AIR EMBOLISM FROM ENEMA RESULTING IN STROKE

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Pneumatosis intestinalis (PI) is the presence of gas within wall small or large intestine. While pathogenesis poorly understood, etiology often secondary to ischemia, obstruction, on occasion, an endoscopic procedure. CASE PRESENTATION: 50-year-old male with past medical history chronic kidney disease stage 4 and uncontrolled insulin-dependent type 2 diabetes presented decreased urine output, shortness breath abdominal distention 3 days. On initial exam, abdomen was firm as well diffusely tender palpation. He alert oriented no focal deficits noted. Initial CT revealed a considerable volume stool colon. Hepatic vasculature were unremarkable. One lactulose enema given without complication at 1155 AM. At 1345 patient documented be slightly lethargic weak by physical therapy. 1435 found unresponsive verbal tactile stimuli developed emesis. Physical exam tachypnea, sluggish pupillary response bilaterally, rigid abdomen. Stat head multiple left cerebral veins. Repeat showed interval colonic pneumatosis intrahepatic portal venous suspected radiology related recent enema. Emergent intubation performed for stabilization. Transfer center capable providing hyperbaric oxygen therapy ventilated initiated. Unfortunately, due lack resources distance facility, ground transport not option. To further complicate picture, air delayed several hours severe weather. Following patient's arrival outside family elected comfort measures subsequently expired shortly thereafter. DISCUSSION: proposed mechanism PI termed mechanical theory. Gas dissects into intestines point disrupted mucosal integrity. This has been reproduced insufflating excised segment in one study [1]. Enema shown cause massive [2] while retrograde embolism demonstrated [3], most following central line removal. In this case, emboli traveled through circulation, then after level heart vessels. our knowledge only case which resulted stroke. CONCLUSIONS: exceedingly rare Being aware possibility can provide early recognition intervention, leading better outcomes future patients. REFERENCE #1: KAY-BUTLER JJ. Interstitial emphysema caecum. Gut. 1962 Sep;3(3):267-8. doi: 10.1136/gut.3.3.267. PMID: 14031571; PMCID: PMC1413346. #2: Ochiai T, Igri K, Kumagai Y, Iida M, Yamazaki S. Education imaging. Gastrointestinal: intestinalis. J Gastroenterol Hepatol. 2010 Jun;25(6):1178. 10.1111/j.1440-1746.2010.06361.x. 20594238. #3: Schlimp CJ, Loimer Rieger Schmidts MB, Lederer W. Pathophysiological immediate treatment embolism. Intensive Med. 2006 Jun;32(6):945. 10.1007/s00134-006-0149-y. Epub Mar 28. 16568273. DISCLOSURES: No relevant relationships Haytham Adada, source=Web Response Mahmoud Amarna, Camelia Chirculescu, Trevor Elswick, Randall Wasson,