Pneumatosis intestinalis in obstru”>American Journal of Emergency Medicine 32 (2014) 395.e1-395.e3

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Case Report

Cecal pneumatosis intestinalis in obstructing sigmoid cancer: Emergency metallic stenting?,??,?

Abstract

An 85-year-old man presented with acute abdomen. Abdominal computed tomography revealed obstructing sigmoid colon cancer with pneumatosis intestinalis of the Ascending colon. A surgeon was consulted for colonic obstruction with impending sepsis, who declined surgery considering the patient’s advanced age. After discussion, the patient consented for emergent endoscopic metallic colonic stent placement. Complete obstruction of the lumen was observed at the sigmoid colon, followed by successful metallic colonic stent placement through the obstructed area. Normal stool passage was achieved after this, and the patient survived the 9- month follow-up period. Acute colonic obstruction from obstructive colon cancer requires emergency management, wherein the pres- ence of pneumatosis intestinalis poses a high risk of cecal perforation. Emergency endoscopic colonic metallic stent placement provides an alternative therapy, particularly when surgery is not feasible, as described here.

An 85-year-old man presented at the emergency department with worsening abdominal pain for a week, with unremarkable medical history. He had experienced progressive abdominal distension for a month and constipation for a week. The patient appeared acutely ill, with a body temperature of 37.8?C and a respiratory rate of 24 breaths/min. Physical examination revealed a distended abdomen with marked tenderness. Laboratory examination revealed mild leukocytosis (white blood cells, 13 600) and anemia (hemoglobin level, 9.5 g/dL). abdominal radiography revealed marked colonic dilatation (Fig. 1), and subsequent abdominal computed tomography confirmed obstructing sigmoid colon cancer with pneumatosis intestinalis of the ascending colon (Fig. 2). A surgeon was consulted for colonic obstruction with impending sepsis, who declined surgery considering the patient’s advanced age. After discussion, the patient consented to conservative medical therapy with emergent metallic colon stent placement. At colonoscopy, complete obstruction of the lumen was observed at the sigmoid colon (Fig. 3). A metallic colon stent was successfully placed through the obstructed area. Normal stool passage was achieved after this procedure, and an appropriate diet was initiated. He was discharged a week later and survived the 9- month clinical follow-up period.

Approximately 20% to 25% patients with colon cancer present with

acute colonic obstruction, as in the present case [1,2]. Emergency surgery for obstructing colon cancer poses a high perioperative risk of

morbidity and mortality [3]; this emergency surgery is performed as a 2- or 3-staged procedure, depending on the patient’s general condition, and most patients receive a stoma. Without treatment, the colonic obstruction progression leads to increased intraluminal pressure and a further increase in the diameter of the obstructed bowel. Colonic mucosal blood flow diminishes, and mucosal ischemia and ulceration follow. Finally, transmural necrosis occurs, and frank bowel perforation leads to sepsis and mortality. The diagnosis of colonic obstruction is suggested on plain radiographs that indicate Bowel obstruction, whereas abdominal CT helps in diagnosing the cause of obstruction [4,5], in evaluating the severity and potential complications of obstruction (eg, intestinal ischemia and perforation), and possibly in detecting synchronous cancer.

Pneumatosis intestinalis refers to the presence of gas in the intestinal wall [6,7]. The presence of pneumatosis intestinalis at the emergency department in cases of acute abdomen without trauma

? Grant support: The authors have no grant support for this manuscript.

?? Disclosures: The authors have no conflict of interest to disclose.

? Writing assistance: Nil. Fig. 1. Abdominal radiograph revealing marked bowel dilatation.

0735-6757/$ - see front matter (C) 2014

395.e2 K.-Y. Fong et al. / American Journal of Emergency Medicine 32 (2014) 395.e1-395.e3

Fig. 3. Simultaneous fluoroscopy and colonoscopy following contrast injection into the obstruction site (arrow) revealing complete colonic obstruction.

particularly in the presence of pneumatosis intestinalis in an unstable patient.

In conclusion, acute colonic obstruction from obstructive colon cancer requires emergency management, and the presence of pneu- matosis intestinalis poses a high risk of cecal perforation in such situations. Furthermore, emergency endoscopic colonic metallic stent placement provides an alternative therapy, particularly in cases unsuitable for surgery, as in the case described here.

The authors would like to thank Enago (www.enago.tw) for the English language review.

Fig. 2. Abdominal CT revealing pneumatosis intestinalis of the ascending colon (arrow).

usually suggests a serious medical condition requiring surgical intervention [5,6]. Moreover, the presence of intestinal ischemia, particularly in the small bowel, usually indicates the requirement of prompt surgery. The presence of intramural cecal gas can be best visualized on abdominal CT, as in the present case [5], and it has been suggested that this is a sign of transmural necrosis and impending rupture in the setting of colonic obstruction. Cecal necrosis was identified in 4 of 7 patients with pneumatosis intestinalis who underwent surgery for malignant large bowel obstruction [5]. Self- expandable metallic stent placement is now a common palliative procedure for malignant gastrointestinal tract obstruction from the esophagus, stomach, biliary tree, and colon [1]. A colonic stent is indicated in 2 situations: palliation alone in inoperable cases or as a bridging procedure to convert emergency surgery to 1-step elective surgery. A study on colonic stent in the setting of malignant colonic obstruction suggested an increased risk of Colonic perforation with stenting than with surgery [8]. With improvements in both the technique and colonic stent design, recent studies have suggested surgical benefits of bridging surgeries involving stent placement [9,10]. As demonstrated in the present case, we observed that emergency endoscopic colonic stent placement is a safe and effective nonsurgical technique for relieving colonic obstruction. The choice between endoscopic stent placement and surgery for colonic obstruction requires prompt multidisciplinary evaluation,

Kai-Yu Fong MD Fu-Yuan Siao MD

Department of Emergency Medicine Changhua Christian Hospital, Changhua

Taiwan, ROC E-mail addresses: [email protected]; [email protected]

Hsu-Heng Yen MD Department of Gastroenterology Changhua Christian Hospital, Changhua

Taiwan, ROC Chung Shan Medical University, Taichung

Taiwan, ROC E-mail addresses: [email protected]; [email protected]

http://dx.doi.org/10.1016/j.ajem.2013.10.040

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