Portal venous gas - benign etiology

Case contributed by Dr René Pfleger

Presentation

Abdominal pain. Unwell. Tachycardia. Dehydration. Electrolyte derangement. Low eGFR.

Patient Data

Age: 70 years
Gender: Male

Hepatic portal venous gas in both lobes is noted along with portal venous gas in central portal vein. Intestinal pneumatosis worrisome for transmural necrosis is also seen. There is high grade arteriosclerosis involving the splanchnic and renal arteries. A biventricular pacemaker is also noted. There is colonic diverticulosis without evidence of diverticulitis.

No evidence of pneumoperitoneum, interloop or gross ascitess ascites nor bowel obstruction. 

Overall findings are worrisome for mesenteric ischemia, especially taking clinical presentation into account. 

Annotated image

Hepatic portal venous gas and pneumatosis intestinalis.

Axial minIP better depicts central portal venous and hepatic portal venous gas.

Volume rendering depicts only mild arteriosclerosis at root of the superior mesenteric artery.

Case Discussion

The patient went on the theater, where exploratory laparoscopy was performed. All intestinal segments were vital. The patient was diagnosed with severe gastroenteritis both clinically and by stool analysis.

Hepatic portal venous gas, when seen on conventional x-rays, is often associated with a poor prognosis. However, with the advent of cross-sectional imagining, the detection of hepatic portal venous gas has improved and several benign causes have been reported in literature 1-2,4

Although a repeat imaging study in stable patients has been proposed, most authors suggest exploratory laparotomy 3 as the standard of care when dealing with symptomatic patients, in order to rule out sinister pathology such as mesenteric ischemia. 

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