Pnuematosis Intestinalis

1. Pnuematosis Intestinalis Brittany Poyhonen

3. General Description Appearance is the same in both large and small intestine Mucosa is raised by small, smooth surfaced cysts Vary in size; several mm to several cm

5. Pathogenesis There are three ways this may form: 1. Mechanical trapping of air along tissue planes due to rupture of blebs in obstructive lung disease 2. Invasion of devitalized bowel wall by gas forming bacteria Pathogenesis- the origin and development of the disease Bleb= protrusion from the surface of a cell, may be filled with fluid devitalized= dead bowel wall. Pathogenesis- the origin and development of the disease Bleb= protrusion from the surface of a cell, may be filled with fluid devitalized= dead bowel wall.

6. Pathogenesis Cont. 3. Excess production of luminal gas by fermentation of carbohydrates with absorption and trapping of the air in the wall of the bowel Luminal – relating to the lumen, of the bowel.Luminal – relating to the lumen, of the bowel.

7. Two Forms of P.I Primary Pneumatosis Intestinalis 15% of the cases, affects the colon More common in adults Secondary Form 85% of cases, affects small intestine Associated with obstructive pulmonary disease Also associated with obstructive and necrotic gastrointestinal disease Obstructive Pulmonary Disease – umbrella term for a group of respiratory tract diseases that are characterized by airflow obstruction or limitation Necrosis- tissue deathObstructive Pulmonary Disease – umbrella term for a group of respiratory tract diseases that are characterized by airflow obstruction or limitation Necrosis- tissue death

8. Discovery Usually an incidental finding Can be diagnosed thru Diagnostic, CT, Ultrasound, MRI, Endoscopy May cause low-grade abdominal pain May resolve spontaneously (gas is reabsorbed)

9. Diagnosis Most often diagnosed by plain films Contrast Studies may be used Demonstrate filling defects within the lumen of intestines CT – more sensitive then x-ray and often can show the underlying cause of P.I

10. Symptoms Primary Pneumatosis Intestinalis is usually asymptomatic “Rarely patients may experience symptoms secondary to the cysts. Signs and symptoms include diarrhea, bloody stools, abdominal pain, abdominal distention, and constipation.”

11. Symptoms Cont. Often P.I may be a sign of an underlying disease In these cases the underlying disease should be investigated immediately in case of bowel necrosis or other life threatening disease

12. Complications Pneumoperitoneum- can be detected as free air on an upright or cross table lateral view of abdomen Often an indication of perforation Gas in the portal system can indicate Bowel Ischemia In both of these cases surgery is recommended Pneumoperitoneum- defined as air or gas in the abdominal cavity, usually seen on x-ray Bowel Ischemia- Pneumoperitoneum- defined as air or gas in the abdominal cavity, usually seen on x-ray Bowel Ischemia-

13. Diseases it’s Associated With Necrotic Gastrointestinal Disease Non-necrotic Gastrointestinal Disease Pulmonary Diseases Necrotic Gastrointestinal Disease= Necrotic Gastrointestinal Disease=

14. Who it affects… No specific race No specific sex Age: Incidence is higher in neonatal babies because of it’s association with NEC May occur in any age group Primary Pneumatosis occurs more in adults NEC= Necrotizing enterocolitis = a condition in which part of the tissue in the intestines is destroyed Most commonly found in premature babiesNEC= Necrotizing enterocolitis = a condition in which part of the tissue in the intestines is destroyed Most commonly found in premature babies

15. Morbidity This can be an ominous radiographic finding- surgery should be performed in cases where patients are not responding to non-operative treatments or in cases where perforation is suspected

16. Treatment Oxygen Therapy- used to increase rate of re-absorption Hyperbaric oxygen- high pressure oxygen Primary treatment is directed towards the underlying cause or disease - Surgery Oxygen Therapy- reduces partial pressure of hydrogen gas in the capillaries and increases resorption of cystic gasses Hyperbaric oxygen- high pressure oxygen at a pressure greater then 1 atmosphereOxygen Therapy- reduces partial pressure of hydrogen gas in the capillaries and increases resorption of cystic gasses Hyperbaric oxygen- high pressure oxygen at a pressure greater then 1 atmosphere

17. My Patient 83 year old female History of: Dementia Osteoarthritis Breast Cancer Bilateral mastectomies and subsequent implants Cardiomegaly Non-Smoker

18. My Patient Hypersthenic Body Habitus Admitted on 4/11/06 Symptoms included- Abdomen pain onset 5 days previous Located in RLQ Experienced occasional chest discomfort Low back pain Weakness, unable to stand w/o assistance

19. My Patient Patient was assessed Two-view abdomen was ordered Patient was brought to x-ray X-rays were taken Patient passed away 12 minutes after x-rays were taken.

23. Two View Abdomen Upright and a KUB (flat plate) Upright – from diaphragm to the inferior border of symphasis pubis KUB – kidneys, ureters, bladder, inferior border of symphasis pubis

24. Positioning Upright- two films crosswise First film- level of armpits Second film- overlapping, include bladder KUB- center at level of iliac crests Technical Factors- 70-80 kV range

25. References Nadel, Martin M.D “Pneumatosis Intestinalis”http://radiology.uchc.edu/eAtlas/GI/1226.htm Fezko, PJ. “Clinical Significance of Pneumatosis of the bowel wall”http://radiographics.rsnajnls.org/cgi/content/abstract/12/6/1069 Goyer, Sameer K. M.D “Pneumatosis Intestinalis”(Jan. 26/2005)http://www.emedicine.com/RADIO/topic560.htm Bontrager, Kenneth L. Radiographic Positioning and Related Anatomy (6th Ed.) St. Louis, 2001. Elsevier Mosby