Transcript Case study presentation (pneumatosis intestinalis)

PNEUMATOSIS INTESTINALIS
Kristen Estima Dietetic Intern at Sodexo 6/1/2013
Definition
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Pneumatosis Intestinalis (PI) or also known as
Pneumatosis cysoides intestinalis- it’s characterized
by the presence of small cysts of air in the
intestines.
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Many cases of PI are asymptomatic
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PI is a rare disease and its etiology is unknown.
Etiology theories
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There are three etiology theories:
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Mechanical theory
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Bacterial theory
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Pulmonary theory
Mechanical theory
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Based on the explanation that that gas could be
forced under pressure through a mucosal defect
into the bowel. This could happen due to trauma,
bowel obstruction, and surgery or simply due to
an endoscopic procedure.
Most accepted theory!
Bacterial theory
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Based on the invasion of bacteria into the bowel.
In some animal experiments when bacterial was
injected into the bowel, pneumatosis intestinalis
resulted in some cases.
Antibiotics have led to the cure of PI, which
leads researcher to believe that bacteria could
play a major role in the disease process of PI.
Pulmonary theory
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Based on the idea that the gas from a ruptured
alveoli could travel though the mesentery into the
bowel wall
Least accepted theory!
Forms of Pneumatosis Intestinalis
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Idiopathic/primary form: characterized by the
presence of multiple thin-wall cysts in the submucosa or
subserosa of the gut. This form is usually diagnosed
through radiography or endoscopy, as it’s usually
asymptomatic and it occurs in 15% of cases
Secondary form (which is the most common) is often
related to OPD (Obstructive Pulmonary Disease)
and/or obstructive and necrotic gastrointestinal disease.
Occurs in 85% of cases.
Symptoms of Pneumatosis Intestinalis
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Diarrhea is mostly common but constipation is
possible.
Vomiting
Blood in stool and emesis.
Abdominal Pain
Abdominal distention
Weight loss
Treatments of Pneumatosis Intestinalis
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Hyperbaric Oxygen Therapy (may be enough to
treat the collection of gas in patients who are
asymptomatic)- oxygen is toxic for the anaerobic
bacteria, which are responsible to the gas
production in the bowel
Surgery/Laparotomy (If severe inflammation,
metabolic acidosis and portal venous gas present).
Antibiotics- kills bacteria in the bowel.
Ischemic Colitis (IC) and P. Instestinalis
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Pneumatosis intestinalis can result from an Ischemic
Bowel.
IC can result from a bowel obstruction either caused by
a tumor; hernias, diverticulitis, volvuli or adhesions.
Congestive congestive heart failure, intense physical
activity, hypotension, and/or shock that result from the
patient’s septic state or hypovolemia can predispose the
patient to IC.
Certain medications such as antibiotics, phentermine
(appetite suppressant), chemotherapy, decongestants,
diuretics, statins, illicit drugs, immunosuppressive drugs,
anti-inflammatory drugs .
Gangrenous Bowel
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Gangrenous bowel means tissue death
Main goal is to resuscitate the tissue, prevent further
propagation of the blockage, prevent reperfusion
injury and restore the blood flow as soon as
possible.
The outcome for patients with gangrene ischemic
bowel can be poor.
If bowel resection is performed, they often develop
short-gut syndrome and therefore requite total
parenteral nutrition or small bowel transplantation.
Medical Nutrition Therapy
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Upon admission a patient is prescribed a NPO diet.
Enteral Nutrition seems to induce a reactive
hypermetabolic response and reduce septic
complications, and therefore improving the mucosal
barrier function and decreasing the bacterial
translocation( Jejunostomy prefered).
Supplementing fiber along with the enteral tube
feeding may help prevent overgrowth of pathogenic
bacteria, as well as helping in the prevention of septic
complications.
Medical Nutrition Therapy
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If patient shows signs of intolerance, total parenteral
nutrition should be given as an alternative.
Elemental formulas have been shown to alter the microflora, and therefore, help with the resolution of PI.
