patients with DKA remains controversial and may be multifactorial, involving metabolic, humoral, and neural processes [1]. The increase in circulating prostaglandins is felt to be the cause of the nausea, vomiting, and abdominal pain that are seen frequently at presentation [2]. The combination of acidosis and increased prostaglandin production leads to peripheral vasodilatation, although volume depletion is present. Acute hyperglycemia has been shown to produce gastroparesis by a direct effect and has adverse effects on esophageal motility and gallbladder contractility. In some cases, the abdominal pain in DKA has been attributed to rapid expansion of the hepatic capsule, presumably secondary to fatty liver or to bowel ischemia secondary to severe volume depletion and metabolic acidosis or mesenteric insufficiency [3]. Some study [4] found that elevation of pancreatic enzymes is common in children with DKA, but clinical pancreatitis is rare. The abdominal pain without an identifiable cause usually spontaneously resolves with correction of hyperglycemia, metabolic acidosis, and electrolyte disturbances. However, in the face of such severe illness and because of fear of missing an intra-abdominal medical or surgical process that may have precipitated the development of ketoacidosis, extensive laboratory and radiologic studies may be ordered. In some instances, exploratory laparotomy is performed without positive results, increasing the cost of medical care and the morbidity and mortality risk in patients with DKA [3]. This case is also a rare complication of DKA with spontaneous pneumomediastinum (SPM). Symptoms and signs of pneumomediastinum such as chest pain, subcutaneous crepitus, and the mediastinal crunch of Hamman can be absent [5]. Retching, prolonged vomiting from any cause, and/or Kussmaul respirations may lead to intrathoracic pressures that are sufficiently high to produce pneumomediastinum. But they may not explain all cases of SPM. In some cases, no precipitating factors can be identified. It is presumed that Kussmaul respiration causes an elevation in alveolar pressure [6]. Spontaneous pneumomediastinum developed from air leakage secondary to the excessive elevation of intrathoracic pressure. The increased intrabronchial pressure leads to alveolar rupture once enough gradient is created to cause air to penetrate the bronchovascular bundles and migrate into the mediastinum. Air collections may appear at different anatomic sites depending on the site of alveolar rupture [7]. Most of the time, SPM may be completely asymptomatic, and prognosis is related to the underlying disorder [8]. Consequently, aggressive investigation, prolonged hospitalization, or repeated chest x-rays and CT scan is rarely necessary if there is clinical improvement [8]. Important pathology, such as esophageal rupture, was not detected in any of the reported cases [7]. The management of SPM in DKA is generally supportive. Inhalation of oxygen is recommended to hasten resorption of extra-alveolar gas. The natural history has
0735-6757/$ – see front matter © 2014 Elsevier Inc. All rights reserved.
Please cite this article as: Sun D, et al, An unusual etiology of abdominal pain and spontaneous pneumomediastinum in a young adult, Am J Emerg Med (2014), http://dx.doi.org/10.1016/j.ajem.2014.01.035
2
D. Sun et al. / American Journal of Emergency Medicine xxx (2014) xxx–xxx
been found to be benign [5-9]. Recognizing that severe DKA may cause pneumomediastinum allows for expedient management. The case we present in this article highlights the need to raise the suspicion of DKA with the presence of abdominal pain and hyperventilation in young adult. To rule out an intra-abdominal medical or surgical process, radiologic investigation should be done carefully. Spontaneous pneumomediastinum usually has a benign character and usually is a selflimited condition. Most SPM cases are successfully treated conservatively. It is, however, important to be aware of the association. Recognizing SPM as a complication of severe DKA can prevent unnecessary, expensive, invasive, and potentially dangerous procedures by treating clinicians. Dalong Sun MMed Fengyuan Chen MMed Chenxi Wang MMed Department of Gastroenterology, Shanghai Fifth People’s Hospital Fudan University, Shanghai 200240 People’s Republic of China
References [1] Barrett EJ, Sherwin RS. Gastrointestinal manifestations of diabetic ketoacidosis (J). Yale J Biol Med 1983;56(3):175–8. [2] Vermeersch N, Stolte C, Fostier K, et al. An unusual case of hyperglycemia, abdominal pain, and increased anion gap acidosis (J). J Emerg Med 2010;39(4): 449–53. [3] Umpierrez G, Freire AX. Abdominal pain in patients with hyperglycemic crises (J). J Crit Care 2002;17(1):63–7. [4] Quiros JA, Marcin JP, Kuppermann N, et al. Elevated serum amylase and lipase in pediatric diabetic ketoacidosis (J). Pediatr Crit Care Med 2008;9(4):418–22. [5] Girard DE, Carlson V, Natelson EA, et al. Pneumomediastinum in diabetic ketoacidosis: comments on mechanism, incidence, and management (J). Chest 1971;60(5):455–9. [6] Makdsi F, Kolade VO. Diabetic ketoacidosis with pneumomediastinum: a case report (J). Cases J 2009;2:8095. [7] Pauw RG, van der Werf TS, van Dullemen HM, et al. Mediastinal emphysema complicating diabetic ketoacidosis: plea for conservative diagnostic approach (J). Neth J Med 2007;65(10):368–71. [8] Chapdelaine J, Beaunoyer M, Daigneault P, et al. Spontaneous pneumomediastinum: are we overinvestigating? (J). J Pediatr Surg 2004;39(5):681–4. [9] Banday W, Tahir M, Jallu S, et al. Spontaneous pneumomediastinum: rare complication of diabetic ketoacidosis (J). BMJ Case Rep 2009(2009).
