EMERGENCY IMAGING FINDINGS • SENIOR RESIDENT / SURGEON

Portal Venous Gas

Peripheral hepatic gas plus a toxic abdominal presentation should trigger urgent evaluation for intestinal ischemia and necrosis.

PROTOTYPE REVIEW REQUIRED

The Call

74-year-old woman with atrial fibrillation

Abrupt severe abdominal pain, fever, diaphoresis, rigid abdomen, leukocytosis, renal dysfunction and lactate 6.7. CT shows portal venous gas with abnormal distal small bowel and right colon.

Toxic • Tachycardic • Peritoneal

The combination of portal venous gas, acidosis and ischemic bowel findings is an operative emergency.

Read the Image • Clinical Data

CT Abdomen Peripheral branching hepatic gas with abnormal bowel should raise concern for mesenteric ischemia. Clinical image slot reserved for this case.

Make the Decision • Commit to a Plan

Portal Venous Gas

74-year-old woman with atrial fibrillation

CT shows portal venous gas and pneumatosis in a patient with pain, lactate 6 and peritonitis. Best next step?

A long segment is questionable after correction of a closed-loop obstruction. Best strategy?

The patient's lactate normalizes and abdominal exam improves after source control, but repeat CT still shows some portal venous gas. Best principle?

Determine perfusion, resect necrosis, preserve salvageable bowel.

Second-look strategy is often part of the operation.

Surgical Pearls

Pitfalls

Portal venous gas is seen in a comfortable patient after endoscopy with normal lactate and a benign abdomen. What is the key distinction from the index case?