Low-residue diet should be slowly initiated as the
patient improves.
Supplementation of glutamine and antioxidants either
through enteral feeding or through PO is beneficial as
these are immunonutrients and improve the patient’s
immune system.
ASPEN guidelines for critically ill patient should be
followed.
Presentation of Patient
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Caucasian
Age: 75 years old
Weight: 200lbs/90.7kg on admission
Height: 71 inches
BMI: 27.9
Chief complaints: 10/10 abdominal pain, fever,
diarrhea and vomiting for two consecutive days,
nausea. Denied blood in stool or emesis. Onset of
respiratory difficulty and arrived at the unit with severe
shortness of breath.
Past Medical History
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Hernia repair (2 months prior to admission)
Hypertension
High Cholesterol
Tonsillectomy
Carpal Tunnel disease
Atrial fibrillation
Smoker in the past (quit over 10 years ago)
Married, considers himself active and healthy and
has great appetite at home.
Medications
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Carvedilol (Coreg)- beta-blocker
Losartan Potassium (Cozar)- antihypertensive drug
Diltitiazem (Cardizem)- calcium channel blocker
Lovastatin (Mevacor, Altoprev)- HMG-CoA
reductase inhibitor (statin) drug
Warfin (Coumadin)- is an anticoagulant drug.
Zofran (ondansetron)- is an antiemetic drug to
prevent nausea and vomiting
Diagnosis
Per MD impression:
 1)Pneumatosis Instestinalis 2)Gangrenous bowel
3)Acute intestinal vascular insufficiency/ ischemic
colitis.
 Coagulopathy was present secondary to
Coumadin/A-Fib.
 Length of stay was 10 days, for which he spent five
days in the Intensive Care Unit and two days on the
telemetry floor.
Admission labs
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Glucose: 100; BUN: 39 (high); Sodium: 143; Potassium:
3.5; Chloride: 105; C02: 26; Creat: 1.43. CK: 223
(high); CKMB: 11.0 (high); AST: 32; ALT: 32; Alkaline
Phosphatase: 74; Amylase: 33; Lipase: 41; Calcium:
8.8; Iron: 13 (low); Phosphorus: 3.6; Magnesium: 2.1;
Uric acid: 9.2 (high); Total Protein: 6.5; Albumin: 3.6;
Triglycerides: 98; HDL: 34 (low); LDL: 64; Cholesterol:
121; WBC: 72; RBC: 2.69 (low), HGB: 8.4 (low); MCV:
91.4; MCH: 30.5; Neutro%: 73.9; Lymph%:13.3(low);
Mono%: 11.5(high); Vitamin B12: 332; Folate: 20.7;
Ferritin: 157.
Diagnostic Tests
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CT of abdomen Pelvis without IV contrast – PI
confirmed
Chest X-ray: revealed poor inspiratory effort. No acute
pulmonary disease
Renal Ultrasound: revealed a 3.2cm left renal cyst.
2.2cm cyst in the hypoechoic area of the right kidney.
Ultrasound of Pelvis: foley cathether, bladder volume
217 cc, prostate 28cc, suspect ileus associated with
infarction.
Abdomen X-ray: mild distention of the hepatic flexure
but not transverse colon. Small bowel dilation observed.
Diagnostic Tests
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Echocardiogram: showed mild pulmonary hypertension
with dilated right ventricle. Normal left ventricular size
and systolic function.
Thrombectomy performed: went in from the right
femoral artery to the mesenteric to visualize arterial
system (it was dying, no vascularization). Thrombectomy
catheter prepped and flushed. Coronary injection
filmed and reviewed. Second unit of Fresh Frozen
Plasma (FFP) complete. Nitrogen given IA. Wire and
cobra removed and third unit of FFP hung.
Prognosis
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Cardiology report: Ischemic Bowel status post
thrombectomy. Pt feels much better and abdomen is
soft. Positive bowel movement and bowel sounds- bowel
was revascularized, No resection needed.
