Clinical communications
Abdominal pain, pneumatosis intestinalis and aeroportia in a hemodialyzed patient
Dolor abdominal, pneumatosis intestinalis y aeroportia en un paciente en hemodiálisis
E. Oliveira
, P. Manuel, J. Alexandre, I. Coelho, F. Girão
Corresponding author
Internal Medicine Department, Centro Hospitalar Tondela-Viseu, King D. Duarte Avenue, 3504-509 Viseu, Portugal
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"apellidos" => "Oliveira" "email" => array:1 [ 0 => "Eurico.oliveira@gmail.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">¿</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "P." "apellidos" => "Manuel" ] 2 => array:2 [ "nombre" => "J." "apellidos" => "Alexandre" ] 3 => array:2 [ "nombre" => "I." "apellidos" => "Coelho" ] 4 => array:2 [ "nombre" => "F." "apellidos" => "Girão" ] ] "afiliaciones" => array:1 [ 0 => array:1 [ "entidad" => "Internal Medicine Department, Centro Hospitalar Tondela-Viseu, King D. Duarte Avenue, 3504-509 Viseu, Portugal" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Dolor abdominal, pneumatosis intestinalis y aeroportia en un paciente en hemodiálisis" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 856 "Ancho" => 999 "Tamanyo" => 97681 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Abdominal contrast-enhanced computed tomography showing large areas of hepatic portal venous gas – <span class="elsevierStyleItalic">aeroportia</span> (white arrows).</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Hemodialyzed patients frequently experience various symptoms intrinsic to the dialysis session, some reflecting acute complications of the procedure. Hypotension is the most common complication, affecting 25–55% of patients,<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> and is not infrequently accompanied by nausea, vomiting, headache, and chest and/or abdominal pain. We present a 51-year-old man with end-stage renal disease receiving hemodialysis, that presented with abdominal pain due to non-occlusive mesenteric ischemia, with <span class="elsevierStyleItalic">aeroportia</span> and <span class="elsevierStyleItalic">pneumatosis intestinalis</span>, unusual findings, but increasingly found in dialysis patients.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Case report</span><p id="par0010" class="elsevierStylePara elsevierViewall">A 51-year-old man with diabetic nephropathy on hemodialysis for the past four years presented to our emergency department because of sudden onset of excruciating abdominal pain, with bilateral dorsal irradiation, nausea and vomiting. He was otherwise asymptomatic until one hour after beginning his regular hemodialysis session, when the pain suddenly began. The dialysis session was interrupted and he was brought to our hospital. Physical examination revealed arterial hypotension (blood pressure 80/64<span class="elsevierStyleHsp" style=""></span>mmHg), tachycardia (130/min), painful abdominal palpation with signs of peritoneal irritation, and absence of bowel sounds. The patient was afebrile and had a normal pulmonary auscultation. The rectal touch was negative for bloody stools or melena.</p><p id="par0015" class="elsevierStylePara elsevierViewall">The results of laboratory examinations were unremarkable, except for a mildly elevated C-reactive protein (3.43<span class="elsevierStyleHsp" style=""></span>mg/dL) and elevations in plasma creatinine and urea (6.3<span class="elsevierStyleHsp" style=""></span>mg/dL and 61<span class="elsevierStyleHsp" style=""></span>mg/dL, respectively). Both chest X-ray and plain radiography of the abdomen were normal. The electrocardiogram revealed sinusal tachycardia, and no signs of ischemic myocardial disease. A computed tomography revealed large amounts of air within the portal venous system along its extension, from the colic veins to the distal branches of the intra-hepatic portal vein (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>). We also found areas of <span class="elsevierStyleItalic">pneumatosis intestinalis</span> in terminal ileum and ascending colon, suggesting intestinal ischemia (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>). Computed tomography multiplan and volumetric reconstructions of mesenteric arteries were performed, and were negative for significant local atherosclerotic disease or thrombosis, suggesting that the pathophysiological process underlying the intestinal ischemia was non-occlusive intestinal hypoperfusion (probably secondary to intradialytic hypotension). The patient was hemodynamically stabilized. An exploratory laparotomy evidenced necrosis of ileum, ascending, transverse and descending colon. A diagnosis of mesenteric ischemia and necrosis was established. Subtotal colectomy was performed with removal of all colonic segments and the distal 20<span class="elsevierStyleHsp" style=""></span>cm of small intestine. There were no signs of perforation or peritonitis. The surgery had no complications and the hospitalization was held with no intercurrences.