The Journal of Emergency Medicine, Vol. -, No. -, pp. 1–2, 2015 Copyright Ó 2015 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter
http://dx.doi.org/10.1016/j.jemermed.2015.05.004
Visual Diagnosis in Emergency Medicine
PNEUMATOSIS INTESTINALIS Chun-Chieh Chiu, MD,* Fu-Yuan Siao, MD,* and Hsu-Heng Yen, MD†‡ *Department of Emergency Medicine, †Department of Gastroenterology, Changhua Christian Hospital, Changhua, Taiwan, and ‡College of Medicine, Chung Shan Medical University, Taichung, Taiwan Reprint Address: Hsu-Heng Yen, MD, Department of Gastroenterology, Changhua Christian Hospital, Changhua, Taiwan
CASE REPORT A 75-year-old man who had been diagnosed as having lung adenocarcinoma with liver metastasis for 2 months was brought to the Emergency Department (ED) with abdominal pain. He received three courses of chemotherapy with intermittent abdominal discomfort and weight loss from 65 kg to 59 kg observed during the period. The discomfort worsened 1 week prior to this admission, accompanied with intermittent vomiting. A side effect from chemotherapy was assumed and the therapy was postponed. The symptom worsened, with diffuse abdominal pain developing, and he was brought to the ED. On physical examination, the abdomen was diffusely distended, with hypoactive bowel sounds. Laboratory examination revealed mild leukocytosis (white blood cells 10,900, segmented neutrophil: 94.5%). An abdominal x-ray study revealed a marked dilatation of small bowel loops with collection of linear intramural air (Figure 1). An abdominal computed tomography scan revealed patent mesenteric vascular structure. Enlarged lymph nodes in the jejunal mesentery with central necrosis were found along with dilatation of the duodenum and jejunum (Figure 2). Pneumatosis intestinalis of the jejunum from intestinal obstruction was diagnosed and the patient was prompted for surgery. On laparotomy, tumor adhesion at the jejunum with ischemic change of the jejunum
Figure 1. The abdominal x-ray study revealed a marked dilatation of the small bowel loops with collection of linear intramural air (arrows).
RECEIVED: 31 October 2014; FINAL SUBMISSION RECEIVED: 23 April 2015; ACCEPTED: 14 May 2015 1
2
C.-C. Chiu et al.
Figure 2. The abdominal computed tomography scan revealed enlarged lymph nodes in the jejunal mesentery with central necrosis found along with dilatation of the duodenum and jejunum.
was found, and segmental resection with re-anastomosis of the jejunum was performed. The patient was discharged 10 days after the surgery. DISCUSSION Pneumatosis intestinalis is a rare clinical condition that refers to the presence of gas in the intestinal wall (1–3). It is a concerning radiological sign and not a disease
itself. Not all of these patients require emergent surgery. It can be classified as benign, requiring no specific therapy, or clinically serious, suggestive of underlying bowel disease that requires surgery. The presence of pneumatosis intestinalis without trauma usually suggests a serious medical condition requiring surgical intervention, such as mesenteric vascular ischemia or bowel obstruction. Pneumatosis intestinalis can be visualized in a plain abdominal image as cystic pockets of gas or linear lucencies within the bowel wall, as in this case. In addition, pneumatosis intestinalis can be accompanied with ‘‘thumb printing’’ sign suggestive of bowel wall edema, hepatic portal venous gas visible as linear branching lucencies of the liver, or subphrenic free in the case of bowel perforation. If pneumatosis intestinalis is visualized with dilatated bowel loops, as in this reported case, an obstructive etiology is suggested. REFERENCES 1. Fong KY, Siao FY, Yen HH. Cecal pneumatosis intestinalis in obstructing sigmoid cancer: emergency metallic stenting. Am J Emerg Med 2014;32:395.e1–3. 2. Wu SS, Yen HH. Images in clinical medicine. Pneumatosis cystoides intestinalis. N Engl J Med 2011;365:e16. 3. Soon MS, Yen HH, Soon A, Lin OS. Endoscopic ultrasonographic appearance of gastric emphysema. World J Gastroenterol 2005;11: 1719–21.
