Clinical Case Conference

1. Clinical Case Conference Ranjeeta Bahirwani August 25, 2010

2. 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

3. 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 Clinical Case

4. 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

5. Laboratory Data 14.2 N-80% 12.3 136 100 25 272 80 3.7 20 2.3 TB - 0.6 AST - 45 ALT - 35 AP - 101 Amylase- 100 Lipase 140 Lactic acid- 4.6 1.1 27.2

6. Clinical Case What’s your differential diagnosis and what would you do next?

7. CT scan

9. Clinical Case What next?

10. Endoscopy

11. Ischemia (most common) Sepsis (pseudomonas, Clostridium) IBD Colon Ca Trauma Iatrogenic (endoscopic procedures) Portal Venous Air

12. Portal Venous Air

13. 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

14. Biliary vs Portal Venous Air

15. Gastric Emphysema vs Emphysematous Gastritis • Both are causes of intramural gas in the stomach (foregut pneumatosis intestinalis) with different (even opposite) outcomes • Can be differentiated radiographically and clinically between the benign (gastric emphysema) and serious (emphysematous gastritis) entities

16. Gastric Emphysema Benign condition caused by disruption of the mucosa leading to air dissection 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

17. Gastric pneumatosis after NG Zenooz NA, Robbin MR, Perez V. Emerg Radiol 2007; 13: 205

18. Zenooz NA, Robbin MR, Perez V. Emerg Radiol 2007; 13: 205

19. Gastric Emphysema D’Cruz R, Emil S. J Ped Surg 2008; 43: 2121

20. 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

21. Emphysematous gastritis Soon MS, Yen HH, Soon A et al. Worl J Gastroenterol 2005; 11:1719

22. Vascular supply

23. Gastric Ischemia Quentin V, Dib N, Thouveny F, et al. Endoscopy 2006; 38: 529

24. 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

25. 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

26. 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 intestinalis) may be due to gastric emphysema (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