The Journal of Emergency Medicine, Vol. -, No. -, pp. 1–2, 2014 Copyright Ó 2014 Elsevier Inc. Printed in the USA. All rights reserved 0736-4679/$ - see front matter
http://dx.doi.org/10.1016/j.jemermed.2014.09.047
Visual Diagnosis in Emergency Medicine
ESOPHAGEAL, GASTRIC, AND INTESTINAL PNEUMATOSIS Wei-Ting Lin, MD,*† Chien-Ming Chao, MD,‡ and Chih-Cheng Lai, MD‡ *Department of Orthopaedics, Chi Mei Medical Center, Tainan, Taiwan, †Department of Physical Therapy, Shu Zen College of Medicine and Management, Kaohsiung, Taiwan, and ‡Department of Intensive Care Medicine, Chi Mei Medical Center, Liouying, Tainan, Taiwan Reprint Address: Chih-Cheng Lai, MD, Department of Intensive Care Medicine, Chi Mei Medical Center, Liouying, Tainan, Taiwan
inal tenderness to deep palpation. Laboratory tests were significant for a white cell count of 18,300/mm3, with a predominance of neutrophils (92.0%), hemoglobin of 12.2 g/dL, platelet count of 72,000/mm3, creatinine of 1.6 mg/dL, and lactate of 4.8 mmol/L. A computed tomography (CT) scan of the abdomen showed circumferential air at the wall of the distal esophagus (Figure 1A, arrow), stomach (Figure 1B, arrow), duodenum, and ileum (Figure 1C, arrow). In addition, air was noted in the portal vein (Figure 1B, arrowhead), and mesenteric vein (Figure 1C, arrowhead). Surgical intervention was recommended for suspected ischemic bowel disease, but his family refused invasive management. Therefore,
CASE REPORT An 85-year-old man presented to the Emergency Department with vomiting and progressively worsening abdominal pain. He had a history of congestive heart failure, chronic obstructive pulmonary disease, chronic atrial fibrillation, and peptic ulcer disease. He denied diarrhea, constipation, passage of tarry or bloody stool, fever, or chills. He was not on anticoagulation. On arrival, his vital signs were temperature of 36 C, pulse rate of 120 beats/ min, respiratory rate of 23 breaths/min, and blood pressure of 158/72 mm Hg. On physical examination, he had an irregularly irregular heartbeat and diffuse abdom-
Figure 1. (A) Computed tomography scan of the abdomen showed that circumferential air presented at the wall of the distal esophagus (arrow), (B) circumferential air presented at the wall of the stomach (arrow), and portal vein gas (arrowhead), (C) circumferential air presented at the wall of the intestine (arrow), and mesenteric vein gas (arrowhead).
RECEIVED: 15 May 2014; FINAL SUBMISSION RECEIVED: 26 September 2014; ACCEPTED: 30 September 2014 1
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only supportive care was given and the patient died 1 week later. DISCUSSION Esophageal, gastric, and intestinal pneumatosis is defined as air within the wall of the esophagogastrointestinal tract, and can be caused by mechanical force, pulmonary disease, ischemia, and bacterial infection (1,2). In our case, we hypothesize that ischemic bowel disease was precipitated by an atrial fibrillation-associated embolic event that resulted in bowel ischemia and infarction and subsequent pneumatosis. Clinical manifestations of ischemic bowel disease, including abdominal pain, lower
gastrointestinal tract bleeding, fever, and tachycardia are nonspecific. CT imaging is diagnostic. Although surgery may be performed for severe ischemic bowel disease, the clinical outcome remains poor.
