CASE REPORT
Management of Pneumatosis Intestinalis in a Pediatric Burn Patient Kyle J. Kalkwarf, MD, Richard D. Betzold, MD, Stephanie Y. Hung, MD, Anne N. Rinewalt, MD, Ronald D. Robertson, MD
Pneumatosis intestinalis is gas in the wall of the gastrointestinal tract. It is not well described in pediatric burn patients. The authors present the case of a 23-month-old girl who sustained 40% total body surface area deep-partial and full-thickness burns as well as a grade two inhalational injury. On postburn day two, radiographic imaging showed extensive pneumatosis of the colon. She was managed with bowel rest, broad-spectrum antibiotics, and parenteral nutrition. Radiographic resolution of pneumatosis intestinalis occurred several days later and was followed by reinitiation of enteral feeds and bowel function. The patient later developed an abscess and a subsequent colocutaneous fistula that resolved with percutaneous drainage and conservative management. She healed and was able to avoid a laparotomy with possible bowel resection. (J Burn Care Res 2016;37:e193–e195)
Pneumatosis intestinalis (PI) is gas in the wall of the gastrointestinal tract. It is well described in the neonatal population, where it is pathognomonic for necrotizing enterocolitis, which is typically managed medically in the absence of complications including perforation or gangrene. PI is less well described in burn patients with only one single-institution case series of adults and one pediatric case described in the literature.1,2
CASE REPORT A 23-month-old girl, caught in a house fire, sustained 40% total body surface area deep-partial and fullthickness burns to her chest, abdomen, perineum, and extremities. She was intubated on the scene and taken to another hospital where initial laboratory values were pH 6.8, Pco2 45 mmHg, Pao2 168 mmHg (6.8/45/168), carboxyhemoglobin 37%, and lactic acid 2.6 mmol/L. She was then transferred to our facility where her arterial blood gas had improved to 7.15/45/87 with a bicarbonate level of 18 mEq/L From the Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas. Address correspondence to Kyle J. Kalkwarf, MD, Department of Surgery, University of Arkansas for Medical Sciences, 4301 W Markham St., Little Rock, Arkansas 72205. Email: kjkalkwarf@ uams.edu. Copyright © 2014 by the American Burn Association 1559-047X/2014 DOI: 10.1097/BCR.0000000000000182
on basic metabolic profile. A bronchoscopy was performed that revealed mucopurulent secretions, generalized erythema that was most prominent in her proximal airways, and carbonaceous deposits throughout her tracheobronchial tree. We diagnosed her with a grade two inhalation injury3 and she was treated with a nebulized heparin and N-acetylcysteine per our institution’s inhalation injury protocol.4 She remained intubated until postburn day 30. She suffered no pulmonary infectious complications from either the inhalation injury or the prolonged ventilator requirement. Enteral feedings were started 6 hours after arrival with a commercially available product designed for enteral feedings (osmolarity 335 mOsM/kg water) and advanced to 20 ml/hr while checking for residuals every 4 hours. On postburn day two, an abdominal radiograph ordered to confirm proper replacement of a feeding tube that had been inadvertently displaced showed large bowel lucencies suggesting PI. A subsequent computed tomography (CT) scan (Figures 1–3) showed extensive pneumatosis of the colon including the hepatic flexure and the descending colon from the splenic flexure to the sigmoid colon. Microperforations of the left colon and a small amount of portal venous gas in the liver were also identified. Bowel rest, broad-spectrum antibiotics, and parenteral nutrition were initiated as treatment for PI. When imaging showed resolution of the pneumatosis 10 days later, enteral feeds were restarted and bowel function returned. e193
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Figure 1. Axial view of computed tomography showing pneumatosis intestinalis of the colon in our pediatric burn patient.
Figure 3. Sagittal view of computed tomography showing pneumatosis intestinalis of the colon in our pediatric burn patient.
On postburn day 39, a CT scan was ordered for increasing leukocytosis, abdominal distention, and high gastric feeding residuals. It showed a large intra-abdominal abscess adjacent to the splenic flexure. Interventional radiology placed a percutaneous eight French pigtail catheter drain and her leukocytosis and abdominal distension improved rapidly. A repeat CT scan was obtained on postburn day 58 which showed resolution of the abscess, but the
drain had eroded into the descending colon. During the next week, the drain was backed out of the skin creating a controlled colocutaneous fistula originating in the descending colon. It was a distal, low output fistula, so enteral feeds were continued and the fistula was sealed within 10 days of drain removal. The patient was eventually discharged to home and has done well on follow up.
