Case of the Month
by Sumeru Mehta, MD
“Case of the Month” is a monthly submission by the San Antonio Uniformed Services
Health Education Consortium (SAUSHEC) Emergency Medicine Residency Program.
A 43-year-old female with past
medical history significant for laproscopic
gastric bypass four years ago
presents to the emergency department
(ED) for three to four day history of
nausea, vomiting and abdominal pain.
During the course of her ED stay, the
patient developed moderate hematemesis,
a distended abdomen with increasing
abdominal pain and severe hypotension.
Her laboratory findings were
significant for a white blood count
(WBC) of 21.7, lactate of 8.1 mmol/L,
and a base deficit of 15 MM/L. Computer
tomography (CT) was performed
to differentiate the etiology of her
abdominal pain and hypotension
(Figure 1). She was resuscitated with
six units of packed RBC and taken to
the OR for further management of her
abdominal pain).
DIAGNOSIS:
Pneumotosis intestinalis. Pneumatosis
intestinalis (PI), the presence of
gas within the wall of the gastrointestinal
(GI) tract, is not a diagnosis but a
physical or radiographic finding that is
the result of an underlying pathologic
process. The significance of PI depends
on the nature and severity of the
underlying condition. Therefore, PI
represents a tremendous spectrum of
conditions and outcomes, ranging
from benign diseases to abdominal
sepsis and death.
Three possibilities have been proposed
as the source of the gas within
the wall of the GI tract: (1) intraluminal
GI gas, (2) bacterial production of
gas, and (3) pulmonary gas. The most
common symptoms attributed to PI
have been diarrhea, bloody stools,
abdominal pain, constipation, weight
loss, and tenesmus, in decreasing
order. Physical examination is rarely
helpful in diagnosis, and it has been
shown that the pattern or extent of PI
does not correlate with the severity of
the symptoms or the severity of the
underlying diseases. Computed
tomography is the best imaging
modality for establishing the diagnosis
of PI, as denoted by findings such as
intramural gas in the gravity-dependent
areas parallel to the bowel wall.
The focus of treatment is almost entirely
on the associated illness inciting
PI. The challenge in evaluating patients
with PI is to identify those who require
surgery. Surgery should be performed
in patients who are not responding to
non-operative management, especially
those with signs of perforation, peritonitis,
or abdominal sepsis. This
patient had developed PI secondary to
an incarcerated, internal hernia (Peterson’s
hernia) as a complication of her
remote roux-en-y-gastric bypass.
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