Fatal extensive pneumatosis intestinalis secondary to enterocolitis in an immunocompromised adult

BEN AMEUR Hazem |

La tunisie chirurgicale - 2019 ; Vol 2019

Resumé

Pneumatosis intestinalis is a condition characterized by the presence of gas within the wall of any part of the alimentary tract. It is most commonly reported in the small intestine. We report a case of a very extensive pneumatosis intestinalis reaching almost all the digestive tract from esophagus to colon. This was secondary to a rapidly progressive acute enterocolitis which was aggravated by the presence of advanced lymphoma. The evolution was fatal due to a severe sepsis.

Mots Clés

pneumatosis, intestine, enterocolitis, lymphoma.

Introduction :

Pneumatosis intestinalis is a condition characterized by the presence of gas within the wall of any part of the alimentary tract [1]. It is most commonly reported in the small intestine [1]. We report a case of a very extensive pneumatosis intestinalis reaching almost all the digestive tract.

Article

Patient and observation

A 39-year-old man presented with diarrhea, weight loss, jaundice and fever. Laboratory test results showed a lymphopenia at 500 /µL, cholestasis and hepatic cytolysis. Hemoculture, coproculture, and HIV serology were negative. Abdominal CT showed an ileocolitis associated with intra- and retroperitoneal lymphadenopathies and hepatic and splenic lesions suggestive of lymphoma. The situation worsened rapidly with more profuse diarrhea, hypotension, tachycardia, very important abdominal distention, renal failure and leukocytosis at 24,500 /µL. A second CT revealed marked gastrointestinal distention and a parietal pneumatosis affecting esophagus (figure 1), stomach (figure 2), small bowel and colon (figure 2, 3). Urgent laparotomy showed diffuse gastrointestinal distention with hyperemia but without necrosis or peritonitis (figure 4). Resection of a lymphadenopathy was performed which permitted to confirm the diagnosis of Hodgkin lymphoma. Patient was died 48 hours later from multi-organ failure.

Discussion

Pneumatosis intestinalis could reach any segment of the alimentary tract, from the esophagus to the rectum, although it is most commonly reported in the small intestine [1]. There were 2 hypotheses for the development of pneumatosis: mechanical and bacterial theories [1, 2]. According to the mechanical theory, gas enters the digestive wall because of increased intraluminal pressure (with a relatively intact mucosa) or increased mucosal permeability (resulting from direct mucosal injury and/or a defective intestinal immune barrier) [1, 2]. The bacterial theory proposes that gas-producing luminal bacteria can lead to formation of intramural gas either by direct mural invasion or by direct gas diffusion [1].

In our case, acute enterocolitis, probably secondary to anaerobic germs, has rapidly spread because of the underlying advanced lymphoma. The subsequent important intraluminal accumulation of gas and the increased mucosal permeability led to the passage of air in the submucosal along which it was then propagated to the esophagus. Then, the two mechanisms were associated. To our knowledge, this is the first case of such extensive pneumatosis intestinalis.

Early surgical intervention should be considered in any patient with signs of perforation or predictors of poor outcomes as such as patients who are immunosuppressed with underlying liver disease, sepsis, and hypotension (like in our patient), pH of less than 7.3, bicarbonate level of less than 20 mEq/L, lactate level of more than 2 mmol/L, amylase level of more than 200 U/L, signs of disseminated intravascular coagulation or the presence of portal venous gas on CT scan [2].

Conclusion

Pneumatose intestinalis is exceptionally diffuse to the almost all of digestive tract. It could be fatal in the context of advanced malignancy and severe sepsis.

 

 

 

Figures legend

Figure 1: transversal section of CT scan showing gas in the esophageal wall.

Figure 2: coronal reconstruction of CT scan showing gas in the wall of stomach, small bowel and colon.

Figure 3: transversal section of CT scan showing gas in the wall of small bowel and colon.

Figure 4: intra operative view showing diffuse intestinal distention with hyperemia but without necrosis.

Références

1. Torres Ulysses S, Fortes Camila DFM, Salvadori Priscila S, Tiferes Dario A, D′Ippolito Giuseppe. Pneumatosis From Esophagus to Rectum: A Comprehensive Review Focusing on Clinico-Radiological Differentiation Between Benign and Life-Threatening Causes. Semin Ultrasound CT MR. 2018;39(2):167-182.

 

2. Feuerstein Joseph D, White Nicole, Berzin Tyler M. Pneumatosis Intestinalis With a Focus on Hyperbaric Oxygen Therapy. Mayo Clin Proc. 2014;89(5):697-703.

 

 

 

 

 

Figure 1: transversal section of CT scan showing gas in the esophageal wall.

Figure 2: coronal reconstruction of CT scan showing gas in the wall of stomach, small bowel and colon.

Figure 3: transversal section of CT scan showing gas in the wall of small bowel and colon.

Figure 4: intra operative view showing diffuse intestinal distention with hyperemia but without necrosis.