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  IN THIS Article
 ::  Abstract
 ::  Introduction
 ::  Case Report
 ::  Discussion
 ::  References
 ::  Article Figures

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CASE REPORT
Year : 2011  |  Volume : 57  |  Issue : 1  |  Page : 42-43

Pneumatosis intestinalis and mesenteric venous gas - A manifestation of bacterascites in a patient with cirrhosis


1 Department of Medicine, Division of Liver Diseases, Mount Sinai School of Medicine, NY, USA
2 Recanati-Miller Transplantation Institute, Mount Sinai School of Medicine, NY, USA
3 Department of Medicine, Division of Liver Diseases, Mount Sinai School of Medicine, NY; Recanati-Miller Transplantation Institute, Mount Sinai School of Medicine, NY, USA

Date of Submission28-Feb-2010
Date of Decision30-Jun-2010
Date of Acceptance28-Sep-2010
Date of Web Publication31-Jan-2011

Correspondence Address:
R K Yellapu
Department of Medicine, Division of Liver Diseases, Mount Sinai School of Medicine, NY
USA
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DOI: 10.4103/0022-3859.74287

PMID: 21206125

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 :: Abstract 

We herein report a patient with decompensated cirrhosis secondary to autoimmune hepatitis, who presented with pneumatosis intestinalis (PI) and portal venous gas. Mesenteric ischemia has been recognized as a common and life-threatening cause of PI which portends a grave prognosis. The patient was found to have bacterascites and recovered after appropriate antibiotic therapy. Spontaneous bacterial peritonitis/bacterascites with gas-forming organisms manifesting as PI has not been previously reported.


Keywords: Bacterascites, mesenteric venous gas, pneumatosis intestinalis


How to cite this article:
Yellapu R K, Rajekar H, Martin J D, Schiano T D. Pneumatosis intestinalis and mesenteric venous gas - A manifestation of bacterascites in a patient with cirrhosis. J Postgrad Med 2011;57:42-3

How to cite this URL:
Yellapu R K, Rajekar H, Martin J D, Schiano T D. Pneumatosis intestinalis and mesenteric venous gas - A manifestation of bacterascites in a patient with cirrhosis. J Postgrad Med [serial online] 2011 [cited 2014 Dec 19];57:42-3. Available from: http://www.jpgmonline.com/text.asp?2011/57/1/42/74287



 :: Introduction Top


Pneumatosis intestinalis (PI) is a relatively rare disease, defined as the presence of gas within the bowel wall. PI ranges from benign disease, which does not require treatment to a need for oxygen, intravenous hydration, and antibiotics, to a life-threatening condition requiring immediate surgery. Here we report a case of pneumatosis intestinalis secondary to bacterasites in a patient with cirrhosis.


 :: Case Report Top


A 60-year-old woman with decompensated cirrhosis, presented with complaints of abdominal discomfort and increasing abdominal distension. She had grade 2 hepatic encephalopathy with generalized abdominal distension and decreased bowel sounds. She was on lactulose for recurrent hepatic encephalopathy. Abdominal radiograph revealed distended small bowel loops and colonic gas, without pneumoperitoneum. A computed tomography (CT) scan of the abdomen demonstrated ascites, dilated stomach, and small bowel. There was bubble-like pneumatosis of multiple small bowel loops as well as mesenteric venous gas [Figure 1]. Complete blood count and electrolytes were unremarkable. There were no other obvious signs of sepsis. Serum lactate was raised marginally without significant acidosis. Ascitic fluid analysis showed non-neutrocytic bacterascites, and yielded Haemophilus parainfluenzae on culture. She was treated conservatively; lactulose was withheld and she was kept on NPO, with nasogastric aspiration, intravenous hydration, and broad-spectrum antibiotics. She improved symptomatically and repeat CT scan showed resolution of both the pnematosis intestinalis and mesenteric venous gas. Three weeks later the patient underwent orthotopic liver transplantation successfully. Intraoperative findings revealed unremarkable bowel and normal celiac and mesenteric vessels.
Figure 1: CT scan showing portal venous gas and bubble-like pneumatosis

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 :: Discussion Top


Pneumatosis cystoides intestinalis is a condition of uncertain cause in which gas accumulates within the wall of the bowel and is characterized by the presence of submucosal and subserosal cysts. The first description of pneumatosis cystoides intestinalis was made by Du Vernoin as a postmortem observation. [1] Two main causative theories have been proposed. A mechanical theory hypothesizes that gas dissects into the bowel wall from either the intestinal lumen or the lungs via interstitial tissue due to some mechanism causing increased pressure. [2],[3] An infective theory proposes that gas-forming organisms enter the submucosa through diseased bowel wall or increased mucosal permeability and produce gas within the bowel wall. [2],[4],[5] Koss's [6] review of 213 cases of PI and Shallal et al.'s [7] review of 410 reported cases found that the condition may affect any part of the small or large intestine and may be localized or extensive. Unlike other collections of gas within the body that are reabsorbed gradually, these gas cysts may persist for a long time. No treatment is necessary for 85% of patients who are asymptomatic. The resolution of gas collections has been reported after inhalation of 70% of oxygen that achieves a PO 2 of 250 mmHg for 5 days and after hyperbaric oxygen therapy at 2.5 atm (252.5 kPa) for 150 min on three successive days. [8] This has been used in the presence of incapacitating symptoms of distension and fecal incontinence, and abdominal discomfort. [9]