http://dx.doi.org/10.1016/j.ajem.2014.01.035
Please cite this article as: Sun D, et al, An unusual etiology of abdominal pain and spontaneous pneumomediastinum in a young adult, Am J Emerg Med (2014), http://dx.doi.org/10.1016/j.ajem.2014.01.035
Contents lists available at ScienceDirect
American Journal of Emergency Medicine journal homepage: www.elsevier.com/locate/ajem
Case Report
An unusual etiology of abdominal pain and spontaneous pneumomediastinum in a young adult☆,☆☆,★ Abstract Among numerous manifestations of diabetic ketoacidosis (DKA), spontaneous pneumomediastinum (SPM) has seldom been described. It usually has a benign character and usually is a self-limited condition. Recently, we encountered a young adult complained of abdominal pain with interesting radiologic findings of SPM, a complication of DKA. We describe our case and review the previous literature. A 24-year-old man was admitted to our hospital with a 4-hour history of abdominal pain and 1 month thirsty. The patient also complained of weakness and nausea. He denied any previous history of abdominal trauma or diabetes mellitus in both himself and his family. His physical examination was remarkable for hyperventilation with characteristic of Kussmaul respiration. Respiratory rate was 32 breaths per minute, temperature of 36.0°C, pulse of 110 beats per minute, and blood pressure of 145/86 mm Hg. The mucous membranes were dry. There was no subcutaneous emphysema. The chest was clear. Cardiac examination showed a regular heartbeat, with no presence of heart murmur. The abdomen was flat, bowel sounds were low, and there was no guarding or rebound tenderness. Laboratory results were blood cell count, leukocyte, 24,390/mm3 (70.5% neutrophils). Plasma glucose was 20.9 mmol/L. The urinalysis was significant for 4+ glucose and 2+ ketones. It also revealed a metabolic acidosis with arterial blood pH 7.021, plasma bicarbonate 2.9 mmol/L, PCO2 1.50 kPa, PO2 20.16 kPa, and base excess −27.4 mmol/L. A computed tomography (CT) study on admission showed an unexpected finding of pneumomediastinum. The diagnosis of severe metabolic acidosis was retained, and he was treated medically for diabetic ketoacidosis (DKA). Treatment consisted in strict bed rest with oxygen therapy, fluid replacement, and insulin. Abdominal symptoms resolved after correction of metabolic, fluid, and electrolyte disturbances. Pneumomediastinum resolved spontaneously and had completely resolved 7 days later. He was discharged with the prescription of multiple daily insulin injection and followed up for 3 months without recurrence of any symptoms. Diabetic ketoacidosis is an acute and serious metabolic complication of diabetes millitus. Although it develops most commonly in patients with type 1 diabetes mellitus, it can be seen in type 2 diabetes mellitus adults and children, especially during acute disease or omission of treatment. Abdominal pain, sometimes mimicking an acute abdomen, is a frequent manifestation in patients with DKA and usually associated with a more severe metabolic acidosis. It may lead the clinicians into diagnostic error. ☆ The paper has not been presented in any meetings. ☆☆ Grant or other financial support: None ★ Conflicts of interest: The authors declared that they have no conflicts of interest to this work.
