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Pneumatosis coli due to pharmacological constipation
At the Focal Point
DISCLOSURE None of the authors have any disclosures to make. Vinay Chandrasekhara, MD, Department of Internal Medicine; Sami Arslanlar, MD, Jayaprakash
Sreenarasimhaiah, MD, Department of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas, USA
doi:10.1016/j.gie.2006.07.005
Commentary Whipworm infection is estimated to infect 800 million people worldwide, but this brings to mind 3 bits of good news: (1) it is not contagious, because the egg is not infective until it is fully embryonated; (2) most individuals with whipworm infection are colonized by a small number of worms and have no symptoms; and (3) the prevalence of immune disorders, eg, irritable bowel disease, is low in regions of the world where infection with nematodes is common. Symptoms of high worm burdens include rectal prolapse; colon obstruction; and mucoid diarrhea, with occasional bleeding; a symptom complex called ‘‘trichuris dysentery.’’ Diagnosis is usually by finding eggs in the stool, and rarely is colonoscopy needed. Colonoscopic and histopathologic findings usually are only minimal, even with heavy worm burdens. What is most exciting to me, however, is the interaction between this nematode and the immune system: whipworms induce Th2 cytokine release and downregulate Th1 responsiveness, thereby dampening the inflammatory response and explaining the benefit seen when patients with ulcerative and Crohn’s colitis are given a diet supplemented by porcine whipworm (Trichuris suis) eggs. The satirist Ambrose Bierse commented ‘‘good to eat, and wholesome to digest, as a worm to a toad, a toad to a snake, a snake to a pig, a pig to a man, and a man to a worm.’’ I do not think he saw the close interplay of worms, pigs, and men in any but a classic evolutionary role. Despite what you may read, the worm inside a bottle of mescal (not tequila) is a marketing ploy with no therapeutic benefit. Lawrence J. Brandt, MD Associate Editor for Focal Points
Pneumatosis coli due to pharmacological constipation
A 56-year-old woman was being treated with tramadol (up to 300 mg/day) for joint pain. After 20 days of treatment, tramadol was discontinued because of intense constipation followed by severe lower abdominal pain, diarrhea, and tenesmus. On admission to the hospital, symptoms per-
sisted; results of standard laboratory tests were unremarkable. A CT scan of the abdomen and pelvis showed a myriad of gas-filled cysts in the wall of the rectum, sigmoid, and descending colon (A, middle). Colonoscopy revealed these lesions to be 5 to 20 mm, subepithelial cyst-like lesions
710 GASTROINTESTINAL ENDOSCOPY Volume 65, No. 4 : 2007
www.giejournal.org
At the Focal Point
protruding into the lumen; the overlying mucosa was normal (B). CT and colonoscopic findings were confirmed by EUS (C). Histopathologic analysis showed a submucosal dissection by gas-filled spaces (D, H&E, orig. mag. 40). Pneumatosis coli due to pharmacological constipation was diagnosed. Antibiotics and high-flow oxygen therapy were followed-up by rapid symptomatic and radiological improvement (A, upper-left corner).
DISCLOSURE The authors have no commercial associations that might be a conflict of interest. Cesar Prieto, MD, Ignacio Fernandez-Urien, MD, Bruno Sangro, MD, PhD, Jose Carlos Subtil, MD, PhD, Digestive Diseases Division; Miguel Angel Idoate, MD, PhD, Department of Pathology; David Cano, MD, Department of Radiology; Miguel Mun˜oz-Navas, MD, PhD, Digestive Diseases Division, University of Navarra, Pamplona, Spain doi:10.1016/j.gie.2006.10.057
Commentary Pneumatosis intestinalis comes in 2 sorts: cystoides and linearis. Given the choice, it is better to have the former because the latter most often is seen in conditions associated with intestinal necrosis and its presence usually mandates surgery. In pneumatosis cystoides, thin-walled, endothelial-lined cysts may be located in the mucosa, submucosa, and serosa. Typically, the endothelial lining gathers and coalesces, forming multinucleated giant cells as the cyst fibroses and is eventually sloughed. The connective tissue surrounding the cysts may show a granulomatous inflammatory reaction made up of a variety of cells, including eosinophils, lymphocytes, plasma cells, and macrophages. Mucosal changes vary from mild focal abnormalities to extensive changes and include granulomas, abnormal crypt branching, cryptitis, crypt abscesses, and rupture. Constipation is better recognized as a symptom rather than a cause, and other symptoms include diarrhea, abdominal pain, hematochezia, mucorrhea, and urgency. Hematochezia may result from ulceration of the mucosa overlying the cysts, while obstructive symptoms may be caused by cyst encroachment on the lumen or by adhesions formed as the cysts collapse. Benign pneumoperitoneum may occur as subserosal cysts rupture; it may recur or persist, but does not causes peritonitis and does not mandate surgery. This case was nicely diagnosed by colonoscopy, CT, and EUS, and treated appropriately with antibiotics and oxygen. Use of antibiotics recognizes the role bacteria play in producing hydrogen, which accounts for up to 25% of the gas in the cysts, in contrast to the luminal gas content of approximately 14%. Use of oxygen serves to lower the partial pressure of nitrogen and hydrogen in the cyst, thus causing a diffusion gradient for the gases to move out of the cysts and into the surrounding capillaries and tissues. Desiderius Erasmus (1466?-1536) said, ‘‘Retain the wind by compressing the belly.’’ I believe this patient and her bacteria misinterpreted his teachings. Lawrence J. Brandt, MD Associate Editor for Focal Points
www.giejournal.org
