Hepatic Portal Venous Gas From Nonischemic Cause

Abstract

A 65-YEAR-OLD obese man with uncontrolled diabetes, uncontrolled hypertension, chronic renal insufficiency, and bladder cancer diagnosed in May 2014 status-post multiple transurethral resection of bladder tumors with incomplete resection of tumor and chemotherapies. He was admitted to a large urban cancer medical center in November for a radical cystectomy with ileal-conduit creation and bilateral peritoneal lymph node dissection. Intraoperative and postoperatively, his course was significant for labile blood pressure, hyperglycemia, and fever with leukocytosis attributed to postoperative atelectasis. On postoperative day 3, he was able to start a regular diet and ambulate with assistance. However, during ambulation he had mild emesis and when he went back to his room and sat down, he was noted to become unresponsive. The hospital emergency response team was activated. On arrival of the emergency response team, the patient was found to be awake and alert,following commands and moving all extremities. His abdomen appeared obese and distended but without any peritoneal signs. His arterial blood gas revealed slight respiratory alkalosis with a pH of 7.48; a CO 2 of 23 mm Hg (normal range, 35-45 mm Hg); a PaO 2 of 141 mm Hg (normal range, 80-95 mm Hg); a bicarbonate of 17 mEq/L (normal range, 22-26 mEq/L); an oxygen saturation of 99% (normal range, 95%-99%); and a lactate of 4.5 mmol/L (normal range, <1.2 mmol/L). His blood glucose was moderately elevated at 217 mg/dL. His vital signs were significant for tachycardia to 120 beats per minute, tachypnea to the 20 seconds, and relative hypotension of 120/ 70 mm Hg. Since he met the criteria for symptoms of systemic inflammatory response syndrome, he was fluid resuscitated and initiated on empiric antibiotics to treat a potential intraabdominal sepsis. A nasogastric tube (NGT) was attempted to decompress the distended abdomen. During NGT insertion, the patient had large volume projectile emesis of approximately 1 L. The patient was subsequently intubated for increased work of breathing and airway protection. His NGT produced an additional 500 mL of bilious output after intubation. The patient was promptly transferred to the intensive care unit for further management. He then received a CT of head, chest, abdomen and pelvis to rule out stroke, pulmonary embolism, and to evaluate for intra-abdominal pathology. Contrast was not used due to his renal insufficiency. Although his head and chest CT were unremarkable,