SESSION TITLE: Critical Care Case Report Posters I
SESSION TYPE: Affiliate Case Report Poster
PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM
INTRODUCTION: Goal directed bedside Ultrasonography has become an invaluable tool for the initial evaluation of critically ill patients. Here we present how this modality helped us make the diagnosis of pneumatosis intestinalis promptly in a patient with cocaine abuse.
CASE PRESENTATION: A 62 year old male with a history of HIV, Hepatitis C, polysubstance abuse presented to the emergency room with right hip pain secondary to a fall. Review of systems was remarkable for abdominal pain, nausea, vomiting and constipation. Vital signs revealed a heart rate of 85, Blood pressure of 115/74 and he was afebrile. Abdominal exam was significant for distension and generalized tenderness with no guarding or rigidity and positive bowel sounds. Initial blood work revealed creatinine of 10.3, blood urea nitrogen: 186, bicarbonate: 12, potassium: 6.5 and creatinine phosphokinase of 49,000. Urine toxicology was positive for cocaine and methadone. On admission to the ICU goal directed bedside Ultrasonography was performed by the ICU team which showed gas in the portal vein as shown in figure 1. CT abdomen showed diffuse dilatation of small bowel with pneumatosis intestinalis in Figure 2. His Lactic acid level was 1.5 and he was managed with fluid resuscitation. Stool was negative for Clostridium difficile. His abdominal pain improved with bowel rest, nasogastric tube to suction and correction of electrolyte abnormalities. He was started on a diet two days after admission and was subsequently discharged home.
DISCUSSION: We are presenting a case of cocaine induced intestinal ischemia that caused pneumatosis intestinalis leading to portal venous gas that was picked up with bedside goal directed Ultrasonagraphy. Cocaine causes bowel ischemia from vasoconstriction and direct toxicity to gut mucosa. CT scan can suggest bowel ischemia but a definite diagnosis of small bowel ischemia is made by exploratory laparotomy. Since cocaine induced ischemia is from small vessel involvement angiography is usually not helpful. One of the causes of gas in the portal venous system is bowel ischemia, which was elegantly demonstrated in the bedside Ultrasonography. In majority of the patients ischemia of the mucosa and sub mucosa is self limited and gets better with conservative management. A delay in the diagnosis can lead to extensive necrosis and a dead bowel warranting surgery.
CONCLUSIONS: Goal directed bedside Ultrasonography has become an invaluable tool for the initial evaluation of critically ill patients. We routinely use this modality and find it extremely valuable in making early diagnosis and management decisions as was illustrated in this case.
Reference #1: Luca Neri, MD; Enrico Storti, MD; Daniel Lichtenstein, MD; Toward an ultrasound curriculum for critical care medicine; Crit Care Med 2007 Vol. 35, No. 5
Reference #2: A. Tiwari,M.Moghal, L. Meleagros; Journal of the Royal Society of Medicine, vol.99,no.2,2006
Reference #3: Nidimusili,AJ; Mennella,J; Shaheen,K; Case reports in gastrointestinal medicine Vol 2013.
DISCLOSURE: The following authors have nothing to disclose: Manju Pillai, Armeen Oonwala, Gopal Narayanswami
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