Mesenteric vascular occlusion, bowel infarction and portal venous gas

Case contributed by Dr Mohammad A. ElBeialy

Presentation

Severe abdominal pain and distension.

Patient Data

Age: 90 years
Gender: Male

Evidence of portal venous gas in the liver, with marked dilatation of the small and large bowel loops as well as air density noted through its wall, suggestive of pneumatosis intestintinalis.

Mild to moderate cardiomegaly associated with mild to moderate bilateral pleural effusions as well as accentuation of bilateral hilar and basal bronchovascular lung markings with interstitial thickening as well as thickening of the right oblique fissure suggesting cardiogenic pulmonary edema.

  • portal venous gas in the liver (open black arrow)
  • dilatation of the small and large bowel loops with pneumatosis (red arrow) 

These findings are highly suggestive of severe ischemic changes of the bowel loops with intestinal obstruction.

The most important finding in the study is the presence of portal venous gas (with linear and branching gas density extending far to the periphery of the liver parenchyma and liver capsule). There is marked dilatation of the small and large bowel loops and gas density throughout the bowel wall, compatible with pneumatosis intestinalis. Gas density is noted within the superior mesenteric vein as well as within the mesentery of the small bowel. A calcified atheromatous plaque is noted within the origin of the superior mesenteric artery. Dense atherosclerotic changes of aorta as well as the splanchnic vessels.  Minimal perihepatic ascites is noted. There is no dilatation of the intrahepatic or extrahepatic bile duct.

The gallbladder is unremarkable without wall thickening, gallstones or pericholecystic fluid.

Bilateral perinephric fat stranding is noted with no otherwise sizable parenchymal distorting solid or cystic renal masses, no evident renal stones or significant back pressure changes on either side.

The spleen and pancreas are unremarkable without parenchymal abnormality. There is no dilatation of the pancreatic duct.

The adrenal glands are unremarkable without nodularity or mass lesion identified.

Underfilling of the renal bladder with gas density noted within likely related to previous catheterization.  Mild enlargement of the prostate. Intact seminal vesicles.  Small bilateral fat-containing oblique inguinal hernia slightly larger on the right side.

The scanned dorsolumbar spine shows spondylotic changes with possible anterior wedging of the D12 as well as L1 vertebral bodies.

The scanned lung bases shows cardiomegaly with dense atheromatous calcifications of the coronary arteries as well as pulmonary congestion and moderate bilateral pleural effusion.

 

Mesenteric vascular occlusion, bowel infarction, superior mesenteric vein and portal venous gas.

Case Discussion

  1. Portal venous gas as well as the dilatation of the small and large bowel loops with pneumatosis intestinalis consistent with severe ischemic changes of the bowel loops with ischemic intestinal obstruction.
  2. Cardiomegaly predominately left atrio-ventricular with dense atheromatous calcifications of the coronary arteries as well as bony congestion and moderate bilateral pleural effusion.
  3. Other incidental findings as detailed above.

The patient was operated and the infarcted bowel was resected from the proximal jejunum down to the distal third of the transverse colon. 

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Case information

rID: 57870
Published: 17th Jan 2018
Last edited: 16th Jul 2018
Inclusion in quiz mode: Included

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