Nephrologist: reports acute tubular necrosis.
Pneumatosis Intestinalis resolved. Bowel movement is
liquid and green from the contrast given.
C-diff negative: Imodium ordered to help with loose
stool.
Hypertension controlled. A-Fib, high WBC but stable
with no fever.
Nutrition care
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First nutrition assessment was done two days after: admission:
Nutritional needs:
Calories: (2275-2548kcal); 25-28kcal/kg; 25x91kg= 2275kcal; 28x91=
2548kcal
Protein: (109-136g); 1.2-1.5g/kg; 1.2x91=109g; 1.5x91=136g
Fluid needs: (2275-2548ml) 1ml per kg.
Nutrition diagnosis: Inadequate oral intake related to GI distress as
evidence by NPO x4days, not meeting needs.
Nutrition goals: 1) Initiate clear liquids by next assessment. 2) Meet >75%
or more of Pt nutrient needs.
Dietetic Intervention: 1) when medically appropriate, initiate clear liquids.
2) Recommend MVI (standard vs. renal).
Monitor: Patient is at high nutrition risk. Monitor ability to initiate nutrition,
weight, labs and progress to goals on follow-up in 3 days.
Nutrition care
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Patient seen for follow-up:
Patient tolerating full liquids diet without
nausea/vomiting. No abdominal pain.
Abdomen soft, non-tender, normal bowel sounds. Loose
stool-present.
Abdomen soft, non-tender, normal bowel sounds. Loose
stool-present.
1) Recommend advancing diet to low-residuals when
medically appropriate.
Monitor diet tolerance, plan of care, labs, weight and
progress to goals on f/u in 3-4days.
Nutrition care
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Patient seen for follow-up:
Patient is on a low-residue diet/ ½ NS with KCL.
Patient tolerating low-residue diet per RN, although
diarrhea was noted in RN sheet.
Acute intestinal ischemia still present. Low magnesium
noted- Mg sulfate ordered.
Patient reports good appetite and is tolerating diet
advancement without abdominal pain. Loose stool
improving with Imodium.
Monitor diet tolerance, labs, weight and plan of care on
f/u in 3-4days.
Summary
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This patient had a really good prognosis and
outcome.
No enteral or parenteral nutrition was needed
during hospitalization and patient tolerated diet
progression well.
In addition, bowel resection was not needed, as the
doctor was able to vascularize the necrotic tissue.
The patient was discharged on a low residue, 2g
sodium, and low cholesterol diet per MD order.
Patient’s weight and labs were stable on discharge.
References
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Saber, Aly. "Pneumatosis intestinalis with complete remission: a case report." Cases
journal 2 (2009): 7079. Dayal, Sanjeev, et al. "Extensive Pneumatosis Intestinalis in
Association With Celiac Disease: A Case Report." Journal of Medical Cases 2.2
(2011): 39-43.
Srivastava, Vivek, Vaibhav Pandey, and Somprakas Basu. "Intestinal Ischemia and
Gangrene.”
McClave, Stephen A., et al. "Guidelines for the provision and assessment of nutrition
support therapy in the adult critically ill patient: Society of Critical Care Medicine
(SCCM) and American Society for Parenteral and Enteral Nutrition (ASPEN)." Journal
of Parenteral and Enteral Nutrition 33.3 (2009): 277-316.
Melis, Marcovalerio, Alessandro Fichera, and Mark K. Ferguson. "Bowel necrosis
associated with early jejunal tube feeding: a complication of postoperative enteral
nutrition." Archives of Surgery 141.7 (2006): 701.
Scaife, Courtney L., Jeffrey R. Saffle, and Stephen E. Morris. "Intestinal obstruction
secondary to enteral feedings in burn trauma patients." The Journal of Trauma and
Acute Care Surgery 47.5 (1999): 859.
Pronsky, Zaneta M., and Jeanne P. Crowe. Food Medication Interactions. Birchrunville,
Penn.: Food-Medication Interactions, 2010. Print.