Small bowel infarction with portal venous gas
2 days of vomiting and abdominal distension. Hypotensive, tachycardic and lactic acidosis on bloods.
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Most of the small bowel is dilated with a transition point in the lower abdomen with swirling of the mesenteric vessels. The terminal 30 cm of small bowel is collapsed. There is poor enhancement of the wall of much of the small bowel, with gas in the submuscosa. Gas is also seen in the mesenteric venous system with extensive liver portal venous gas. Whilst there is extensive atheromatous disease, the major vessels enhance normally.
The cause of the small bowel obstruction was felt to be adhesions. With prolonged bowel obstruction, the bowel wall perfusion is compromised and results in ischaemia. The end stage of bowel ischaemia is infarction, with a break down in the mucosa leading to bacterial translocation and gas entry into the submucosa and then the mesenteric venous channels. Portal venous gas is considered a pre-mortem sign.