Mesenteric Vein Thrombosis Complicating Pneumatosis Intestinalis, A Case Report
Annals of Colorectal Research: September 30, 2013, 1 (2); 71-2
July 30, 2013
Article Type: Case Report
August 20, 2013
August 24, 2013
K. Mesenteric Vein Thrombosis Complicating Pneumatosis Intestinalis, A Case Report,
Ann Colorectal Res.
Pneumatosis intestinalis is usually considered as a benign condition. Here we report the association of this condition with mesenteric vein thrombosis leading to gangrenous bowel which, to our best knowledge, is the first reported association.
The patient was a 71-year old Iranian smoker man, who was diagnosed with pneumatosis intestinalis for 11 months and then developed the abdominal pain which was confirmed to be due to the mesenteric vein thrombosis complicated by bowel gangrene.
Although pneumatosis intestinalis is not usually threatening in adults, its new onset in the abdomen of these patients should prompt the complications such as mesenteric vein thrombosis.
Mesenteric vein thrombosis, Pneumatosis intestinalis; Case report
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Pneumatosis intestinalis (PI) is a rare condition characterized with the presence of gas in the wall of either or both small or large bowels (
1, 2). Although it is almost always a Grave's sign in neonates with resultant high mortality rate, in adults it is usually considered as a benign self-limited condition. Indeed most adults with PI are usually asymptomatic. The pathogenesis of this condition is not clear but there are also several associated conditions ( 3). The list is large and includes bowel infections, mucosal diseases such as inflammatory bowel diseases, intraabdominal catastrophes like bowel gangrene from any cause, as a complication of endoscopic procedures and pulmonary diseases including chronic obstructive pulmonary disease (COPD) ( 1, 2, 4, 5). Here we present a case of apparently benign PI for a long time which was then complicated with superior mesenteric vein thrombosis (SMVT).
2. Case Presentation
Our patient was a 71-year old Iranian male farmer, water pipe smoker and occasional opium inhaler with abdominal bloating and distension for many years. Work ups showed free air in the abdominal cavity in abdominal X-ray and no other finding was observed in the abdominal CT scan. Patient underwent a diagnostic laprascopy showed multiple bullae in the wall of intestine with no evidence of peritonitis or perforation. He was diagnosed with pneumatosis cystoides intestinalis and was advised to discontinue smoking and dimethicone, domperidone, ranitidine orally and ipratropium bromide spray were administrated. Then he was followed in the out patients
' department for the next 11 months. In all of these visits abdominal distention was present but there was no sign of peritoneal irritation. Bowel sounds were normal. Colonoscopy, upper endoscopy and color Doppler sonography of abdominal vessels were also normal. The other abdominal and pelvic CT scans were also normal except the multiple bullae in the wall of large bowel. He decreased his use of water pipe and opium. About a year after the first visit in our center, he developed progressive abdominal pain for six hours. On admission in emergency room, he had diffuse abdominal tenderness accompanied with decreased bowel sounds. Another CT scan was done which revealed SMVT. Patient underwent lapratomy, revealed a twenty cm gangrenous bowel, which was resected. Blood clots in the superior mesenteric vein were also evacuated. Unfractionated heparin administrated in postoperative period followed by warfarin. He got well two years after the second operation. The only complaints were occasional abdominal distension responsive to the treatment with dimethicone, domperidone and famotidine.
PI in adults is usually a disease of elderly presenting after the sixth decade of the life. In acute form it may be a manifestation of generous bowel which is considered as a medical emergency case. But in the chronic form, which is the mostly common in adults, is usually asymptomatic or presents with non specific symptoms with a benign course. As mentioned above PI may be complicated by bowel gangrene after superior mesenteric vein thrombosis (SMVT) (
6) but the reverse association in patients with PI has not been reported to our best knowledge so far. In our case ,as there was a long lag period between the initial manifestation and the second surgery, it is apparent that the SMVT occurred after PI. This association might be related to the raised intra abdominal pressure leading to decreased venous flow and resultant thrombosis.
The concept of benign nature of chronic PI needs to be modified. This case presentation should make physicians both in primary and specialty care aware of the possibility of severe complications of PI. This should be considered when the clinical course of these patients is changed and they present new and progressive signs.
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