Presentation
Unwell for 2 days. Initially vague abdominal discomfort. Now profoundly septic.
Patient Data
Widespread linear low density streaking along the wall of the bowel indicates diffuse pneumatosis of the small bowel.
Rigler sign is seen on the right side, indicating pneumoperitoneum.
Linear streaks of gas also noted over the right upper quadrant, raising the possibility of portal venous gas.
Despite timing for a portal venous phase study, the images are relatively arterial, reflecting a poor cardiac output.
There is a large pneumoperitoneum and gas in the wall of the entire small bowel. The large bowel contains fluid but no gas in its wall. Gas is also present within the mesenteric veins and extends into the hepatic portal veins.
Patchy enhancement of the liver and spleen may reflect infarcts.
There are tight stenoses at the origins of the celiac axis and superior mesenteric arteries. A short occlusion of the SMA is also present with very narrow caliber branches beyond the occluded segment.
The inferior vena cava is flat and the adrenals are hyper-enhancing, consistent with shock.
Case Discussion
Occlusion of the superior mesenteric artery has led to extensive small bowel infarction. Gas enters the bowel wall due to loss of mucosal integrity, passes into the mesenteric venous system and ultimately into the portal vein branches of the liver. The friability of the bowel wall also leads to perforation. The presence of portal venous gas in the liver in the setting of bowel ischemia is a sign of very poor prognosis.
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