Volume 65, No. 4 : 2007 GASTROINTESTINAL ENDOSCOPY 711
DISCLOSURE None of the authors have any disclosures to make. Vinay Chandrasekhara, MD, Department of Internal Medicine; Sami Arslanlar, MD, Jayaprakash
Sreenarasimhaiah, MD, Department of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas, USA
doi:10.1016/j.gie.2006.07.005
Commentary Whipworm infection is estimated to infect 800 million people worldwide, but this brings to mind 3 bits of good news: (1) it is not contagious, because the egg is not infective until it is fully embryonated; (2) most individuals with whipworm infection are colonized by a small number of worms and have no symptoms; and (3) the prevalence of immune disorders, eg, irritable bowel disease, is low in regions of the world where infection with nematodes is common. Symptoms of high worm burdens include rectal prolapse; colon obstruction; and mucoid diarrhea, with occasional bleeding; a symptom complex called ‘‘trichuris dysentery.’’ Diagnosis is usually by finding eggs in the stool, and rarely is colonoscopy needed. Colonoscopic and histopathologic findings usually are only minimal, even with heavy worm burdens. What is most exciting to me, however, is the interaction between this nematode and the immune system: whipworms induce Th2 cytokine release and downregulate Th1 responsiveness, thereby dampening the inflammatory response and explaining the benefit seen when patients with ulcerative and Crohn’s colitis are given a diet supplemented by porcine whipworm (Trichuris suis) eggs. The satirist Ambrose Bierse commented ‘‘good to eat, and wholesome to digest, as a worm to a toad, a toad to a snake, a snake to a pig, a pig to a man, and a man to a worm.’’ I do not think he saw the close interplay of worms, pigs, and men in any but a classic evolutionary role. Despite what you may read, the worm inside a bottle of mescal (not tequila) is a marketing ploy with no therapeutic benefit. Lawrence J. Brandt, MD Associate Editor for Focal Points
Pneumatosis coli due to pharmacological constipation
A 56-year-old woman was being treated with tramadol (up to 300 mg/day) for joint pain. After 20 days of treatment, tramadol was discontinued because of intense constipation followed by severe lower abdominal pain, diarrhea, and tenesmus. On admission to the hospital, symptoms per-
sisted; results of standard laboratory tests were unremarkable. A CT scan of the abdomen and pelvis showed a myriad of gas-filled cysts in the wall of the rectum, sigmoid, and descending colon (A, middle). Colonoscopy revealed these lesions to be 5 to 20 mm, subepithelial cyst-like lesions
710 GASTROINTESTINAL ENDOSCOPY Volume 65, No. 4 : 2007
www.giejournal.org
At the Focal Point
protruding into the lumen; the overlying mucosa was normal (B). CT and colonoscopic findings were confirmed by EUS (C). Histopathologic analysis showed a submucosal dissection by gas-filled spaces (D, H&E, orig. mag. 40). Pneumatosis coli due to pharmacological constipation was diagnosed. Antibiotics and high-flow oxygen therapy were followed-up by rapid symptomatic and radiological improvement (A, upper-left corner).
DISCLOSURE The authors have no commercial associations that might be a conflict of interest. Cesar Prieto, MD, Ignacio Fernandez-Urien, MD, Bruno Sangro, MD, PhD, Jose Carlos Subtil, MD, PhD, Digestive Diseases Division; Miguel Angel Idoate, MD, PhD, Department of Pathology; David Cano, MD, Department of Radiology; Miguel Mun˜oz-Navas, MD, PhD, Digestive Diseases Division, University of Navarra, Pamplona, Spain doi:10.1016/j.gie.2006.10.057
Commentary Pneumatosis intestinalis comes in 2 sorts: cystoides and linearis. Given the choice, it is better to have the former because the latter most often is seen in conditions associated with intestinal necrosis and its presence usually mandates surgery. In pneumatosis cystoides, thin-walled, endothelial-lined cysts may be located in the mucosa, submucosa, and serosa. Typically, the endothelial lining gathers and coalesces, forming multinucleated giant cells as the cyst fibroses and is eventually sloughed. The connective tissue surrounding the cysts may show a granulomatous inflammatory reaction made up of a variety of cells, including eosinophils, lymphocytes, plasma cells, and macrophages. Mucosal changes vary from mild focal abnormalities to extensive changes and include granulomas, abnormal crypt branching, cryptitis, crypt abscesses, and rupture. Constipation is better recognized as a symptom rather than a cause, and other symptoms include diarrhea, abdominal pain, hematochezia, mucorrhea, and urgency. Hematochezia may result from ulceration of the mucosa overlying the cysts, while obstructive symptoms may be caused by cyst encroachment on the lumen or by adhesions formed as the cysts collapse. Benign pneumoperitoneum may occur as subserosal cysts rupture; it may recur or persist, but does not causes peritonitis and does not mandate surgery. This case was nicely diagnosed by colonoscopy, CT, and EUS, and treated appropriately with antibiotics and oxygen. Use of antibiotics recognizes the role bacteria play in producing hydrogen, which accounts for up to 25% of the gas in the cysts, in contrast to the luminal gas content of approximately 14%. Use of oxygen serves to lower the partial pressure of nitrogen and hydrogen in the cyst, thus causing a diffusion gradient for the gases to move out of the cysts and into the surrounding capillaries and tissues. Desiderius Erasmus (1466?-1536) said, ‘‘Retain the wind by compressing the belly.’’ I believe this patient and her bacteria misinterpreted his teachings. Lawrence J. Brandt, MD Associate Editor for Focal Points
www.giejournal.org
Volume 65, No. 4 : 2007 GASTROINTESTINAL ENDOSCOPY 711