Portal-venous gas unrelated to mesenteric ischemia

CT evaluation of bowel wall enhancement in pneumatosis intestinalis: preventing non-therapeutic laparotomies

PURPOSE

To evaluate the diagnostic performance of bowel wall enhancement for diagnosing concomitant bowel ischemia in patients with parietal pneumatosis (PI) diagnosed at abdominal CT.

MATERIALS AND METHODS

From January 1, 2012 to December 31, 2021, 226 consecutive patients who presented with PI on abdominal CT from any bowel segment were included. Variables at the time of the CT were retrospectively extracted from medical charts. CT examinations were blindly analyzed by two independent radiologists. The third reader classified all disagreement of bowel enhancement in three categories: (1) normal bowel enhancement; (2) doubtful bowel wall enhancement; (3) absent bowel wall enhancement. Multivariable logistic regression analysis was performed. Concomitant bowel ischemia was defined as requirement of bowel resection specifically due to ischemic lesion in operated patients and death from bowel ischemia in non-operated patients.

RESULTS

Overall, 78/226 (35%) patients had PI associated with concomitant bowel ischemia. At multivariate analysis, Only absence or doubtful bowel wall enhancement was associated with concomitant bowel ischemia (OR = 167.73 95%CI [23.39-4349.81], P < 0,001) and acute mesenteric ischemia associated with PP (OR = 67.94; 95%CI [5.18-3262.36], P < 0.009). Among the 82 patients who underwent a laparotomy for suspected bowel ischemia, rate of non-therapeutic laparotomy increased from 15/59 (25%), 2/6 (50%) and 16/17 (94%) when bowel wall enhancement was absent, doubtful and normal respectively.

CONCLUSION

Absence of enhancement of the bowel wall is the primary feature associated with concomitant bowel ischemia. It should be carefully assessed when PI is detected to avoid non-therapeutic laparotomy.

Bezoar as a cause of portal vein pneumatosis: a case report

Pneumatosis of the portal vein is considered a rare imaging sign rather than a disease. It usually occurs in patients with digestive tract diseases such as intestinal obstructive diseases, mesenteric vascular diseases, closed abdominal trauma, and liver transplantation. Because of its high mortality rate, it is also termed the "sign of death." Hawthorn contains tannic acid, and seafood is rich in calcium, iron, carbon, iodine, and other minerals and proteins. Thus, consuming both hawthorn and seafood together can result in the formation of an indigestible complex in the body, acting as the main pathogenic factor in patients with intestinal obstruction. We herein describe a patient with duodenal obstruction caused by hawthorn who developed the hepatic portal venous gas sign and was cured by nonsurgical treatment.

Hepatic portal venous gas and combined colchicine-bortezomib toxicity

Hepatic portal venous gas was found at the abdomen CT of a patient who presented abdomonal pain and ileus in the course of colchine-bortezomib therapy. Drug toxicity was suspected as there was no evidence of intestinal ischemia at laparatomy.

Porto-mesenteric venous gas as a sign of gastric mucosal damage remitted after surgery: a case report

Porto-mesenteric venous gas (PMVG) is a severe sign of abdominal organs damage. Imaging diagnostic criteria allow the detection of PMVG and should be applied in the presence of severe symptoms and signs of abdominal organs damage. Our case had clinical signs of epigastric pain and abdominal tenderness and ultrasonography and computed tomography evidence of PMVG and gastric cancer. The subsequent surgery, without complications, induced PMVG to disappear and the patient to be dismissed from hospital.

Hepatic Portal Venous Gas in a Patient with Penetrating Injuries

Hepatic portal venous gas (HPVG) refers to the branching area of low attenuation extending to within 2 cm of the liver capsule in computed tomography scan. The most common causes of HPVG are mesenteric ischaemia in adults and necrotising enterocolitis in infants. HPVG in trauma patients is mostly reported in cases of blunt abdominal trauma. We present a deceased patient who had chest and abdominal wall penetrating injuries with concomitant hypovolemic shock. A computed tomography scan revealed HPVG and pulmonary artery air emboli. The mechanism of the presentation of HPVG in this patient and the possible cause of death would be discussed. (Hong Kong j.emerg.med. 2013;20:382-384)

A Case of Hepatic Portal Venous Gas: Hypothesis of a Transient Direct Communication between a Penetrating Antral Gastric Ulcer and Mesenteric Varices

Hepatic portal venous gas (HPVG) is a rare radiological sign that usually signifies an acute intra-abdominal process, most commonly bowel ischemia and sepsis. Few reports described an association with underlying gastric pathologies. We report a 60-year-old patient who presented with melena and chills and was discovered to have a gastric ulcer that appeared to have penetrated into a mesenteric varix. This, in turn, likely caused development of HPVG associated with fungemia. Treatment with a proton pump inhibitor and bowel rest was sufficient to resolve symptoms and the HPVG.