DISCUSSION
Figure 2. Coronal view of computed tomography showing pneumatosis intestinalis of the colon in our pediatric burn patient.
Gastrointestinal complications after thermal injury are rare, occurring in approximately 1% of burn patients. Reported complications include ileus, bleeding, ulcers, pancreatitis, obstruction, acute cholecystitis, thrombosis, and ischemia. Burns encompassing more than 40% total body surface area, involving sepsis, or causing PI increase the risk for ischemic necrotic bowel which results very high rates of bowel resection and a mortality of 60–73%.5 There are several theories that attempt to explain the development of PI. In thermal injuries, the two most likely causes are mechanical and microbiological. The mechanical theory postulates that submucosal gas accumulates in the bowel wall after dissecting through injured intestinal mucosa secondary to increased intraluminal pressure caused by obstruction, ischemia, or trauma. The microbiologic theory involves bacterial entry through mucosal injuries and subsequent production of gas.1,2 Other conditions associated with PI include immunocompromise,
Journal of Burn Care & Research Volume 37, Number 2
hypoalbuminemia, inhalation injury, and prolonged mechanical ventilation.2 Our patient suffered from all of these conditions as a result of her extensive burn. Continuous hyperosmolar tube feeds have also been associated with an increased risk of intestinal ischemia, but she did not receive these feeds and Huzar et al1 found no survival difference based on the timing and rate of initial tube feeding in adult patients who sustained burns. PI is a clinical or radiographic finding indicative of an ongoing disease process. In pediatrics, its most common etiologies are infection, ischemia, and obstruction. The severity of PI is based on the underlying condition and associated findings. In one series of non-neonatal pediatric patients, resolution of PI from all etiologies occurred in 78% of patients with medical management.6 The success of nonoperative management of PI has not carried over to adults as 94% of burn patients with PI were found to have intestinal ischemia.1 Other findings indicative of poor outcomes with PI including portal venous gas, serum lactic acid greater than 2 mmol/L, and rectal bleeding.1,2,6 Surgery should be reserved for complications including perforation, peritonitis, or abdominal sepsis.2 Our patient was treated with medical management, similar to a neonate with necrotizing enterocolitis. Her eventual outcome was good, but PI likely indicated ischemia that resulted in a perforation or bacterial translocation that formed a subsequent abscess. Laparotomy may have identified this earlier, but she
Kalkwarf et al e195
was able to avoid an unnecessary surgery that would have made abdominal skin grafting more difficult and may not have improved her eventual outcome.
CONCLUSIONS Treatment of postburn PI remains a difficult decision in children due to a lack of evidence and more research is needed. This case report shows that nonoperative management is an option in carefully selected pediatrics patients with thermal injury who develop PI. It also demonstrated a possible complication resulting from initiating enteral feeds in a pediatric burn patient before proper volume resuscitation. REFERENCES 1. Huzar TF, Oh J, Renz EM, et al. Pneumatosis intestinalis in patients with severe thermal injury. J Burn Care Res 2011;32:e37–44. 2. Balledux J, McCurry T, Zieger M, Coleman JJ, Sood R. Pneumatosis intestinalis in a burn patient: case report and literature review. J Burn Care Res 2006;27:399–403. 3. Endorf FW, Gamelli RL. Inhalation injury, pulmonary perturbations, and fluid resuscitation. J Burn Care Res 2007;28:80–3. 4. Miller AC, Rivero A, Ziad S, Smith DJ, Elamin EM. Influence of nebulized unfractionated heparin and N-acetylcysteine in acute lung injury after smoke inhalation injury. J Burn Care Res 2009;30:249–56. 5. Kowal-Vern A, McGill V, Gamelli RL. Ischemic necrotic bowel disease in thermal injury. Arch Surg 1997;132:440–3. 6. Kurbegov AC, Sondheimer JM. Pneumatosis intestinalis in non-neonatal pediatric patients. Pediatrics 2001;108:402–6.