http://dx.doi.org/10.1016/j.jemermed.2015.05.004
Visual Diagnosis in Emergency Medicine
PNEUMATOSIS INTESTINALIS Chun-Chieh Chiu, MD,* Fu-Yuan Siao, MD,* and Hsu-Heng Yen, MD†‡ *Department of Emergency Medicine, †Department of Gastroenterology, Changhua Christian Hospital, Changhua, Taiwan, and ‡College of Medicine, Chung Shan Medical University, Taichung, Taiwan Reprint Address: Hsu-Heng Yen, MD, Department of Gastroenterology, Changhua Christian Hospital, Changhua, Taiwan
CASE REPORT A 75-year-old man who had been diagnosed as having lung adenocarcinoma with liver metastasis for 2 months was brought to the Emergency Department (ED) with abdominal pain. He received three courses of chemotherapy with intermittent abdominal discomfort and weight loss from 65 kg to 59 kg observed during the period. The discomfort worsened 1 week prior to this admission, accompanied with intermittent vomiting. A side effect from chemotherapy was assumed and the therapy was postponed. The symptom worsened, with diffuse abdominal pain developing, and he was brought to the ED. On physical examination, the abdomen was diffusely distended, with hypoactive bowel sounds. Laboratory examination revealed mild leukocytosis (white blood cells 10,900, segmented neutrophil: 94.5%). An abdominal x-ray study revealed a marked dilatation of small bowel loops with collection of linear intramural air (Figure 1). An abdominal computed tomography scan revealed patent mesenteric vascular structure. Enlarged lymph nodes in the jejunal mesentery with central necrosis were found along with dilatation of the duodenum and jejunum (Figure 2). Pneumatosis intestinalis of the jejunum from intestinal obstruction was diagnosed and the patient was prompted for surgery. On laparotomy, tumor adhesion at the jejunum with ischemic change of the jejunum
Figure 1. The abdominal x-ray study revealed a marked dilatation of the small bowel loops with collection of linear intramural air (arrows).
RECEIVED: 31 October 2014; FINAL SUBMISSION RECEIVED: 23 April 2015; ACCEPTED: 14 May 2015 1
2
C.-C. Chiu et al.
Figure 2. The abdominal computed tomography scan revealed enlarged lymph nodes in the jejunal mesentery with central necrosis found along with dilatation of the duodenum and jejunum.
was found, and segmental resection with re-anastomosis of the jejunum was performed. The patient was discharged 10 days after the surgery. DISCUSSION Pneumatosis intestinalis is a rare clinical condition that refers to the presence of gas in the intestinal wall (1–3). It is a concerning radiological sign and not a disease
itself. Not all of these patients require emergent surgery. It can be classified as benign, requiring no specific therapy, or clinically serious, suggestive of underlying bowel disease that requires surgery. The presence of pneumatosis intestinalis without trauma usually suggests a serious medical condition requiring surgical intervention, such as mesenteric vascular ischemia or bowel obstruction. Pneumatosis intestinalis can be visualized in a plain abdominal image as cystic pockets of gas or linear lucencies within the bowel wall, as in this case. In addition, pneumatosis intestinalis can be accompanied with ‘‘thumb printing’’ sign suggestive of bowel wall edema, hepatic portal venous gas visible as linear branching lucencies of the liver, or subphrenic free in the case of bowel perforation. If pneumatosis intestinalis is visualized with dilatated bowel loops, as in this reported case, an obstructive etiology is suggested. REFERENCES 1. Fong KY, Siao FY, Yen HH. Cecal pneumatosis intestinalis in obstructing sigmoid cancer: emergency metallic stenting. Am J Emerg Med 2014;32:395.e1–3. 2. Wu SS, Yen HH. Images in clinical medicine. Pneumatosis cystoides intestinalis. N Engl J Med 2011;365:e16. 3. Soon MS, Yen HH, Soon A, Lin OS. Endoscopic ultrasonographic appearance of gastric emphysema. World J Gastroenterol 2005;11: 1719–21.
