Chimaobi Anugwom, MD
MD
University of Minnesota
Minneapolis, Minnesota
Chimaobi Anugwom, MD1, Dupinder Singh, MD1, Michael Levitt, MD2
1University of Minnesota Medical School, Minneapolis, MN; 2Minneapolis VA Health Care System, Minneapolis, MN
Introduction: Radiological evidence of extensive gas collections in the bowel wall and, particularly, the portal vein commonly suggests a life-threatening process. We present a patient with massive intramural and portal gas that was adjudged to be of benign origin and managed conservatively with high flow nasal oxygen.
Case Description/Methods: A 74-year-old male with a history of coronary artery bypass surgery and a 40 pack-year history of smoking was admitted with a two-week history of abdominal discomfort with food ingestion, bloating and belching. History was negative for gastrointestinal bleeding, prior abdominal surgeries or fever. On examination, he was afebrile, hemodynamically stable, and had no abdominal tenderness, rebound or guarding. Initial laboratory measurements were normal and notable for normal white blood cell count of 9180/mm3 and a lactic acid of 1.8mmol/L. A stool exam for pathogens was obtained. A Computed tomography (CT) scan of the abdomen showed extensive pneumatosis involving the upper small intestine and the stomach, and a relatively massive collection of portal venous gas (see Figure 1). He was admitted to the hospital with the diagnosis of possible ischemia of the small bowel and/or stomach. Despite the ominous abdominal imaging findings, he had a normal physical exam and lack of evidence of sepsis which suggested a benign etiology of the pneumatosis. The patient was essentially asymptomatic throughout his 6-day hospital course. The stool screen for 20 pathogens revealed enteropathogenic E. coli. On the second day of hospitalization, high inhalational oxygen ( >50%) via nasal cannula was instituted in addition to an elemental diet. A repeat CT scan on day 5 of hospitalization showed virtually complete resolution of intramural small bowel and gastric gas, and only small residual portal venous gas remained. He was discharged home on antibiotics for 3 weeks and has continued to do well
Discussion: Pneumatosis intestinalis should be recognized as a clinical sign and not a diagnosis and should warrant careful review of the clinical context, signs/symptoms and laboratory data. The counter-perfusion supersaturation theory has been proposed as the pathophysiology in most benign cases. It involves increased hydrogen production by intestinal bacteria which supersedes the nitrogen tension in the blood stream. High flow or hyperbaric oxygen may help in the establishment of a nitrogen gradient between intramural gas and blood with improvement of intramural gas
Citation: Chimaobi Anugwom, MD; Dupinder Singh, MD; Michael Levitt, MD. P2604 - TREATING GAS WITH GAS: A CASE OF BENIGN EXTENSIVE PNEUMATOSIS INTESTINALIS. Program No. P2604. ACG 2019 Annual Scientific Meeting Abstracts. San Antonio, Texas: American College of Gastroenterology.