S4021 A Rare Complication of Pneumatosis Intestinalis in Pancreatitis

Introduction: Pneumatosis intestinalis (PI) occurs in 0.03% of the population and is more rare as a complication of acute pancreatitis. Case Description/Methods: A 60-year-old woman with past medical history chronic alcohol abuse and alcoholic liver disease presented with 3-day history of confusion and jaundice along with leg and abdominal swelling for a few weeks. On arrival to hospital she was disorganized, in respiratory distress and had a seizure after which she was intubated and admitted to the Intensive Care Unit (ICU). She was treated for hepatic encephalopathy (HE) and alcoholic hepatitis. Liver ultrasound revealed hepatomegaly, steatosis and cholelithiasis. Abdominal distension was noted and computed tomography (CT) abdomen was done revealing acute pancreatitis predominantly in the region of the body and tail. Hepatobiliary scan was negative for biliary obstruction. 4 days later she was again noted to have abdominal distension and no bowel movements. Abdominal radiograph showed signs of Ileus and CT Abdomen confirmed PI involving the right and proximal transverse colon. Due to overall poor prognosis she was deemed not a surgical candidate and ultimately palliated. Discussion: HE is a well-documented complication of decompensated cirrhosis and is associated with increased morbidity and mortality. The diagnosis of acute pancreatitis adds to the burden of organ dysfunction. Its occurrence in cirrhotic patients has been associated with significantly higher ICU mortality rates and worse clinical outcomes. The development of PI is consistent with previous studies, which report PI as a rare, fatal colonic complication of pancreatitis. Increased intraluminal pressure, gas forming bacteria or in this case inflammatory injury result in mucosal compromise and gas entry into the bowel wall. The transverse colon is most commonly affected by ischemia, followed by ascending colon while bowel perforation as a result of PI was commonly identified in the sigmoid colon in one study and carries a high mortality rate. It is important that PI be differentiated from pneumatosis cystoides coli (PCC) which appears as cyst like collections of gas in the bowel submucosa versus circumferential collections that are indicative of bowel infarction. PCC is treated conservatively with dietary modification, hyperbaric oxygen and antibiotics while PI is treated with urgent surgical intervention. In eligible candidates with PI and bowel obstruction, endoscopy with fine needle aspiration of cysts and sclerotherapy may be appropriate for diagnosis and treatment.