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0020" class="elsevierStylePara elsevierViewall">The presence of <span class="elsevierStyleItalic">pneumatosis intestinalis</span> is a rare finding in clinical medicine, and gas accumulation in portomesenteric vessels, or <span class="elsevierStyleItalic">aeroportia</span>, is an even rarer finding. They are both consequence of serious conditions and carry high mortality.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> The primary cause is mesenteric ischemia, accounting for about 70% of all cases. Other causes of <span class="elsevierStyleItalic">pneumatosis intestinalis</span> and <span class="elsevierStyleItalic">aeroportia</span> are ulcerative colitis, gastric ulcers, diverticulitis, acute pancreatitis and following invasive procedures.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a><span class="elsevierStyleItalic">Pneumatosis intestinalis</span> can also arise in the context of less serious conditions like asthma or emphysema.</p><p id="par0025" class="elsevierStylePara elsevierViewall">In patients on chronic hemodialysis there have been some case reports of <span class="elsevierStyleItalic">pneumatosis intestinalis</span> with <span class="elsevierStyleItalic">aeroportia</span>.<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4–6</span></a> In these patients the pathophysiological mechanism is prolonged central hypoperfusion during dialysis, leading to non-occlusive intestinal necrosis. In addition to this, hemodialyzed patients frequently have membrane changes in enterocytes, with greater predisposition to bacterial translocation into bloodstream.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> In this particular group of patients the microbial flora is heterogeneous, comprising not only aerobial agents, but also anaerobial agents.<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> Other factors contributing to intestinal ischemia in the hemodialyzed patient appear to be the early and aggressive erythropoietin therapy and vascular calcifications in mesenteric vessels, resulting from deregulated phosphocalcic metabolism.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In those patients in which mesenteric ischemia coexists with <span class="elsevierStyleItalic">aeroportia</span>, the clinician should expect probabilities of transmural necrosis and mortality of, respectively, 91 and 75%,<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> reason why the clinical suspicion, early diagnosis and precocious treatment are fundamental. Nonocclusive mesenteric ischemia is thus a recognized and often lethal complication in hemodialysis patients, and its frequency is increasing in this group of patients,<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">9</span></a> being about 1.9% per patient-year, compared to 0.09–0.2% per patient-year in the general population.<a class="elsevierStyleCrossRefs" href="#bib0050"><span class="elsevierStyleSup">10,11</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Portal venous gas and <span class="elsevierStyleItalic">pneumatosis intestinalis</span> are rare entities, with increasing incidence in hemodialyzed patients. The pathogenic pathways and risk factors are known, and are almost always preventable with simple measures such as avoiding prolonged periods of intradialytic hypotension and controlling inter-dialytic weight gain. They often cause significant morbidity and mortality, and should always be suspected in patients suffering abdominal pain during or after dialysis sessions, since prompt diagnosis and treatment are key factors for a good outcome.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Case report" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Discussion" ] 2 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2012-11-12" "fechaAceptado" => "2012-12-06" "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 856 "Ancho" => 999 "Tamanyo" => 97681 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Abdominal contrast-enhanced computed tomography showing large areas of hepatic portal venous gas – <span class="elsevierStyleItalic">aeroportia</span> (white arrows).</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 895 "Ancho" => 999 "Tamanyo" => 83621 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Abdominal contrast-enhanced computed tomography showing <span class="elsevierStyleItalic">pneumatosis intestinalis</span> in ascending colon and terminal ileum (white arrows).