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Gastroduodenal emphysema
Journal of Pediatric Surgery (2008) 43, 2121–2123
www.elsevier.com/locate/jpedsurg
Gastroduodenal emphysema Rachel D'Cruz, Sherif Emil ⁎ Division of Pediatric Surgery, University of California Irvine School of Medicine, Orange, CA 92868, USA Received 23 June 2008; revised 21 July 2008; accepted 22 July 2008
Key words: Pneumatosis intestinalis; Foregut; Stomach; Duodenum; Obstruction; Gastric emphysema; Emphysematous gastritis
Abstract Pneumatosis intestinalis of the foregut is a very rare finding. It may represent emphysematous gastritis secondary to inflammatory conditions or gastric emphysema secondary to proximal foregut obstruction and high intragastric pressure. We present a case of gastroduodenal pneumatosis secondary to partial duodenal obstruction in an infant with Down's syndrome. © 2008 Elsevier Inc. All rights reserved.
Pneumatosis intestinalis in children has several etiologies but is most commonly seen in neonates with necrotizing enterocolitis, where the small or large bowel or both are affected. Pneumatosis of the foregut is exceedingly rare. We present a case of gastroduodenal pneumatosis secondary to congenital partial duodenal obstruction.
1. Case report A 9-month-old girl with Down's syndrome, born at term by repeat cesarean delivery, had chronic nonbilious emesis interpreted by her physicians as gastroesophageal reflux. There was no history of polyhydramnios. The only congenital anomaly detected at birth was a small patent ductus arteriosus that closed spontaneously. She presented to a community emergency department with worsening emesis for 5 days described as “sometimes projectile” by her mother. The patient was initially discharged from the outside facility ⁎ Corresponding author. Tel.: +1 514 412 4497; fax: +1 514 412 4341. E-mail address: [email protected] (S. Emil). 0022-3468/$ – see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2008.07.019
after intravenous hydration, but the parents were contacted and asked to return to the emergency department after plain films had been reviewed by the radiologist. An abdominal computed tomographic scan was performed at the outside facility, and the patient was subsequently transferred to our children's hospital. On arrival at our facility, the patient appeared lethargic and dehydrated. She weighed 5.48 kg (15th percentile). Result of abdominal examination was entirely benign. Electrolyte analysis revealed a severe hypokalemic, hypochloremic metabolic alkalosis (Na+, 134 mEq/L; K+, 2.8 mEq/L; Cl−, 69 mEq/L; HCO3−, 38 mEq/L; blood urea nitrogen, 30 mg/dL; Cr, 0.4 mg/dL). A complete blood count showed evidence of hemoconcentration without leukocytosis or left shift. The abdominal plain film and computed tomographic scan from the referring facility showed clear evidence of partial duodenal obstruction and pneumatosis intestinalis of the stomach and duodenum (Figs. 1 and 2). Additional imaging was not performed. The patient was treated with nasogastric decompression, intravenous hydration, and antibiotics. A benign abdominal examination result persisted. After the patient was adequately hydrated and the metabolic alkalosis corrected, she
2122
Fig. 1 Plain film shows severe gastric emphysema with outlining of both the lesser and greater curvature (thin arrows) by intramural air. The pylorus (thick arrow) is also clearly seen outlined by air. A rim of air (short arrows) can also be seen along the second portion of the duodenum.
was taken to the operating room. A partial duodenal obstruction secondary to a web in the proximal second portion of the duodenum was identified. Duodenotomy, lateral web excision, and duodenoplasty were performed to repair the obstruction. The patient was started on oral intake on the second postoperative day and discharged 7 days after admission. At 6-month follow-up, she was thriving without any further emesis, and her weight had improved to the 40th percentile.
R. D'Cruz, S. Emil of the gastric mucosa such as necrotizing enterocolitis (NEC), systemic infections, and hypoperfusion during cardiac surgery [5]. In NEC, it is believed that inflammation of the gastric mucosa allows gas producing bacteria to penetrate the mucosa. Although distinguishing between gastric emphysema and emphysematous gastritis is possible on clinical grounds, radiologic differences have also been described [5]. Gastric emphysema is generally characterized by a linearly arrayed or “streaky” gas pattern around the distended stomach, as seen in our case. Emphysematous gastritis, in comparison, is characterized by a cystic or bubbly appearance of gas, more typical of NEC. However, in both conditions, radiographic overlap does occur [5,6]. Perhaps the most important difference between gastric emphysema and emphysematous gastritis is the prognosis. Gastric emphysema responds remarkably well to gastric decompression and correction of the initial cause of obstruction, as was evidenced in our case. Radiographic improvement has been reported in as little as 4 hours [2] and resolution in 16 to 24 hours [7]. Emphysematous gastritis in association with NEC is a poor prognostic feature. It has been implicated in more severe cases of NEC with widespread gastrointestinal involvement [5]. In summary, our case raises awareness of a rare entity, gastroduodenal pneumatosis. It also reminds that chronic emesis in a patient with Down's syndrome, whether bilious or not, should be considered partial duodenal obstruction until proven otherwise and should be investigated promptly. Finally, a proximal, long-standing preampullary duodenal obstruction can present with the same electrolyte abnormalities seen in pyloric stenosis.
