Should there be air there? Elizabeth M. Regan November 22, 2013 Dr. Cameron; Dr. P.Smith, Dr. Ebersole

CC: abdominal pain, N/V, T101.3 HPI: Patient is a 42 y/o female who originally presented to the ED on 10/26 with 1 month history of cough and markedly elevated WBC of 200. Patient was diagnosed with ALL and admitted for workup and initiation of chemotherapy. Her hospital stay became complicated by an UE DVT, large left- sided pleural effusion and retroperitoneal hematoma s/p BM biopsy. On 11/11 patient developed mid-epigastric abdominal pain, N/V and became febrile to F. PMH: HTN, UE DVT, left-sided pleural effusion, hematoma PSH: nill Allergies: NKA Social: never smoker, denies alcohol and drug use CASE: OS (MR: ) 2

Physical Exam: – Vitals: T99.3, BP 136/70, HR 112, RR 20, O2 97% – CONSTITUTIONAL: NAD – LUNGS: CTAB – CARDIOVASCULAR: NSR normal S1 and S2, no S3 or S4, no murmur – ABDOMEN: Normal bowel sounds, soft, mildly distended, TTP over epigastric and RUQ – EXTREMITIES: no LE edema, Left upper extremity - no longer edematous surrounding PICC, not TTP – NEURO: A&Ox3, CNII-XII grossly intact – SKIN: no rashes Labs: – Neutropenic – Normal lactate CASE

Acute Abdominal Pain, Fever – Ulcer – Pancreatitis – Infectious (Viral, Abscess) – Biliary Obstruction (cholecystitis, cholangitis, malignancy) – Tumor Lysis Imaging Modalities to consider – Ultrasound vs CT vs MRI? – Contrast? – Decision: CT abdomen and pelvis with IV contrast Working Clinical Diagnoses

Appropriateness Criteria

Normal CT Abdomen (Level of Stomach) Axial CT (with PO contrast)

OS CT Abdomen (Stomach)

CT Abdomen (Small Bowel)

Pneumatosis intestinalis seen in posterior gastric wall, small bowel, as well as air within draining gastric vein What’s next? – Investigate for pneumoperitoneum

OS KUB- 1 view

OS CXR-No pneumoperitoneum

Abnormal CXR: Free Air under Diaphragm

Pneumatosis Intestinalis – Gas within the wall of the bowel; Can occur anywhere between esophagus and rectum – Symptom of multiple disease states, both GI and non-GI related – Can be benign or an emergency Emergencies include pneumoperitoneum, bowel ischemia/infarction Most presentations are benign; most patients are actually asymptomatic – Most Common in adults ages as well as in the neonate population (associated with Necrotizing enterocolitis). Equal prevalence in males and females Working Diagnosis/ Pathology

– Most commonly associated disease states: COPD Immunocompromised states Inflammatory or infectious causes of GI tract Recent surgical or endoscopic procedures Diabetes Ischemia – Clinical Presentation usually includes: N/V, abdominal pain, mucus or blood in stools, weight loss

Plain Films: – Intramural gas can be linear, curvilinear, or circular in appearance – Linear pneumatosis tends to be more ominous, but can be benign – If pneumoperiotoneum is also present, look for: free air under the diaphragm, Rigler’s sign, falciform ligament sign CT: – More sensitive – Circumferential collections of air adjacent to lumen of bowel Characteristic Findings

Patient was non-peritonitic, complaining only of mild pain No pneumoperitoneum Surgery consulted, no evidence for bowel infarction/ischemia Serial abdominal exams, prontonix, and fluid resuscitation Patient improved within 36 hours. No surgical intervention needed. Outcome/Treatment