Massive gut ischaemia and necrosis post overdose

Case contributed by Dr Craig Hacking

Presentation

Unconscious collapse. GCS 3 in ED, now intubated with tense abdomen. Acidotic and decreasing sats. Past history of schizophrenia and overdose on bleach, PEG in situ.

Patient Data

Age: 51
Gender: Female

ETT tip is just above the carina. The lungs and pleural spaces are clear. Heart size and mediastinal contours are normal. No pneumothorax or free subdiaphragmatic gas. Massively distended gas-filled stomach.

Massively gas-filled distended stomach with a PEG appearing in good position. Gas is seen within the stomach wall and there is also pneumatosis of several loops of small and large bowel (particularly in the right iliac fossa). Branching lucency projected over the liver is concerning for portal venous gas. No free gas however identified. Overall features are highly concerning for extensive gastrointestinal tract ischaemia or necrosis and CT is advised.

Extremely extensive new necrosis is demonstrated involving the stomach, the entire small bowel, and right side of colon extending to the splenic flexure. There is no appreciable neural enhancement. Extensive portal venous gas is demonstrated, such that an air contrast level is demonstrated in the main portal vein, with extensive gas filling of branches of the left portal vein within the liver. The descending colon and sigmoid colon appear unremarkable, with normal enhancing walls. Part of the stomach mucosa appeared to enhance. PEG in situ.

The coeliac trunk, superior mesenteric artery, and inferior mesenteric artery opacify normally, with no thromboembolism or occlusion evident. The abdomen appears distended, with compression of the IVC.

A 10 cm pelvic mass is present, which is smaller and hypodense compared to earlier CT scans from last year - ? degenerative fibroid.

The kidneys, liver, pancreas and spleen are normally perfused.

Heart, mediastinum, lungs and pleura are unremarkable in appearance.

Conclusion

Very extensive necrosis involving the stomach, small bowel and right-sided colon. Portal venous gas.

Case Discussion

Urgent laparotomy was performed and confirmed almost total necrosis of the GIT from the stomach (below the PEG) to the splenic flexure. Intraoperative consultant surgical decision was that this extent of injury was non-survivable and the abdomen was closed.

The patient died a few hours later.

With the history of mental illness and a significant esophagogastric injury from previous bleech (alkali) ingestion, a repeat overdose is likely to have caused this injury.

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Case information

rID: 40239
Case created: 13th Oct 2015
Last edited: 5th Mar 2016
Inclusion in quiz mode: Included

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