Pneumatosis Intestinalis 09.26.2011

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DEPARTMENT OF PEDIATRICSSCHOOL OF MEDICINE

Morning Report 9-26-2011

B.Kalm


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HPI KT is a 35 m/o F presenting for abdominal pain 2 months after

fenestrated Fontan procedure for HLHS. Abd pain x 2-3 weeks daily - mostly lower abd dull and constant

Seen by cardiology a few days after pain started and told she wasfine

Saw PCP several days later and viral illness diagnosed Seen again by cards for ? Atrial tachycardia and no issues found 1 week prior noted stool with BRB on outside thought constipation

Had a couple more and saw PCP who started miralax Last few days more tired and not eating well


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ROS

Some rare vomiting (NB/NB) in last few

weeks, decreased stooling, mild rash onchest, decreased urine output

All else negative


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PMH 1. Hypoplastic left heart syndrome with aortic and mitral atresia.

2. Status post stage 1 Norwood with a 6 mm RV-PA conduit.3. Status post bidirectional Glenn with ligation of the conduit.4. s/p 20mm extracardiac Fontan with 4 mm fenestration.5. Allergic reaction in OR, diffuse rash and hypotension (etiology unknown).

6. Failure to grow 7. Constipation

Meds: Furosemide, Aspirin, Cyproheptadine, Miralax Allergies: None definitively known

FH: polycystic kidney, adult heart disease SH: Lives w/ M/D, 2 bros, 1 GF. Recent camping trip with mosquito bites,

no nonpotable water


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What are you thinking of so far?


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PE T 37.1 HR 120 RR 26 Sats initially 78% on admit (upset and crying), later increased to 94% on

RA, BP 112/85Wt: 13.7 kg

GENERAL: No acute distress, well developed and nourished, upset with exam.HEAD: NC/AT. EYES: Normal red reflex bilaterally, PERRL, EOMI, conjugate gaze. EARS:normal exam. NOSE: No discharge or obstruction. OROPHARYNX: MMM, tonsils withoutexudate, and no pharyngeal erythema or lesions.NECK: Supple without lymphadenopathy.CARDIOVASCULAR: Normal rate with irregular rhythm without murmur, gallop. Normal S1, S2.Femoral and pedal pulses appropriate. Capillary refill time < 2 seconds.LUNGS: Clear to auscultation bilaterally with good air entry. No wheeze or crackles. Noincreased work of rbeathing. No grunting, flaring or retractions.ABDOMEN: Soft, non-tender, non-distended, and without masses, liver palpable 2cm below

costal margin. Normal bowel sounds. No rebound or guarding.EXTREMITIES: Warm and well perfused. No clubbing, cyanosis, or edema.GENITOURINARY: Normal.NEUROLOGICAL: CN II-XII grossly intact. Nl muscle tone and strength, no focal motor orsensory deficits.PSYCH: normal mentation for age, interacting appropriately.SKIN: No rashes, jaundice, cyanosis or pallor.


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Expand or contract yourdifferential


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Pneumatosis Intestinalis

AKA: Necrotizing Enterocolitis(neonatology)

AKA: Typhlitis (oncology)

AAKA: pneumatosis cystoides intestinalis,intramural gas, pneumatosis coli,

pseudolipomatosis, intestinal emphysema,bullous emphysema of the intestine, andlymphopneumatosis


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Causes: Not quite sure

Mechanical: Air goes through mucosal

breaches and tracks along mesentery Bacterial: Bacteria get through mucosal

breaches and grow and produce gas

Biochemical: Intraluminal bacteria makehydrogen gas with enough pressure to getthrough the mucosa


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How to get Mucosal Breaches

Premature Babies: Immature host

defense, poor circulation, microbialovergrowth, tissue toxic medications

Oncologic: Decreased neutrophils lead to

poor defenses Other: Poor circulation, IBD, Bad bacteria


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Symptoms

Vomiting, abdominal distention, weight

loss, abdominal pain, diarrhea,hematochezia, constipation, flatulence,loss of appetite, and tenesmus.


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Complications:

Big complication is separation of blood

vessels from the intestines; i.e. dead gut This can cause significant

morbidity/mortality


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Treatment: Get rid of the cause

Antibiotics: Vanc, gent, and metronidazole oftenused in prematurity Pipericillin/tazobactamoften used in older patients Cover intestinalflora and anaerobes

Oxygen: Keeps anaerobes from growing

Elemental formula or bowel rest: No substratefor bacteria to use allow bowel wall to heal

Surgery: Only if the bowel dies


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Summary:

Think about pneumatosis intestinalis in

susceptible patients (its a virus onlyworks so well)

The most important therapy is getting rid

of the cause Other therapies are often used but may or

may not be helpful


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Pneumatosis Intestinalis 09.26.2011

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