2. Discussion The images shown here represent a rare radiographic finding, pneumatosis intestinalis of the foregut. Only 33 cases of gastric pneumatosis have been reported in the literature in infants [1], including two associated with duodenal stenosis [2,3]. Air in the wall of the stomach, or gastric pneumatosis, can be divided into 2 main categories as follows: gastric emphysema and emphysematous gastritis. Gastric emphysema is hypothesized to be caused by an increase in intragastric pressure that results in a breach in the mucosa. These breaches allow air to enter the gastric wall. Gastric emphysema has been described in conditions that cause gastric outlet obstruction such as pyloric stenosis, gastric malrotation, duodenal atresia, duodenal web, and annular pancreas [1-4]. Emphysematous gastritis is thought to occur in conditions that cause ischemia or inflammation
Fig. 2 Computed tomographic scan showing a severely distended stomach and proximal duodenum. Duodenal intramural air is clearly seen (arrows).
Gastroduodenal emphysema
References [1] Travaldi JN, Patole SK, Simmer K. Gastric pneumatosis in neonates: revisited. J Paediatr Child Health 2003;39:560-2. [2] Kawano S, Tanaka H, Daimon Y, et al. Gastric pneumatosis associated with duodenal stenosis and malrotation. Pediatr Radiol 2001;31:656-8. [3] Diallo O, Ziereisen F, Christophe C, et al. Gastric pneumatosis as a sign of duodenal stenosis in a child with Down syndrome. J Radiol 2001;82: 924-6.
2123 [4] Baxter K, Blair G, Jamieson D. Gastric pneumatosis. J Pediatr Surg 2002;37:263-4. [5] Duran R, Vatansever U, Aksu B, et al. Gastric pneumatosis intestinalis: an indicator of intestinal perforation in preterm infants with necrotizing enterocolitis. J Pediatr Gastroenterol Nutr 2006;43:539-41. [6] Soon MS, Yen HH, Soon A, et al. Endoscopic ultrasonographic appearance of gastric emphysema. World J Gastroenterol 2005;11: 1719-21. [7] Bajaj M, Ogilvy-Stuart AL. Gastric pneumatosis/interstital emphysema of the stomach. Arch Dis Child Fetal Neonatal Ed 2004;89: F188.
www.elsevier.com/locate/jpedsurg
Gastroduodenal emphysema Rachel D'Cruz, Sherif Emil ⁎ Division of Pediatric Surgery, University of California Irvine School of Medicine, Orange, CA 92868, USA Received 23 June 2008; revised 21 July 2008; accepted 22 July 2008
Key words: Pneumatosis intestinalis; Foregut; Stomach; Duodenum; Obstruction; Gastric emphysema; Emphysematous gastritis
Abstract Pneumatosis intestinalis of the foregut is a very rare finding. It may represent emphysematous gastritis secondary to inflammatory conditions or gastric emphysema secondary to proximal foregut obstruction and high intragastric pressure. We present a case of gastroduodenal pneumatosis secondary to partial duodenal obstruction in an infant with Down's syndrome. © 2008 Elsevier Inc. All rights reserved.
Pneumatosis intestinalis in children has several etiologies but is most commonly seen in neonates with necrotizing enterocolitis, where the small or large bowel or both are affected. Pneumatosis of the foregut is exceedingly rare. We present a case of gastroduodenal pneumatosis secondary to congenital partial duodenal obstruction.
1. Case report A 9-month-old girl with Down's syndrome, born at term by repeat cesarean delivery, had chronic nonbilious emesis interpreted by her physicians as gastroesophageal reflux. There was no history of polyhydramnios. The only congenital anomaly detected at birth was a small patent ductus arteriosus that closed spontaneously. She presented to a community emergency department with worsening emesis for 5 days described as “sometimes projectile” by her mother. The patient was initially discharged from the outside facility ⁎ Corresponding author. Tel.: +1 514 412 4497; fax: +1 514 412 4341. E-mail address: [email protected] (S. Emil). 0022-3468/$ – see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2008.07.019
after intravenous hydration, but the parents were contacted and asked to return to the emergency department after plain films had been reviewed by the radiologist. An abdominal computed tomographic scan was performed at the outside facility, and the patient was subsequently transferred to our children's hospital. On arrival at our facility, the patient appeared lethargic and dehydrated. She weighed 5.48 kg (15th percentile). Result of abdominal examination was entirely benign. Electrolyte analysis revealed a severe hypokalemic, hypochloremic metabolic alkalosis (Na+, 134 mEq/L; K+, 2.8 mEq/L; Cl−, 69 mEq/L; HCO3−, 38 mEq/L; blood urea nitrogen, 30 mg/dL; Cr, 0.4 mg/dL). A complete blood count showed evidence of hemoconcentration without leukocytosis or left shift. The abdominal plain film and computed tomographic scan from the referring facility showed clear evidence of partial duodenal obstruction and pneumatosis intestinalis of the stomach and duodenum (Figs. 1 and 2). Additional imaging was not performed. The patient was treated with nasogastric decompression, intravenous hydration, and antibiotics. A benign abdominal examination result persisted. After the patient was adequately hydrated and the metabolic alkalosis corrected, she
2122
Fig. 1 Plain film shows severe gastric emphysema with outlining of both the lesser and greater curvature (thin arrows) by intramural air. The pylorus (thick arrow) is also clearly seen outlined by air. A rim of air (short arrows) can also be seen along the second portion of the duodenum.