On CT scan, two types of PI are described: one is the presence of multiple cysts (cystic type) and the other the presence of linear collections of gas (linear type). [10],[11] PI ranges from benign disease, which does not require treatment to a need for oxygen, intravenous hydration, and antibiotics, to a life-threatening condition requiring immediate surgery. There have been a few case reports of PI and portal venous gas occurring in patients with cirrhosis. Necrotizing enterocolitis and lactulose therapy have been suggested as the possible cause of PI in these patients. [12],[13],[14],[15] In our patient, the isolation of H. parainfluenzae from the ascitic fluid raised the possibility of infection by gas-producing organisms giving rise to PI. H. influenzae and H. parainfluenzae have been described as rare causes of intra-abdominal or retroperitoneal abscesses. H. influenzae and H. parainfluenzae normally occur in the human respiratory tract, but they also colonize the gastrointestinal tract. [16] There has been one reported case of primary peritonitis in a female child with H. parainfluenzae, an otherwise healthy child. [17] This is the first report linking PI with bacterascites secondary to cirrhosis. PI is not commonly seen in SBP, but in the presence of a gas-forming organisms in the ascitic fluid, the possibility of infection of the ascitic fluid as a cause of PI must be considered. In conclusion, the clinician needs to be aware that rapid diagnosis, strict monitoring of sepsis parameters, and medical therapy are very important in these cases.

 
 :: References Top

1.Du Vernoin JG. Anatomische Beobachtungen der unter der aussern und innern Haut der Gedarme eingeschlossenen luft. Phys Med Abhandl Acad Wissensch Petersb 1783;2:182-8.   Back to cited text no. 1
    
2.Galandiuk S, Fazio VW. Pneumatosis cystoides intestinalis: a review of the literature. Dis Colon Rectum 1986;29:358-63.  Back to cited text no. 2
[PUBMED]    
3.Pear BL. Pneumatosis intestinalis: a review. Radiology 1998;207:13-9.   Back to cited text no. 3
[PUBMED]  [FULLTEXT]  
4.Gagliardi G, Thompson IW, Hershman MJ, Forbes A, Hawley PR, Talbot IC. Pneumatosis coli: a proposed pathogenesis based on study of 25 cases and review of the literature. Int J Colorectal Dis 1996;11:111-8.  Back to cited text no. 4
[PUBMED]  [FULLTEXT]  
5.Yale CE, Balish E, Wu JP. The bacterial etiology of pneumatosis cystoides intestinalis. Arch Surg 1974;109:89-94.  Back to cited text no. 5
[PUBMED]  [FULLTEXT]  
6.Koss LG. Abdominal gas cysts. Arch Path 1952;53:523-49.  Back to cited text no. 6
    
7.Shallal JA, Heerden JAN, Bartholomew LG, Cain JC. Pneumatosis cystoides intestinalis Mayo Clinic Proc 1974;49:180-4.   Back to cited text no. 7
    
8.Forgacs P, Wright PH, Wijatt AP. Treatment of intestinal gas cysts by oxygen breathing. Lancet 1973;1:579-82.  Back to cited text no. 8
    
9.Down RH, Castleden WM. Oxygen therapy for pneumatosis coli. Br Med J 1975;1:493-4.  Back to cited text no. 9
[PUBMED]  [FULLTEXT]  
10.Soyer P, Martin-Grivaud S, Boudiaf M, Malzy P, Duchat F, Hamzi L, et al. Linear or bubbly: a pictorial review of CT features of intestinal pneumat osis in adults. J Radiol 2008;89:1907-20.  Back to cited text no. 10
[PUBMED]  [FULLTEXT]  
11.Ochiai T, Igri K, Kumagai Y, Iida M, Yamazaki S. Education and imaging. Gastrointestinal: massive portal venous gas and pneumatosis intestinalis. J Gastroenterol Hepatol 2010;25:1178.  Back to cited text no. 11
[PUBMED]  [FULLTEXT]  
12.Tameda Y, Hamada M, Hamaguchi T, Sugimoto K, Katou H, Nakazawa S, et al. Pneumatosis intestinalis and necrotizing enterocolitis associated with liver cirrhosis. J Gastroenterol 1996;31:596-8.  Back to cited text no. 12
[PUBMED]    
13.Lee JS, Joo SY, Park CH, Park SY, Park HC, Kim HS, et al. A case of pneumatosis cystoides intestinalis in a cirrhosis patient. Korean J Gastroenterol 2007;50:56-60.  Back to cited text no. 13
[PUBMED]  [FULLTEXT]  
14.Goodman RA, Riley TR 3rd. Lactulose-induced pneumatosis intestinalis and pneumoperitoneum. Dig Dis Sci 2001;46:2549-53.  Back to cited text no. 14
[PUBMED]  [FULLTEXT]  
15.Zhang J, Yan R. Inferior vena cava gas, portal venous system gas, and pneumatosis intestinalis. J Gastrointest Surg 2010;14:1338-9.  Back to cited text no. 15
[PUBMED]  [FULLTEXT]  
16.Megraud F, Bebear C, Dabernat H, Delmas C. Haemophilus species in the human gastrointestinal tract. Eur J Clin Microbiol Infect Dis 1988;7:437-8.  Back to cited text no. 16
    
17.Mayer MP, Schweizer P. Primary peritonitis in a child caused by Haemophilus parainfluenzae. Pediatr Surg Int 2002;18:728-9.  Back to cited text no. 17
[PUBMED]  [FULLTEXT]  


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