REFERENCES 1. Van Mook WN, van der Geet S, Goessens ML, Schoon EJ, Ramsay G. Gas within the wall of the stomach due to emphysematous gastritis: case report and review. Eur J Gastroenterol Hepatol 2002; 14:1155–60. 2. Pineda Bonilla JJ, Diehl DL, Babameto GP, Smith RE. Massive hepatic portal venous gas and gastric pneumatosis secondary to gastric ischemia. Gastrointest Endosc 2013;78:540:discussion 541.
http://dx.doi.org/10.1016/j.jemermed.2014.09.047
Visual Diagnosis in Emergency Medicine
ESOPHAGEAL, GASTRIC, AND INTESTINAL PNEUMATOSIS Wei-Ting Lin, MD,*† Chien-Ming Chao, MD,‡ and Chih-Cheng Lai, MD‡ *Department of Orthopaedics, Chi Mei Medical Center, Tainan, Taiwan, †Department of Physical Therapy, Shu Zen College of Medicine and Management, Kaohsiung, Taiwan, and ‡Department of Intensive Care Medicine, Chi Mei Medical Center, Liouying, Tainan, Taiwan Reprint Address: Chih-Cheng Lai, MD, Department of Intensive Care Medicine, Chi Mei Medical Center, Liouying, Tainan, Taiwan
inal tenderness to deep palpation. Laboratory tests were significant for a white cell count of 18,300/mm3, with a predominance of neutrophils (92.0%), hemoglobin of 12.2 g/dL, platelet count of 72,000/mm3, creatinine of 1.6 mg/dL, and lactate of 4.8 mmol/L. A computed tomography (CT) scan of the abdomen showed circumferential air at the wall of the distal esophagus (Figure 1A, arrow), stomach (Figure 1B, arrow), duodenum, and ileum (Figure 1C, arrow). In addition, air was noted in the portal vein (Figure 1B, arrowhead), and mesenteric vein (Figure 1C, arrowhead). Surgical intervention was recommended for suspected ischemic bowel disease, but his family refused invasive management. Therefore,
CASE REPORT An 85-year-old man presented to the Emergency Department with vomiting and progressively worsening abdominal pain. He had a history of congestive heart failure, chronic obstructive pulmonary disease, chronic atrial fibrillation, and peptic ulcer disease. He denied diarrhea, constipation, passage of tarry or bloody stool, fever, or chills. He was not on anticoagulation. On arrival, his vital signs were temperature of 36 C, pulse rate of 120 beats/ min, respiratory rate of 23 breaths/min, and blood pressure of 158/72 mm Hg. On physical examination, he had an irregularly irregular heartbeat and diffuse abdom-
Figure 1. (A) Computed tomography scan of the abdomen showed that circumferential air presented at the wall of the distal esophagus (arrow), (B) circumferential air presented at the wall of the stomach (arrow), and portal vein gas (arrowhead), (C) circumferential air presented at the wall of the intestine (arrow), and mesenteric vein gas (arrowhead).
RECEIVED: 15 May 2014; FINAL SUBMISSION RECEIVED: 26 September 2014; ACCEPTED: 30 September 2014 1
2
W.-T. Lin et al.
only supportive care was given and the patient died 1 week later. DISCUSSION Esophageal, gastric, and intestinal pneumatosis is defined as air within the wall of the esophagogastrointestinal tract, and can be caused by mechanical force, pulmonary disease, ischemia, and bacterial infection (1,2). In our case, we hypothesize that ischemic bowel disease was precipitated by an atrial fibrillation-associated embolic event that resulted in bowel ischemia and infarction and subsequent pneumatosis. Clinical manifestations of ischemic bowel disease, including abdominal pain, lower
gastrointestinal tract bleeding, fever, and tachycardia are nonspecific. CT imaging is diagnostic. Although surgery may be performed for severe ischemic bowel disease, the clinical outcome remains poor.
REFERENCES 1. Van Mook WN, van der Geet S, Goessens ML, Schoon EJ, Ramsay G. Gas within the wall of the stomach due to emphysematous gastritis: case report and review. Eur J Gastroenterol Hepatol 2002; 14:1155–60. 2. Pineda Bonilla JJ, Diehl DL, Babameto GP, Smith RE. Massive hepatic portal venous gas and gastric pneumatosis secondary to gastric ischemia. Gastrointest Endosc 2013;78:540:discussion 541.
