A 59-year-old Japanese man was transferred to our hospital because of aggravated abdominal pain after initial treatment for DCS at the previous hospital.
The patient was a fisherman and recreational diver and previously had DCS twice, which was treated conservatively both times. In addition, he was taking aspirin 100 mg/day because he had a history of percutaneous cardiac intervention for angina pectoris. He dove to a depth of 100 feet 3 days in a row using a self-contained underwater breathing apparatus (SCUBA) to search for a lost item. After surfacing, he experienced sudden abdominal and postcervical pain, so he visited a community hospital.
Computed tomography (CT) revealed a large amount of intravenous gas throughout his whole body, including in the portal vein (PV) (Fig. 1a), superior mesenteric vein (SMV) (Fig. 1b), inferior mesenteric vein (IMV), and femoral vein (FV). He was therefore diagnosed with DCS and transferred to the previous hospital to undergo hyperbaric oxygen therapy (HBOT). On admission to that hospital, US Navy Treatment Table 6, the most common type of HBOT, was performed. The following day, the intravenous gas had been mitigated according to the CT findings; however, pneumatosis intestinalis of the transverse colon developed. His abdominal pain remained, and he complained that the severity of the pain was worsening. Due to concerns about mesenteric ischemia, he was transferred to our hospital for additional treatment.
On arrival, he was oriented, and his vital signs were as follows: blood pressure, 123/69 mmHg; pulse rate, 120 bpm; and oxygen saturation, 93% with 3 L/min O2 administration. Mottling and cutis marmorata were noted on his stomach. A physical examination revealed a distended and mildly hardened abdomen, strong abdominal pain, tense muscles, and tenderness, suggesting peritonitis on palpation. The laboratory data revealed an elevated white blood cell (WBC) count (22400/μL; normal range, 4000–8500/μL) and C-reactive protein (CRP) level, hemoconcentration, acute kidney injury, acute hepatic injury, and coagulopathy (hemoglobin [Hb] 21.4 g/dL, normal range 13.0–17.0 g/dL; hematocrit [Ht] 59.9%, normal range 40.050.0%; platelet count 134000/μL, normal range 150000–300000/μL; creatinine [Cr] 3.72 mg/dL, normal range 0.61–1.04 mg/dL; aspartate aminotransferase [AST] 119 U/L, normal range 10–40 U/L; alanine aminotransferase [ALT] 127 U/L, normal range 5–40 U/L; creatine kinase [CK] 2018 U/L, normal range 58–249 U/L; CRP 17.21 mg/dL, normal range ≤ 0.30; prothrombin time [PT] 52.1%, normal range ≥ 75%; activated partial prothrombin time [APTT] 36.6 s, normal range 25–38 s; D-dimer 7.3 μg/mL, normal range ≤ 1.0 μg/mL; and fibrin degradation production [FDP] 11.8 μg/mL, normal range ≤ 5.0 μg/mL).
Because of his kidney dysfunction, contrast-enhanced CT was avoided, and plain CT was conducted. CT revealed pneumatosis intestinalis of the transverse colon (Fig. 1c), suggesting potential mesenteric ischemia, so we decided to perform an exploratory laparoscopy to obtain an accurate diagnosis and provide subsequent treatment. Laparoscopy revealed that the transverse colon and mesentery were dark red in color, suggesting mesenteric ischemia (Fig. 2a, b). After switching to an open laparotomy, a partial transverse colon resection and colostomy with the ascending colon were performed. In addition, we inserted a feeding tube into the jejunum to provide early nutrition after surgery. Discoloration was found in all layers of the resected specimen (Fig. 2c)
After surgery, the patient was admitted to the intensive care unit. He was on mechanical ventilation, and meropenem, a broad-spectrum antibiotic, was administered for 6 days for peritonitis and bacterial translocation. Ulinastatin, a protease inhibitor, was administered for 3 days for acute circulatory failure, and sivelestat sodium hydrate, a neutrophil elastase inhibitor, was also administered for 5 days for acute lung injury. On postoperative day 3, early nutrition was started with the feeding tube. The patient was extubated 6 days after surgery. On postoperative day 36, he was discharged in good condition. Two months later, surgery for colostomy closure was performed. He is following an uneventful course.
A pathological examination revealed diffuse edema, congestion, hemorrhaging, and necrotic changes in the mucosal, submucosal, and muscle layers and part of the subserosa (Fig. 3a). In some of the dilated veins, there were a few gas embolus-like oval transparent spaces (Fig. 3b yellow arrow), and thrombus formation was found near the peripheral side (Fig. 3b black arrow). Because of these findings, he was diagnosed with MVT.