was taken to the operating room. A partial duodenal obstruction secondary to a web in the proximal second portion of the duodenum was identified. Duodenotomy, lateral web excision, and duodenoplasty were performed to repair the obstruction. The patient was started on oral intake on the second postoperative day and discharged 7 days after admission. At 6-month follow-up, she was thriving without any further emesis, and her weight had improved to the 40th percentile.
R. D'Cruz, S. Emil of the gastric mucosa such as necrotizing enterocolitis (NEC), systemic infections, and hypoperfusion during cardiac surgery [5]. In NEC, it is believed that inflammation of the gastric mucosa allows gas producing bacteria to penetrate the mucosa. Although distinguishing between gastric emphysema and emphysematous gastritis is possible on clinical grounds, radiologic differences have also been described [5]. Gastric emphysema is generally characterized by a linearly arrayed or “streaky” gas pattern around the distended stomach, as seen in our case. Emphysematous gastritis, in comparison, is characterized by a cystic or bubbly appearance of gas, more typical of NEC. However, in both conditions, radiographic overlap does occur [5,6]. Perhaps the most important difference between gastric emphysema and emphysematous gastritis is the prognosis. Gastric emphysema responds remarkably well to gastric decompression and correction of the initial cause of obstruction, as was evidenced in our case. Radiographic improvement has been reported in as little as 4 hours [2] and resolution in 16 to 24 hours [7]. Emphysematous gastritis in association with NEC is a poor prognostic feature. It has been implicated in more severe cases of NEC with widespread gastrointestinal involvement [5]. In summary, our case raises awareness of a rare entity, gastroduodenal pneumatosis. It also reminds that chronic emesis in a patient with Down's syndrome, whether bilious or not, should be considered partial duodenal obstruction until proven otherwise and should be investigated promptly. Finally, a proximal, long-standing preampullary duodenal obstruction can present with the same electrolyte abnormalities seen in pyloric stenosis.
2. Discussion The images shown here represent a rare radiographic finding, pneumatosis intestinalis of the foregut. Only 33 cases of gastric pneumatosis have been reported in the literature in infants [1], including two associated with duodenal stenosis [2,3]. Air in the wall of the stomach, or gastric pneumatosis, can be divided into 2 main categories as follows: gastric emphysema and emphysematous gastritis. Gastric emphysema is hypothesized to be caused by an increase in intragastric pressure that results in a breach in the mucosa. These breaches allow air to enter the gastric wall. Gastric emphysema has been described in conditions that cause gastric outlet obstruction such as pyloric stenosis, gastric malrotation, duodenal atresia, duodenal web, and annular pancreas [1-4]. Emphysematous gastritis is thought to occur in conditions that cause ischemia or inflammation
Fig. 2 Computed tomographic scan showing a severely distended stomach and proximal duodenum. Duodenal intramural air is clearly seen (arrows).
Gastroduodenal emphysema
References [1] Travaldi JN, Patole SK, Simmer K. Gastric pneumatosis in neonates: revisited. J Paediatr Child Health 2003;39:560-2. [2] Kawano S, Tanaka H, Daimon Y, et al. Gastric pneumatosis associated with duodenal stenosis and malrotation. Pediatr Radiol 2001;31:656-8. [3] Diallo O, Ziereisen F, Christophe C, et al. Gastric pneumatosis as a sign of duodenal stenosis in a child with Down syndrome. J Radiol 2001;82: 924-6.
2123 [4] Baxter K, Blair G, Jamieson D. Gastric pneumatosis. J Pediatr Surg 2002;37:263-4. [5] Duran R, Vatansever U, Aksu B, et al. Gastric pneumatosis intestinalis: an indicator of intestinal perforation in preterm infants with necrotizing enterocolitis. J Pediatr Gastroenterol Nutr 2006;43:539-41. [6] Soon MS, Yen HH, Soon A, et al. Endoscopic ultrasonographic appearance of gastric emphysema. World J Gastroenterol 2005;11: 1719-21. [7] Bajaj M, Ogilvy-Stuart AL. Gastric pneumatosis/interstital emphysema of the stomach. Arch Dis Child Fetal Neonatal Ed 2004;89: F188.