</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0005" "bibliografiaReferencia" => array:11 [ 0 => array:3 [ "identificador" => "bib0005" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Complications during hemodialysis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "H. Bregman" 1 => "J.T. Daugirdas" 2 => "T.S. Ing" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "LibroEditado" => array:3 [ "titulo" => "Handbook of dialysis" "paginaInicial" => "149" "serieFecha" => "1994" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0010" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Aeroportia and acute abdominal pain: ischemic bowel necrosis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "P. Ortega-Deballon" 1 => "F. Radais" 2 => "O. 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Cluzel" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Nephrol Dial Transplant" "fecha" => "2003" "volumen" => "18" "paginaInicial" => "911" "paginaFinal" => "917" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/12686664" "web" => "Medline" ] ] ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0050" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Acute abdomen in the hemodialysis patient population" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "J.S. Bender" 1 => "L.E. Ratner" 2 => "T.H. Magnuson" 3 => "M.E. Zelilman" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Surgery" "fecha" => "1995" "volumen" => "117" "paginaInicial" => "494" "paginaFinal" => "497" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/7740419" "web" => "Medline" ] ] ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib0055" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Mesenteric ischemia in hemodialysis patients" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "M. Picazo" 1 => "M. Cuxart" 2 => "R. Sans" 3 => "C. Sardá" 4 => "E. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 October | 0 | 8 | 8 |
| 2024 September | 0 | 11 | 11 |
| 2024 August | 0 | 9 | 9 |
| 2024 June | 0 | 4 | 4 |
| 2024 May | 0 | 2 | 2 |
| 2024 March | 0 | 6 | 6 |
| 2024 February | 0 | 5 | 5 |
| 2024 January | 0 | 13 | 13 |
| 2023 December | 0 | 24 | 24 |
| 2023 November | 0 | 4 | 4 |
| 2023 October | 0 | 3 | 3 |
| 2023 September | 0 | 5 | 5 |
| 2023 August | 0 | 11 | 11 |
| 2023 July | 0 | 28 | 28 |
| 2023 June | 0 | 26 | 26 |
| 2023 May | 0 | 38 | 38 |
| 2023 April | 0 | 22 | 22 |
| 2023 March | 2 | 27 | 29 |
| 2023 February | 0 | 21 | 21 |
| 2023 January | 0 | 29 | 29 |
| 2022 December | 0 | 26 | 26 |
| 2022 November | 0 | 22 | 22 |
| 2022 October | 0 | 26 | 26 |
| 2022 September | 0 | 33 | 33 |
| 2022 August | 0 | 23 | 23 |
| 2022 July | 0 | 8 | 8 |
| 2022 June | 0 | 7 | 7 |
| 2022 May | 0 | 5 | 5 |
| 2022 April | 0 | 17 | 17 |
| 2022 March | 0 | 27 | 27 |
| 2022 February | 0 | 13 | 13 |
| 2022 January | 0 | 23 | 23 |
| 2021 December | 0 | 12 | 12 |
| 2021 November | 0 | 15 | 15 |
| 2021 October | 0 | 25 | 25 |
| 2021 September | 0 | 6 | 6 |
| 2021 August | 0 | 12 | 12 |
| 2021 July | 0 | 3 | 3 |
| 2021 June | 0 | 7 | 7 |
| 2021 May | 0 | 12 | 12 |
| 2021 April | 0 | 30 | 30 |
| 2021 March | 0 | 19 | 19 |
| 2021 February | 0 | 16 | 16 |
| 2021 January | 0 | 18 | 18 |
| 2020 December | 0 | 11 | 11 |
| 2020 November | 0 | 18 | 18 |
| 2020 October | 0 | 11 | 11 |
| 2020 September | 0 | 2 | 2 |
| 2020 August | 0 | 8 | 8 |
| 2020 July | 0 | 2 | 2 |
| 2020 June | 0 | 5 | 5 |
| 2020 May | 0 | 8 | 8 |
| 2020 April | 0 | 9 | 9 |
| 2020 March | 1 | 9 | 10 |
| 2020 February | 0 | 11 | 11 |
| 2020 January | 0 | 12 | 12 |
| 2019 December | 0 | 19 | 19 |
| 2019 November | 0 | 12 | 12 |
| 2019 October | 0 | 14 | 14 |
| 2019 September | 0 | 15 | 15 |
| 2019 August | 0 | 6 | 6 |
| 2019 July | 0 | 20 | 20 |
| 2019 June | 0 | 31 | 31 |
| 2019 May | 0 | 60 | 60 |
| 2019 April | 0 | 27 | 27 |
| 2019 March | 0 | 3 | 3 |
| 2019 February | 0 | 6 | 6 |
| 2019 January | 0 | 6 | 6 |
| 2018 December | 0 | 6 | 6 |
| 2018 November | 0 | 6 | 6 |
| 2018 October | 0 | 3 | 3 |
| 2018 September | 0 | 2 | 2 |
| 2018 August | 0 | 1 | 1 |
| 2018 June | 0 | 2 | 2 |
| 2018 May | 0 | 1 | 1 |
| 2018 March | 0 | 1 | 1 |
| 2018 February | 20 | 2 | 22 |
| 2018 January | 24 | 4 | 28 |
| 2017 December | 26 | 4 | 30 |
| 2017 November | 28 | 5 | 33 |
| 2017 October | 23 | 7 | 30 |
| 2017 September | 29 | 6 | 35 |
| 2017 August | 22 | 7 | 29 |
| 2017 July | 17 | 10 | 27 |
| 2017 June | 13 | 7 | 20 |
| 2017 May | 28 | 6 | 34 |
| 2017 April | 20 | 13 | 33 |
| 2017 March | 21 | 78 | 99 |
| 2017 February | 22 | 3 | 25 |
| 2017 January | 17 | 0 | 17 |
| 2016 December | 46 | 15 | 61 |
| 2016 November | 52 | 9 | 61 |
| 2016 October | 56 | 9 | 65 |
| 2016 September | 50 | 9 | 59 |
| 2016 August | 27 | 0 | 27 |
| 2016 July | 15 | 3 | 18 |
| 2016 June | 0 | 6 | 6 |
| 2016 May | 0 | 5 | 5 |
| 2016 April | 0 | 1 | 1 |
| 2016 March | 0 | 1 | 1 |
| 2016 February | 1 | 1 | 2 |
| 2016 January | 0 | 6 | 6 |
| 2015 December | 2 | 0 | 2 |
| 2015 October | 1 | 16 | 17 |
| 2015 September | 2 | 0 | 2 |
| 2014 December | 1 | 0 | 1 |
| 2014 October | 1 | 0 | 1 |
| 2014 August | 2 | 0 | 2 |
| 2014 July | 1 | 0 | 1 |
| 2014 June | 2 | 0 | 2 |
| 2014 May | 6 | 0 | 6 |
Show all
