Case of Day - Portal Venous Gas

An abdominal radiograph shows diffuse distention of the small bowel, relative paucity of colonic gas and hepatic portal venous gas at the corner of the image.

Facts:
- Rare condition occurring when intraluminal gas and/or gas produced by intestinal bacteria enters the portal venous circulation
- Initially thought to be an ominous sign with an estimated mortality of 75%-80% (more recently, mortality rates are 25%-35%)
- Main factors that allow development of portal venous gas: intestinal wall alteration, bowel distention, ischemia and sepsis

Etiology:
- Most common = intestinal ischemia with or without documented mesenteric thrombosis, necrotizing enterocolitis (NEC)
- Others = C.difficile colitis, peptic ulcer disease, gastric cancer, diverticulitis, abdominal trauma, intra-abdominal abscess, inflammatory bowel disease
- Iatrogenic = complications of endoscopic and radiological procedures

Imaging
- Diagnosis can be made by abdominal x-ray or ultrasound, but CT is the gold standard
- Branching lucencies extending to within 2 cm of the liver capsule (predominantly in the anterior-superior aspect of the left lobe)
- On US, it appears as echogenic particles flowing within the portal vein

Our case - patient with sepsis, severe ischemic/infarcted colitis and end-staged pancreatic cancer

Reference:
Alqahtani S, Coffin CS, Burak K, et al. Hepatic portal venous gas: a report of two cases and a review of the epidemiology, pathogenesis, diagnosis and approach to management. Can J Gastroenterol 2007; 21:309.

Source: RiT (partner of radRounds)