Article

An avoidable abdominal surgery: pneumatosis coli

Case Report

An avoidable abdominal surgery: pneumatosis coli Abstract

We report on the case of a 90-year-old man who presented to the emergency department with constipation for 1 week and Abdominal fullness for 2 days. abdominal plain film radiography disclosed intramural air in the colon, which indicated pneumatosis coli (PC). Exploratory laparotomy was performed immediately under the impression of ischemic bowel disease. Through examination of the mesentery, the intestine and colon revealed no sign of perforation and ischemia. Surgery for PC is limited to patients with signs of perforation, peritonitis, Intra-abdominal abscess, or Bowel ischemia. Conservative treatment with oxygen supply, Hyperbaric oxygen therapy, and antibiotics remain to be the mainstay for most patients with PC.

First described by Du Vernoi in 1783, Pneumatosis intestinalis (PI) is an uncommon condition characterized by the presence of gas in the wall of the gastrointestinal system. Pneumatosis intestinalis can involve the small bowel, colon, or both. When intramural gas involves only the colon, it is called pneumatosis coli (PC). Pneumatosis intestinalis often leads physicians to make a diagnosis of serious underlying diseases such as ischemic bowel disease and bowel perforation, and then surgical intervention ensues. We present a case of PC in an elderly patient with a debilitating condition. He underwent exploratory laparotomy immediately under the impression of ischemic bowel disease. Through examination of the mesentery, the intestine and colon revealed no sign of perforation and ischemia. The patient’s postoperative course was complicated by pulmonary infection, and he was then discharged with intact bowel function.

A 90-year-old man with a medical history of congestive heart failure, atrial fibrillation, hypertension, and cerebral vascular disease presented to our emergency department with abdominal fullness and abdominal pain that exacerbated for 2 days. The patient had been in bedridden status for years, and he was a resident of a nursing home. His family reported that his appetite diminished for 2 weeks, and he suffered from constipation for 1 week.

Upon arrival to our emergency department, the patient was conscious, was in moderate distress, and had a blood pressure

of 103/63 mm Hg, a heart rate of 80 beats/min, and a respiratory rate of 21 breaths/min. His physical examination was remarkable for bilateral coarse breathing sounds, abdominal distension, and localized mid-abdominal tender- ness without rebound or muscle rigidity. Bowel sounds were hypoactive. The blood examinations showed a white cell count of 6710 per microliter, a blood urea nitrogen level of 52 mg/dL, a creatinine level of 1.0 mg/dL, a sodium level of 155 mEq/L, and a potassium level of 3.7 mEq/L. Chest radiography showed no subphrenic Free air, and abdominal plain film radiography disclosed a marked dilated colon with obvious intramural air (Fig. 1A). Contrast-enhanced com- puted tomography of the abdomen showed a dilated bowel loop with extensive intramural air from the Ascending colon to the transverse colon (Fig. 1B). Exploratory laparotomy was performed immediately under the impression of PI owing to ischemic bowel disease. Through examination of the mesentery, the intestine and colon revealed no sign of perforation and ischemia. Diffuse, foamy, and emphysema- tous change with minimal clear ascites was noted from the ascending colon to the transverse colon. The patient was then admitted to the surgical intensive care unit for 5 days. His postoperative course was complicated by pulmonary infec- tion, and he was then discharged uneventfully.

Pneumatosis intestinalis is a radiographic finding of the underlying pathologic process. When intramural gas involves only the colon, it is called PC–sometimes it is called pneumatosis cystoides intestinalis according to its cystic appearance. Pneumatosis coli is an uncommon disorder that can be seen in several underlying conditions such as ischemic bowel disease, colon perforation, blunt abdominal trauma, inflammatory bowel diseases, chronic obstructive pulmonary diseases, immunosuppression, and use of steroid [1-3].

The pathogenesis of PC is not fully understood. The variety of the clinical picture and that of the underlying condition suggest that there may be more than one mechanism responsible for the development of intramural air. Three hypotheses have been proposed as the source of intramural gas: (a) mechanical theory, (b) bacterial produc- tion of gas, and (c) pulmonary gas [1,2,4]. Clinical courses and manifestations of PC are not related to the extent of intramural gas but to the underlying pathology.

Our patient’s case was characterized by multiple debilitating underlying diseases, and he was a resident of a

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517.e2 Case Report

Fig. 1 A, Abdominal plain film revealing a marked dilated ascending colon with obvious intramural air. B, Contrast-enhanced computed tomographic scan image of the abdomen showing a dilated bowel loop with extensive intramural air from the ascending colon to the transverse colon.

nursing home. He suffered from constipation for approxi- mately 1 week and abdominal fullness for days. Combining these conditions, his PC might have originated from colonic

pseudo-obstruction, which is also named the Ogilvie syndrome [5]. The ileus caused an increase in luminal pressure and thus the colon intramural air. Mucosal damage and bacterial production of gas might also play an important part. The patient was treated conservatively with intravas- cular fluid supplements and took nothing by mouth for days after the operation. He recovered uneventfully and was discharged home after recovering his bowel function.

In conclusion, PI is only a presentation of a wide range of underlying diseases, and PC is one of the entities. Surgery for PC is limited to those patients with signs of perforation, peritonitis, intra-abdominal sepsis, or bowel ischemia [1]. Conservative treatment with oxygen supply, hyperbaric oxygen therapy, and antibiotics remain to be the mainstay for most patients with PC [5-7].

Bor-Hen Wu MD

Emergency Department Shin-Kong Wu Ho-Su Memorial Hospital

Taipei 111, Taiwan

Chien-Chih Chen MD, MS Tzong-Luen Wang MD, PhD Chee-Fah Chong MD, MS Emergency Department

Shin-Kong Wu Ho-Su Memorial Hospital

Taipei 111, Taiwan School of Medicine

Fu Jen Catholic University Taipei 242, Taiwan

Chen-Yang Hsu MD

Department of Emergency Medicine

Taipei City Hospital Zhongxiao Branch Taipei 103, Taiwan

E-mail address: [email protected] doi:10.1016/j.ajem.2007.08.021

References

  1. St Peter SD, Abbas MA, Kelly KA. The spectrum of pneumatosis intestinalis. Arch Surg 2003;138:68-75.
  2. Gagliardi G, Thompson IW, Hershman MJ, et al. Pneumatosis coli: a proposed pathogenesis based on study of 25 cases and review of the literature. Int J Colorectal Dis 1996;11:111-8.
  3. Jona JZ. Benign pneumatosis intestinalis coli after blunt trauma to the abdomen in a child. Pediatr Surg 2000;35:1109-11.
  4. Pear BL. Pneumatosis intestinalis: a review. Radiology 1998;207:13-9.
  5. Lustberg AM, Fantry GT, Cotto-Cumba C, et al. Hyperbaric Oxygen treatment for intractable diarrhea caused by pneumatosis coli. Gastro- intest Endosc 2002;56:935-7.
  6. Saunders MD, Kimmey MB. Systemic review: acute colonic pseudo- obstruction. Aliment Pharmacol Ther 2005;22:917-25.
  7. Ellis BW. Symptomatic treatment of primary pneumatosis coli with metronidazole. Br Med J 1980;15:763-4.

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