Portal vein gas as an ominous radiological sign. Clinical case.
Posted in Pictures on 8 August 2017
Ana Otero (Gastrointestinal surgery specialist) Hospital Clínic, Barcelona – Spain
A 73-year-old female patient, with a history of Parkinson’s disease. AnEndoscopic Gastrostomy Prosthesis was placed with a tube for endoscopic administration of duodopa.
The patient came to the emergency room 5 days later presenting with abdominal pain, distension and feeling poorly overall. A blood analysis was performed, highlighting an elevated CRP with normal leukocytes.
Given the physical examination it was decided to perform an abdominalCT Scan, which showed a dilation of the bowel, more evident in the left flank, at the jejunal level, with a thinning intestinal wall, intestinal pneumatosis and gas in the mesenteric and portals intrahepatic veins. These findings suggested an intestinal ischemia with no identified the cause as the first diagnostic option. A edema in the ileal wall of the bowel on the right flank was a nonspecific finding, but it could indicate an intestinal ischemia at an earlier stage with respect to the previous ones. Gastric distension with liquid content and the presence of a percutaneous gastrostomy catheter entry with a distal end in the jejunum were also found.
We decided to perform an emergency surgery.
Treatment: The patient was hemodynamically unstable, requiring vasoactive drugs. It was decided to perform an exploratory laparotomy.
The findings were consistent with fecaloid peritonitis secondary to leakage of the gastric – intestinal contents around the gastrostomy tube. No signs of ischemia were identified in any organ in the abdominal cavity.
The gastrostomy was repaired with a double suture and fixation of the same to the abdominal wall. In addition, abundant washes of the abdomen were performed and two drains were placed.
Outcome: The postoperative course was correct, and the vasoactive drugs were gradually removed. The gastrostomy functioned properly and the oral diet was well tolerated.
Portal vein gas is a diagnostic sign which indicates a serious intra-abdominal pathology requiring emergency surgery in the majority of patients. Benign hepatic portal vein gas due to less dangerous diseases can be treated conservatively after the exclusion of an intra-abdominal catastrophe. The correlation between clinical and diagnostic findings is important to design the management plan.