The exact pathophysiology of abdominal pain in patients with DKA remains controversial and may be multifactorial, involving metabolic, humoral, and neural processes [1]. The increase in circulating prostaglandins is felt to be the cause of the nausea, vomiting, and abdominal pain that are seen frequently at presentation [2]. The combination of acidosis and increased prostaglandin production leads to peripheral vasodilatation, although volume depletion is present. Acute hyperglycemia has been shown to produce gastroparesis by a direct effect and has adverse effects on esophageal motility and gallbladder contractility. In some cases, the abdominal pain in DKA has been attributed to rapid expansion of the hepatic capsule, presumably secondary to fatty liver or to bowel ischemia secondary to severe volume depletion and metabolic acidosis or mesenteric insufficiency [3]. Some study [4] found that elevation of pancreatic enzymes is common in children with DKA, but clinical pancreatitis is rare. The abdominal pain without an identifiable cause usually spontaneously resolves with correction of hyperglycemia, metabolic acidosis, and electrolyte disturbances. However, in the face of such severe illness and because of fear of missing an intra-abdominal medical or surgical process that may have precipitated the development of ketoacidosis, extensive laboratory and radiologic studies may be ordered. In some instances, exploratory laparotomy is performed without positive results, increasing the cost of medical care and the morbidity and mortality risk in patients with DKA [3]. This case is also a rare complication of DKA with spontaneous pneumomediastinum (SPM). Symptoms and signs of pneumomediastinum such as chest pain, subcutaneous crepitus, and the mediastinal crunch of Hamman can be absent [5]. Retching, prolonged vomiting from any cause, and/or Kussmaul respirations may lead to intrathoracic pressures that are sufficiently high to produce pneumomediastinum. But they may not explain all cases of SPM. In some cases, no precipitating factors can be identified. It is presumed that Kussmaul respiration causes an elevation in alveolar pressure [6]. Spontaneous pneumomediastinum developed from air leakage secondary to the excessive elevation of intrathoracic pressure. The increased intrabronchial pressure leads to alveolar rupture once enough gradient is created to cause air to penetrate the bronchovascular bundles and migrate into the mediastinum. Air collections may appear at different anatomic sites depending on the site of alveolar rupture [7]. Most of the time, SPM may be completely asymptomatic, and prognosis is related to the underlying disorder [8]. Consequently, aggressive investigation, prolonged hospitalization, or repeated chest x-rays and CT scan is rarely necessary if there is clinical improvement [8]. Important pathology, such as esophageal rupture, was not detected in any of the reported cases [7]. The management of SPM in DKA is generally supportive. Inhalation of oxygen is recommended to hasten resorption of extra-alveolar gas. The natural history has
0735-6757/$ – see front matter © 2014 Elsevier Inc. All rights reserved.
Please cite this article as: Sun D, et al, An unusual etiology of abdominal pain and spontaneous pneumomediastinum in a young adult, Am J Emerg Med (2014), http://dx.doi.org/10.1016/j.ajem.2014.01.035
2
D. Sun et al. / American Journal of Emergency Medicine xxx (2014) xxx–xxx
been found to be benign [5-9]. Recognizing that severe DKA may cause pneumomediastinum allows for expedient management. The case we present in this article highlights the need to raise the suspicion of DKA with the presence of abdominal pain and hyperventilation in young adult. To rule out an intra-abdominal medical or surgical process, radiologic investigation should be done carefully. Spontaneous pneumomediastinum usually has a benign character and usually is a selflimited condition. Most SPM cases are successfully treated conservatively. It is, however, important to be aware of the association. Recognizing SPM as a complication of severe DKA can prevent unnecessary, expensive, invasive, and potentially dangerous procedures by treating clinicians. Dalong Sun MMed Fengyuan Chen MMed Chenxi Wang MMed Department of Gastroenterology, Shanghai Fifth People’s Hospital Fudan University, Shanghai 200240 People’s Republic of China
References [1] Barrett EJ, Sherwin RS. Gastrointestinal manifestations of diabetic ketoacidosis (J). Yale J Biol Med 1983;56(3):175–8. [2] Vermeersch N, Stolte C, Fostier K, et al. An unusual case of hyperglycemia, abdominal pain, and increased anion gap acidosis (J). J Emerg Med 2010;39(4): 449–53. [3] Umpierrez G, Freire AX. Abdominal pain in patients with hyperglycemic crises (J). J Crit Care 2002;17(1):63–7. [4] Quiros JA, Marcin JP, Kuppermann N, et al. Elevated serum amylase and lipase in pediatric diabetic ketoacidosis (J). Pediatr Crit Care Med 2008;9(4):418–22. [5] Girard DE, Carlson V, Natelson EA, et al. Pneumomediastinum in diabetic ketoacidosis: comments on mechanism, incidence, and management (J). Chest 1971;60(5):455–9. [6] Makdsi F, Kolade VO. Diabetic ketoacidosis with pneumomediastinum: a case report (J). Cases J 2009;2:8095. [7] Pauw RG, van der Werf TS, van Dullemen HM, et al. Mediastinal emphysema complicating diabetic ketoacidosis: plea for conservative diagnostic approach (J). Neth J Med 2007;65(10):368–71. [8] Chapdelaine J, Beaunoyer M, Daigneault P, et al. Spontaneous pneumomediastinum: are we overinvestigating? (J). J Pediatr Surg 2004;39(5):681–4. [9] Banday W, Tahir M, Jallu S, et al. Spontaneous pneumomediastinum: rare complication of diabetic ketoacidosis (J). BMJ Case Rep 2009(2009).
http://dx.doi.org/10.1016/j.ajem.2014.01.035
Please cite this article as: Sun D, et al, An unusual etiology of abdominal pain and spontaneous pneumomediastinum in a young adult, Am J Emerg Med (2014), http://dx.doi.org/10.1016/j.ajem.2014.01.035
