clinical case conference ranjeeta bahirwani august 25, 2010
Post on 21-Dec-2015
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Clinical Case
56 AAM with DM,HTN,CKD admitted with one day h/o severe abdominal pain and nausea; pt reported being in USOH until day of admission when he developed severe crampy epigastric/RUQ pain (10/10 in intensity); +associated nausea but no vomiting; no melena or hematochezia, no F/C
+ cocaine use 1 day PTA
ROS: no weight loss, no early satiety, no
dysphagia/odynophagia
Clinical Case Past Medical History
DM HTN CKD (baseline Cr 2) Hyperlipidemia
Surgical History L BKA
Family History Mom/Dad-vasculopaths
Allergies None
Social History+ tobacco 1PPD+ ETOH (“few beers” weekly)
+ intranasal cocaine use
Medications Insulin Lisinopril Atenolol ASA Zocor Fish oil
Physical Examination
VS: T - 98.0, HR – 88, BP - 160/74, RR – 16, O2 Sat - 99% RA
GEN: NAD HEENT: no scleral icterus-did not assess for deviated
septum etc etc CV: RRR Chest: CTA B Abd: soft, obese, mild epigastric TTP, no
rebound/guarding Ext: L BKA
Laboratory Data
14.2N-80%
12.3272
136 100 25
2.3203.780
TB - 0.6AST - 45ALT - 35AP - 101
1.127.2
Amylase- 100Lipase 140
Lactic acid- 4.6
Portal Venous AirPortal Venous Air
Ischemia (most common) Sepsis (pseudomonas,
Clostridium) IBD Colon Ca Trauma Iatrogenic (endoscopic
procedures)
Pneumobilia Air in the biliary tree Commonly seen in patients following biliary-enteric
anastomosis or sphincterotomy Nonsurgical causes of pneumobilia include infection,
neoplasm, biliary-enteric fistula, emphysematous cholecystitis and incompetence of the sphincter of Oddi
Gastric Emphysema vs Gastric Emphysema vs Emphysematous GastritisEmphysematous Gastritis
Both are causes of intramural gas in the stomach Both are causes of intramural gas in the stomach (foregut pneumatosis intestinalis) with different (even (foregut pneumatosis intestinalis) with different (even opposite) outcomesopposite) outcomes
Can be differentiated radiographically and clinically Can be differentiated radiographically and clinically between the benign (gastric emphysema) and serious between the benign (gastric emphysema) and serious (emphysematous gastritis) entities(emphysematous gastritis) entities
Gastric EmphysemaGastric EmphysemaBenign condition caused by disruption of the mucosa leading to airdissection into the gastric wall without associated wall thickening;can be associated with portal venous air as well
Causes include: GOO (PUD, pyloric stenosis, gastric volvulus) Increased gastric intraluminal pressure and superficial tear due to vomiting Partial/complete duodenal obstruction (pancreatic/ampullary Ca, duodenal
stenosis, gallstones, bezoars, SMA syndrome) Instrumentation (biliary stenting, NG tube placement, endoscopy, PEG) Cystic pneumatosis (benign idiopathic condition causing intraluminal air
bubbles) PTX or rupture of pulmonary bullae with dissection of mediastinal air through
paraesophageal tissues into stomach)
Clinical manifestations are non-specific including abdominal pain, distension, N/V
Emphysematous gastritis Phlegmonous gastritis formed by gas forming organisms arising
from local spread through the mucosa or distant hematogenous dissemination
Stomach affected very rarely due to acidity and efficient mucosal barrier
Common organisms include Enterobacter species, Pseudomonas, Candida, Staph aureus, Clostridium Welchii, Streptococcus
Intramural air on imaging which is streaky and irregular/mottled (without rounded air bubbles as in gastric emphysema), with associated gastric wall thickening
Associated with ancillary findings of ischemia (bowel wall thickening, arterial occlusion, PV air, mesenteric venous engorgement, infarction of other organs
High mortality without surgical intervention
Cocaine-induced ischemia Vasoconstriction via norepinephrine/dopamine release Increased platelet aggregation leading to intravascular
thrombosis (increased thromboxane A activity and decreased prostacycline activity)
Focal endothelial injury of the microvasculature causing a fall in cardiac output
**Rectal and gastric involvement are NOT a common feature of cocaine induced ischemia, reflecting the rich arterial supply of these regions
COCAINE ASSOCIATED ENTEROCOLITIS
Retrospective review of 18 patients with cocaine induced enterocolitis
Anatomical locations of disease were: proximal colon (14 pts), distal colon (3 pts), and small bowel/gastric (1 pt)
72 % patients had intranasal cocaine use (most common) Onset of symptoms was within 72 hrs for most patients
17% total mortality 15 patients were managed conservatively and 13 had an
uneventful recovery-(one pt died of shock, one had laparotomy for peritonitis)
Surgical intervention was performed in 4 patients (for peritonitis); 2 died post-operatively
Ellis CN, McAlexander WW. Dis Colon Rectum 2005; 48: 2313
Take Home Points
Portal venous air is most often seen in the setting of ischemia
The stomach is an uncommon site for ischemia due to its rich vascular supply
Intramural gas in the stomach (foregut pneumatosis Intramural gas in the stomach (foregut pneumatosis intestinalis) may be due to gastric emphysema intestinalis) may be due to gastric emphysema (benign) or emphysematous gastritis (serious)(benign) or emphysematous gastritis (serious)
Cocaine-induced ischemia is most common in the proximal colon and resolves with conservative management in the majority of cases