Management of Pneumatosis Intestinalis in a Pediatric Burn Patient Kyle J. Kalkwarf, MD, Richard D. Betzold, MD, Stephanie Y. Hung, MD, Anne N. Rinewalt, MD, Ronald D. Robertson, MD
Pneumatosis intestinalis is gas in the wall of the gastrointestinal tract. It is not well described in pediatric burn patients. The authors present the case of a 23-month-old girl who sustained 40% total body surface area deep-partial and full-thickness burns as well as a grade two inhalational injury. On postburn day two, radiographic imaging showed extensive pneumatosis of the colon. She was managed with bowel rest, broad-spectrum antibiotics, and parenteral nutrition. Radiographic resolution of pneumatosis intestinalis occurred several days later and was followed by reinitiation of enteral feeds and bowel function. The patient later developed an abscess and a subsequent colocutaneous fistula that resolved with percutaneous drainage and conservative management. She healed and was able to avoid a laparotomy with possible bowel resection. (J Burn Care Res 2016;37:e193–e195)
Pneumatosis intestinalis (PI) is gas in the wall of the gastrointestinal tract. It is well described in the neonatal population, where it is pathognomonic for necrotizing enterocolitis, which is typically managed medically in the absence of complications including perforation or gangrene. PI is less well described in burn patients with only one single-institution case series of adults and one pediatric case described in the literature.1,2
CASE REPORT A 23-month-old girl, caught in a house fire, sustained 40% total body surface area deep-partial and fullthickness burns to her chest, abdomen, perineum, and extremities. She was intubated on the scene and taken to another hospital where initial laboratory values were pH 6.8, Pco2 45 mmHg, Pao2 168 mmHg (6.8/45/168), carboxyhemoglobin 37%, and lactic acid 2.6 mmol/L. She was then transferred to our facility where her arterial blood gas had improved to 7.15/45/87 with a bicarbonate level of 18 mEq/L From the Department of Surgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas. Address correspondence to Kyle J. Kalkwarf, MD, Department of Surgery, University of Arkansas for Medical Sciences, 4301 W Markham St., Little Rock, Arkansas 72205. Email: kjkalkwarf@ uams.edu. Copyright © 2014 by the American Burn Association 1559-047X/2014 DOI: 10.1097/BCR.0000000000000182
on basic metabolic profile. A bronchoscopy was performed that revealed mucopurulent secretions, generalized erythema that was most prominent in her proximal airways, and carbonaceous deposits throughout her tracheobronchial tree. We diagnosed her with a grade two inhalation injury3 and she was treated with a nebulized heparin and N-acetylcysteine per our institution’s inhalation injury protocol.4 She remained intubated until postburn day 30. She suffered no pulmonary infectious complications from either the inhalation injury or the prolonged ventilator requirement. Enteral feedings were started 6 hours after arrival with a commercially available product designed for enteral feedings (osmolarity 335 mOsM/kg water) and advanced to 20 ml/hr while checking for residuals every 4 hours. On postburn day two, an abdominal radiograph ordered to confirm proper replacement of a feeding tube that had been inadvertently displaced showed large bowel lucencies suggesting PI. A subsequent computed tomography (CT) scan (Figures 1–3) showed extensive pneumatosis of the colon including the hepatic flexure and the descending colon from the splenic flexure to the sigmoid colon. Microperforations of the left colon and a small amount of portal venous gas in the liver were also identified. Bowel rest, broad-spectrum antibiotics, and parenteral nutrition were initiated as treatment for PI. When imaging showed resolution of the pneumatosis 10 days later, enteral feeds were restarted and bowel function returned. e193
Journal of Burn Care & Research March/April 2016
e194 Kalkwarf et al
Figure 1. Axial view of computed tomography showing pneumatosis intestinalis of the colon in our pediatric burn patient.
Figure 3. Sagittal view of computed tomography showing pneumatosis intestinalis of the colon in our pediatric burn patient.
On postburn day 39, a CT scan was ordered for increasing leukocytosis, abdominal distention, and high gastric feeding residuals. It showed a large intra-abdominal abscess adjacent to the splenic flexure. Interventional radiology placed a percutaneous eight French pigtail catheter drain and her leukocytosis and abdominal distension improved rapidly. A repeat CT scan was obtained on postburn day 58 which showed resolution of the abscess, but the
drain had eroded into the descending colon. During the next week, the drain was backed out of the skin creating a controlled colocutaneous fistula originating in the descending colon. It was a distal, low output fistula, so enteral feeds were continued and the fistula was sealed within 10 days of drain removal. The patient was eventually discharged to home and has done well on follow up.