Hepatic portal venous gas in pancreatic solitary metastasis from an esophageal squamous cell carcinoma

BACKGROUND

Hepatic portal venous gas (HPVG) is a rare entity commonly associated with intestinal necrosis and fatal outcome, and various underlying diseases have been reported. Pancreatic solitary metastasis without local extension is also rare in esophageal squamous cell carcinoma.

METHODS

This report describes an interesting and unusual case of HPVG arising from pancreatic tumor. Autopsy revealed pathogenesis of HPVG and synchronous tumors of the esophagus and pancreas.

RESULTS

A 73-year-old man developed synchronous double tumor in the esophagus and pancreas several months before acute abdomen and his death, which were generated by HPVG. Autopsy revealed that HPVG was caused by gastric wall infarction owing to expansion of an isolated pancreatic metastasis from esophageal squamous cell carcinoma.

CONCLUSIONS

This is the first case of HPVG that was derived from pancreatic tumor infiltration. If he had been diagnosed with solitary pancreatic metastasis from esophageal squamous cell carcinoma in the first time, he might have an option for chemotherapy, which could let him live longer.

Portomesenteric venous gas: is gas distribution linked to etiology and outcome?

PURPOSE

To investigate various anatomical locations of portomesenteric venous gas detected by computed tomography (CT) and their relationship with the underlying etiology and the outcome.

METHODS

The study group consisted of 47 cases with evidence of portomesenteric venous gas detected on abdominal CT examinations, 12 cases were identified through a retrospective PACS search, 35 were prospectively included. The presence of gas at specific anatomical locations in the portomesenteric venous vasculature was assessed according to a pre-defined classification: the arcade vessels close to the bowel segments followed by segmental vessels, the superior mesenteric vein, the extra- and intrahepatic portal vein. The etiology of portomesenteric venous gas and its prognosis were assessed by review of surgical reports, histopathology and medical records. Surgery was performed on 30 patients.

RESULTS

Overall 68.1% of cases were of ischemic etiology. Gas present in the arcade vessels was the best indicator for ischemia (sensitivity 93.8%; specificity 70.0%, positive predictive value 90.9%, negative predictive value 77.8%) compared to other locations and the mere presence of portomesenteric gas independent from the location. The overall mortality rate was 53.2%. Only gas in the arcade and segmental vessels were associated with considerably higher mortality rates (65.8% and 75.0%, respectively) and acceptable frequency (occurrence in 80.9% and 59.6%, respectively).

CONCLUSIONS

The study results indicate that the presence of gas at specific anatomical locations in the portomesenteric venous system, namely the arcade and segmental vessels, may serve as strong indicator for ischemic etiology and poor prognosis in the assessment of individual cases.

Sonographic detection of transient gas in the portal vein in an infant following abdominal surgery: a possible sign of adhesive small bowel obstruction

We present a case of sonographically detected transient gas in the portal vein in a 4.5-month-old infant who had a history of two consecutive jejunectomies due to jejunal stenoses and was admitted to our hospital with clinical and laboratory findings consistent with a subacute small bowel obstruction and dehydration. Sonography excluded other pathologies and the patient was treated conservatively with success. The presence of gas in the portal vein could be a sign of an underlying mechanical obstacle, as another episode of small bowel obstruction 1 month later required surgical treatment of adhesive intestinal obstruction.

A rare case of portal vein gas: accidental hydrogen peroxide ingestion

Hydrogen peroxide (H(2)O(2)) is a colourless and odourless liquid with oxidant characteristics used for various purposes. Whereas in lower concentrations (3%), H(2)O(2) is used as a disinfectant in home cleaning products and wound care, in higher concentrations (35%) it is used in textile and paper industry as a bleaching agent and is diluted for use in lightening hair dyes. Like other caustic substances, direct injuries may develop if H(2)O(2) is swallowed and systemic air embolisms may occur due to the resultant gaseous oxygen. This study discusses a patient who was detected with the presence of gas in the portal venous system due to H(2)O(2) intoxication and was treated conservatively.

Portal venous gas: is it a premorbid indicator?

A 72-year-old Caucasian man presented with subtle and insidious symptoms of pain in the left iliac fossa and vomiting. The first clinical impression was of diverticulitis but he did not improve with conservative management. An initial contrast tomography (CT) scan demonstrated no diagnostic features. Four days later, a repeat CT scan demonstrated intramural gas in the ascending colon and in the intrahepatic portal venous radicles. There was a thrombus in the superior mesenteric artery with infarction of the caecum and ascending colon. An urgent right hemicolectomy was carried out. Although there was resolution of the thrombus and air in the portal system, the patient died 8 days later from intestinal haemorrhage.

