Hepatic Portal Venous Gas with Pneumatosis Intestinalis

Abstract

Hepatic portal venous gas with pneumatosis intestinalis are radiological clues of intestinal ischemia. Prompt evaluation and a high index of clinical suspicion for the diagnosis of acute mesenteric ischemia are necessary given the high mortality of this condition. We present a case of mesenteric ischemia, radiological clues to diagnosis, and associated mechanisms. Key words: Pneumatosis intestinalis; Esenteric ischemia; Hepatic portal venous gas Case reportA 77 year old male with the past medical history of diabetes mellitus type 2 complicated by a right BKA, hypertension, hypercholesterolemia, and chronic kidney disease presents to the ED for shortness of breath and abdominal pain. Three days prior to admission he noted a sudden onset of crampy and aching pain across his lower abdomen, constant in nature, relieved somewhat with over-the-counter Maalox and Pepcid, but never completely subsiding. The same evening the pain started, he experienced nausea, but no vomiting. He had no history of biliary colic, or abdominal angina. The patient also noted increasing dyspnea, and was found sitting on the edge of his bed trying to catch his breath. He denied any recent fever or chills, hematochezia, or melena. In the ED, he was afebrile with a BP 101/50 mmHg, pulse of 93/min, and oxygen saturation of 92% on 2 liters nasal cannula, and respirations of 24/min. His cardiac exam was regular. His lungs revealed bibasilar crackles. His abdomen exam revealed an obese abdomen with some pain to deep palpation in the lower quadrants, but overall fairly benign. Bowel sounds were normoactive, and there was no hepatosplenomegaly. Rectal exam was guaic negative without any masses.Laboratory data was significant for a creatinine 3.6 mg/ dl, with normal liver function tests and coagulation tests. A V/Q scan was read as high probability for pulmonary embolism, later revised to intermediate probability. He was admitted to the hospital for treatment with IV unfractionated heparin, with the diagnosis of pulmonary embolism. His abdominal pain was never clarified on admission, but was still concerning and a CT scan of the abdomen without contrast because of renal insufficiency was ordered in the morning. Figure 1 shows portal venous air in the left hepatic lobe. Figure 2 shows mesenteric venous air throughout much of the right-sided mesenteric system and an air/blood level within the SMV. Figure 3 shows pneumatosis of the right hemicolon, findings consistent with acute mesenteric ischemia. STAT surgical consultation was obtained and after discussion with the family regarding the high operative risk of mortality versus certain sepsis and mortality without surgery, the patient and family decided to become comfort care. The patient's pain was controlled, and comfort measures were

Nonocclusive mesenteric ischemia and heart failure: A case report and bowel ischemia imaging

“…These are imagiological signs traditionally associated with bowel ischemia [10]. Recently, many nonischemic causes of aeroportia and pneumatosis intestinalis were identified, usually when one of these signs presents alone [10,11]. Despite this, the simultaneous presence of both findings is still highly predictive of bowel ischemia, frequently representing transmural involvement and a limited prognosis [12].…”