John Sharp, MDa; and Kelley Chuang, MDb,c Correspondence: John Sharp (jasharp@mednet.ucla.edu)
aUniversity of California, Los Angeles bGreater Los Angeles Veterans Affairs Healthcare System, California cDavid Geffen School of Medicine at University of California, Los Angeles
Author disclosures
The authors report no actual or potential conflicts of interest or outside sources of funding with regard to this article.
Disclaimer
The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the US Government, or any of its agencies.
Ethics and consent
Informed consent was not obtained from the patient or surrogate decision maker. Patient identifiers were removed to protect the patient’s identity.
Background: Pneumatosis intestinalis is the presence of gas within the walls of the intestine on imaging and has variable clinical significance, ranging from an incidental finding to a harbinger of intra-abdominal catastrophe. There are multiple mechanisms by which this radiographic finding develops, including bacterial gas production, increased intraluminal pressure within the gastrointestinal tract, mechanical disruption of the gut mucosa, and tracking of pulmonary gas along the mesenteric vasculature.
Case Presentation: We present the case of a 61-year-old male veteran who had sustained a remote anoxic brain injury resulting in chronic dependence on a gastrostomy tube for enteral nutrition, found incidentally to have pneumatosis intestinalis without signs of intra-abdominal catastrophe.
Conclusions: Appropriate interpretation of this finding can lead to life-saving interventions and avoid unnecessary surgical procedures.
Pneumatosis intestinalis (PI) is the finding of gas within the walls of the intestine on imaging. It is most commonly detected via radiograph or computed tomography (CT). The diseases leading to the accumulation of gas within the submucosal space of the gastrointestinal (GI) tract are heterogenous, and the finding of PI itself has a wide range of clinical implications from impending clinical deterioration to an incidental finding of minimal consequence.
We present the case of a veteran who had sustained a remote anoxic brain injury resulting in chronic dependence on a gastrostomy tube for enteral nutrition, found incidentally to have PI without signs of intra-abdominal catastrophe. An exclusion of other, more lifethreatening causes of PI led to a diagnosis of benign PI secondary to the presence of his gastrostomy tube. This case highlights the importance of interpreting the finding of PI in the clinical context of the specific patient and how conservative management may be appropriate in some cases.
Case Presentation
A 61-year-old male patient was admitted for fever. The patient had a remote history of cardiac arrest complicated by anoxic brain injury requiring tracheostomy, gastrostomy tube, and a suprapubic catheter with recurrent catheter-associated urinary tract infections (CAUTI), secondary seizure disorder, atrial fibrillation off anticoagulation due to recurrent GI bleeding, and treatment naive chronic hepatitis C virus. His ability to provide a clinical history was limited by his nonverbal status. He had no prior surgical history but had presented a month earlier for a high-grade small bowel obstruction (SBO) with pneumobilia that was managed conservatively as the surgical team deemed him a poor candidate for surgical intervention with his extensive comorbidities. A bioethics consultation at the time supported minimizing potential surgical risk in favor of conservative medical management; this was discussed with the patient’s surrogate decision maker, who also wished to avoid surgery. The SBO resolved with conservative management. He had been residing in a nursing home and doing well until 24 hours prior to admission when he developed fevers.
Vital signs on admission showed a temperature of 100.8 °F, heart rate 100 beats per minute, blood pressure 116/85, respiratory rate 22 per minute, and oxygen saturation of 100% on 6 L of oxygen via tracheostomy collar. His initial examination was notable for clear lung sounds, a nondistended nonrigid abdomen with an indwelling percutaneous gastrostomy tube, and absence of areas of skin breakdown or erythema. Notable laboratory studies showed a leukocytosis and urinalysis suggestive of CAUTI (Table). His urinary catheter was exchanged, he was fluid resuscitated and started on empiric vancomycin and piperacillin-tazobactam for management of sepsis due to CAUTI.
For the first 3 days of his hospitalization, he demonstrated clinical improvement on vancomycin and piperacillin-tazobactam while awaiting results from his urine bacterial culture. On hospital day 3, hedeveloped recurrent nonbloody, nonbilious emesis despite no change in the rate or formulation of his enteral nutrition. He also had 3 watery brown bowel movements. His vital signs remained within normal limits. His abdominal examination at this point showed mild distention and was hypertympanic to percussion, but there was no rigidity or involuntary guarding. On hospital day 4, he continued to have emesis with an unchanged abdominal examination. The differential diagnosis included recurrence of prior SBO, ileus, intestinal ischemia, enteral nutrition intolerance, Clostridioides difficile (C difficile) colitis, and GI dysmotility because of his anoxic brain injury.
