Hepatic Portal Venous Gas in Presence of Pneumatosis Intestinalis

Abstract

Hepatic portal venous gas (HPVG) and pneumatosis intestinalis (PI) are rare conditions characterized by formation of gas in portal venous system and within the walls of small or large intestine respectively.We report a case of HPVG in association with PI in a patient with transmural bowel infarction. A 54 year old male with history of severe atherosclerotic disease was admitted to the hospital for workup of non-sustained ventricular tachycardia. Two days post left heart catheterization, patient developed worsening non-bloody diarrhea and abdominal pain.Physical examination was significant for distended tender abdomen with absence of bowel sounds. Laboratory workup revealed white cell count of 33500(cmm, lactic acid of 5.4 mmol/L and pH of 7.18. A computed tomography (CT) of abdomen showed widespread diffuse air in hepatic portal venous system (figure 1) with air in small and large bowel wall (figure 2). Patient underwent immediate exploratory laparotomy, which showed transmural infarction of complete small bowel and right colon consistent with complete occlusion of superior mesenteric artery. In adults, HPVG is associated with a variety of pathological conditions including intestinal ischemia and necrosis (70%-75%), ulcerative colitis (8%), intra-abdominal abscess (6%), and idiopathic causes (15%). PI is idiopathic (15%) or secondary (85%) to bowel ischemia, inflammatory bowel disease, clostridium difficile infection, scleroderma, COPD, and drug therapy. CT provides conclusive diagnosis in most cases. Findings of HPVG or PI by itself at CT should be carefully evaluated in the context of clinical findings. However, the combination of two in adults is suggestive of a life threatening bowel ischemia. Physicians should recognize that HPVG in combination with PI is an ominous sign of transmural bowel infarction and needs emergent intervention. [figure 1][figure 2]Figure 1Figure 2