DISCUSSION
Figure 2. Coronal view of computed tomography showing pneumatosis intestinalis of the colon in our pediatric burn patient.
Gastrointestinal complications after thermal injury are rare, occurring in approximately 1% of burn patients. Reported complications include ileus, bleeding, ulcers, pancreatitis, obstruction, acute cholecystitis, thrombosis, and ischemia. Burns encompassing more than 40% total body surface area, involving sepsis, or causing PI increase the risk for ischemic necrotic bowel which results very high rates of bowel resection and a mortality of 60–73%.5 There are several theories that attempt to explain the development of PI. In thermal injuries, the two most likely causes are mechanical and microbiological. The mechanical theory postulates that submucosal gas accumulates in the bowel wall after dissecting through injured intestinal mucosa secondary to increased intraluminal pressure caused by obstruction, ischemia, or trauma. The microbiologic theory involves bacterial entry through mucosal injuries and subsequent production of gas.1,2 Other conditions associated with PI include immunocompromise,
Journal of Burn Care & Research Volume 37, Number 2
hypoalbuminemia, inhalation injury, and prolonged mechanical ventilation.2 Our patient suffered from all of these conditions as a result of her extensive burn. Continuous hyperosmolar tube feeds have also been associated with an increased risk of intestinal ischemia, but she did not receive these feeds and Huzar et al1 found no survival difference based on the timing and rate of initial tube feeding in adult patients who sustained burns. PI is a clinical or radiographic finding indicative of an ongoing disease process. In pediatrics, its most common etiologies are infection, ischemia, and obstruction. The severity of PI is based on the underlying condition and associated findings. In one series of non-neonatal pediatric patients, resolution of PI from all etiologies occurred in 78% of patients with medical management.6 The success of nonoperative management of PI has not carried over to adults as 94% of burn patients with PI were found to have intestinal ischemia.1 Other findings indicative of poor outcomes with PI including portal venous gas, serum lactic acid greater than 2 mmol/L, and rectal bleeding.1,2,6 Surgery should be reserved for complications including perforation, peritonitis, or abdominal sepsis.2 Our patient was treated with medical management, similar to a neonate with necrotizing enterocolitis. Her eventual outcome was good, but PI likely indicated ischemia that resulted in a perforation or bacterial translocation that formed a subsequent abscess. Laparotomy may have identified this earlier, but she
Kalkwarf et al e195
was able to avoid an unnecessary surgery that would have made abdominal skin grafting more difficult and may not have improved her eventual outcome.
CONCLUSIONS Treatment of postburn PI remains a difficult decision in children due to a lack of evidence and more research is needed. This case report shows that nonoperative management is an option in carefully selected pediatrics patients with thermal injury who develop PI. It also demonstrated a possible complication resulting from initiating enteral feeds in a pediatric burn patient before proper volume resuscitation. REFERENCES 1. Huzar TF, Oh J, Renz EM, et al. Pneumatosis intestinalis in patients with severe thermal injury. J Burn Care Res 2011;32:e37–44. 2. Balledux J, McCurry T, Zieger M, Coleman JJ, Sood R. Pneumatosis intestinalis in a burn patient: case report and literature review. J Burn Care Res 2006;27:399–403. 3. Endorf FW, Gamelli RL. Inhalation injury, pulmonary perturbations, and fluid resuscitation. J Burn Care Res 2007;28:80–3. 4. Miller AC, Rivero A, Ziad S, Smith DJ, Elamin EM. Influence of nebulized unfractionated heparin and N-acetylcysteine in acute lung injury after smoke inhalation injury. J Burn Care Res 2009;30:249–56. 5. Kowal-Vern A, McGill V, Gamelli RL. Ischemic necrotic bowel disease in thermal injury. Arch Surg 1997;132:440–3. 6. Kurbegov AC, Sondheimer JM. Pneumatosis intestinalis in non-neonatal pediatric patients. Pediatrics 2001;108:402–6.
