Article, Gastroenterology

Diagnostic laparoscopy for pneumatosis intestinalis

Diagnostic laparoscopy for pneumatosis i”>Case Report

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American Journal of Emergency Medicine

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Diagnostic laparoscopy for Pneumatosis intestinalis To do or not to do?

Abstract

Pneumatosis intestinalis is a rare clinical condition, which is commonly associated with mesenteric vascular ischemia, Bowel obstruction, and chemotherapy. Although the pathophysiology of PI remains unclear, 2 theories, one mechanical and the other bacterial, have been proposed. Nonoperative medical treatment and observa- tion should be considered in mild cases, but occasionally, the situation requires emergency surgical intervention. In cases of suspectful complicated PI, the clinician should not avoid performing diagnostic laparoscopy to rule out Bowel ischemia and perforation.

Pneumatosis intestinalis (PI) is a Serious condition, which is characterized by the presence of intramural gas within the bowel wall. Pneumatosis intestinalis is a clinical sign rather than a disease. Conservative treatment with fasting and antibiotics can be considered in mild cases [1]. However, the situation occasionally requires surgical intervention and can be life threatening. Lee et al [2] demonstrated that the mesenteric vascular ischemia, bowel obstruction, and chemotherapy were the most common causes of PI. Twenty percent of their patients were categorized as idiopathic PI because of having no significant medical history or no related diagnosis.

The treatments and outcomes of patients with PI have only been examined by small case series studies; moreover, none of these studies have compared the outcomes of surgery and nonsurgical methods directly [3-6].

Here, we represent a case of PI in which a decision for observative treatment was not possible because of the patients’ serious clinical and laboratory findings.

A 63-year-old man had abdominal pain and constipation while under treatment for diffuse large B-cell non-Hodgkin lymphoma at hematology department. His chemotherapy protocol was consisting of rituximab 375 mg/m2, etoposide 40 mg/m2, cytarabine 2 mg/m2, and cisplatin 25 mg/m2. Laboratory examination revealed mild leukocytosis (white blood cell [WBC], 12 400). Plain abdominal radiograph and Abdominal ultrasonography revealed no abnormality except minimally dilated colonic segments. After progressive abdom- inal distension and severe pain especially in lower quadrants of the abdomen, the patient was consulted to general surgery department. Physical examination revealed Abdominal distention with severe rebound tenderness. Consecutive WBC counts were 17 300, 22 700, and 30 800, respectively. Abdominal computed tomography revealed PI in descending and sigmoid colon (Fig. 1), but there was no sign of perforation and portal venous gas radiologically. Because of the patients’ severe clinical signs such as fever, tachypnea and peritoneal irritation findings, and progressive increase in WBC levels, we decided to perform a diagnostic laparoscopy to rule out microperforations and bowel ischemia.

On laparoscopy, PI was observed at mesocolon and wall of the sigmoid colon and descending colon extending to the middle part of the transverse colon (Fig. 2). There was no sign of ischemia, perforation, free liquid, or small intestinal extension. No additional surgical process was performed. postoperative course was uneventful with fasting and antibiotic treatment. The patient was discharged on postoperative fourth day.

Pneumatosis intestinalis, which is characterized by the presence of extraluminal gas within the bowel wall, is a serious clinical sign rather than a disease. Although the pathophysiology of PI remains unclear, mainly 2 theories have been proposed. The mechanical theory postulates that gas enters the wall of the bowel from either the luminal surface through breaks in the mucosa or through the serosal surface by tracking along mesenteric blood vessels, and the gas may spread along the mesentery to distant sites [7,8]. The bacterial theory postulates that luminal bacteria produce excessive amounts of hydrogen gas through fermentation of carbohydrates and other foodstuffs. As the pressure of the gas within the intestinal lumen

Fig. 1. Reformatted Multy-planar reconstruction (MPR) images of the coronal contrast- enhanced computed tomography revealed PI in mesocolon and extraluminal area of the sigmoid and descending colon.

0735-6757/(C) 2014

Fig. 2. Intraoperative image of PI affecting especially sigmoid and descending colon and the mesocolon. There is no sign of ischemia and perforation in the affected colonic segments.

increases, gas may be forced directly through the mucosa and become trapped within the mucosa[3,9].

Two types of PI, bubble-like or cystic (with isolated air bubbles in the bowel wall) and band-like or linear, have been reported [10,11]. The latter one is associated with bowel obstruction, volvulus, intussuscep- tion, hemorrhage, and bowel infarction in approximately 90% of cases. Pneumatosis intestinalis is reported to be an emerging complica- tion of small molecule tyrosine kinase inhibitors [12-14] and is well described in association with bevacizumab, sorafenib, and sunitinib. There have been 16 cases of PI complicating imatinib mesylate therapy reported to the Food and Drug Administration, but only 2 of them are published cases [15]. Fourteen of these cases have occurred in the setting of acute lymphoblastic leukemia treatment. One of the drugs in

chemotherapy protocol is thought to be the reason of PI in our case.

Pneumatosis intestinalis is also reported to be in association with various clinical conditions such as myasthenia gravis [16], Crohn disease [17], obstructing sigmoid cancer [18], and appendicitis [19]. Immunosuppression seems to be the common point of most of the diseases or their treatment related with PI.

The decision for the management of PI should be based on combined patients’ history, physical, clinical, radiologic, and labora- tory findings. Although some of the patients with PI have moderate course, occasionally, they need surgical intervention to reduce morbidity and mortality. Therefore, it is essential to distinguish the patients who need surgery and those who should be treated by nonsurgical methods.

Lee et al [2] developed a radiologic scoring system to predict mortality in patients with the diagnosis of PI. In fact, it would be more helpful to develop a preoperative scoring system for distinguishing the patients who need surgery from those who should be treated by nonoperative observation.

Despite all findings, in suspicion of complicated PI and when the benefits outweigh the risks, with patients’ constent, the clinician should not avoid to perform a diagnostic laparoscopy to rule out bowel perforation and ischemia.

T. Karabuga, MD

O. Yoldas, MD

I. Ozsan, MD

Izmir University, Faculty of Medicine Department of General Surgery, Karsiyaka, Izmir, Turkey

U.M. Yildirim, MD

Izmir University, Faculty of Medicine Department of Radiology, Karsiyaka, Izmir, Turkey

U. Aydin

Izmir University, Faculty of Medicine Department of General Surgery, Karsiyaka, Izmir, Turkey Corresponding author. Yeni Girne Bulvari 1825 sk. Karsiyaka/Izmir.

Tel.: +90 505 210 3413.

E-mail address: [email protected] http://dx.doi.org/10.1016/j.ajem.2014.04.042

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