Pneumatosis intestinalis versus pseudo-pneumatosis: review of CT findings and differentiation

Pneumatosis intestinalis is defined as the presence of gas within the wall of the gastrointestinal tract. Originally described on plain abdominal radiographs, it is an imaging sign rather than a specific diagnosis and it is associated with both benign and life-threatening clinical conditions. The most common life-threatening cause of pneumatosis intestinalis is bowel ischaemia. Computed tomography (CT) is usually requested to detect underlying disease. The presence of pneumatosis intestinalis often leads physicians to make a diagnosis of serious disease. However, an erroneous diagnosis of pneumatosis intestinalis may be made (i.e. pseudo-pneumatosis) when intraluminal beads of gas are trapped within or between faeces and adjacent mucosal folds. The purpose of this pictorial essay is to review and describe the CT imaging findings of pneumatosis and pseudo-pneumatosis intestinalis and to discuss key discriminatory imaging features.

Portal gas in a diabetic patient under pharmacotherapy with an alpha-glucosidase inhibitor: report of a case with emphasis on US findings

Portal gas is relatively rare, and its relation to ischemic bowel diseases has been emphasized. We report the case of a 56-year-old diabetic man under pharmacotherapy with an alpha-glucosidase inhibitor in which portal gas was incidentally detected by ultrasound (US). It showed multiple echo spots moving in the portal vein. Doppler signals confirmed them to be bidirectional and spiky, which immediately led to the diagnosis of portal gas. A change in oral antidiabetic drug caused the portal gas to disappear. We stress the usefulness of US and Doppler US for detecting and diagnosing portal gas. Although detailed analysis of a larger series of diabetic patients under this therapy is needed to draw a definitive conclusion, our observation merits attention. We also briefly review the literature.

Natural history, clinical pattern, and surgical considerations of pneumatosis intestinalis

Objective

Pneumatosis intestinalis has been increasingly detected in recent years with the more frequent use of computed tomography for abdominal imaging of the intestine. The underlying causes of the gas found during radiographic studies of the bowel wall can vary widely and different hypotheses regarding its pathophysiology have been postulated. Pneumatosis intestinalis often represents a benign condition and should not be considered an argument for surgery. However, it can also require life-threatening surgery in some cases, and this can be a difficult decision in some patients.

Methods

The spectrum of pneumatosis intestinalis is discussed here based on various computed tomographic and surgical findings in patients who presented at our University Medical Centre in 2003-2008. We have also systematically reviewed the literature to establish the current understanding of its aetiology and pathophysiology, and the possible clinical conditions associated with pneumatosis intestinalis and their management.

Results

Pneumatosis intestinalis is a primary radiographic finding. After its diagnosis, its specific pathogenesis should be ascertained because the appropriate therapy is related to the underlying cause of pneumatosis intestinalis, and this is sometimes difficult to define. Surgical treatment should be considered urgent in symptomatic patients presenting with an acute abdomen, signs of ischemia, or bowel obstruction. In asymptomatic patients with otherwise inconspicuous findings, the underlying disease should be treated first, rather than urgent exploratory surgery considered. Extensive and comprehensive information on the pathophysiology and clinical findings of pneumatosis intestinalis is provided here and is incorporated into a treatment algorithm.

Conclusions

The information presented here allows a better understanding of the radiographic diagnosis and underlying aetiology of pneumatosis intestinalis, and may facilitate the decision-making process in this context, thus providing fast and adequate therapy to particular patients.

Fatal systemic venous air embolism during endoscopic retrograde cholangiopancreatography

Hepatic portal venous air embolism is the rarest complication of gastrointestinal endoscopy, resulting from penetration of gas into the portal veins, and may occur during endoscopic retrograde cholangiopancreatography and endoscopic biliary sphincterotomy. The likely mechanism is intramural dissection of insufflated air into the portal venous system through duodenal vein radicles transected during the procedure. Hepatic portal air embolism may be fatal. Cerebral air embolism may also occur. So far 13 cases of air embolism after endoscopic retrograde cholangiopancreatography have been reported, with 4 cases of systemic spread that proved fatal. Death was due to pulmonary air embolism in 2 cases, and cerebral air embolism in another 2. We report on an additional such fatal case, concerning a 78-year-old male patient, who several years previously had undergone surgical gastroduodenal resection with cholecystectomy and papillotomy, and was admitted for recurrent ascending cholangitis secondary to bile duct stones. During the third endoscopic cholangioscopic procedure for removal of bile duct stones, sudden cardiopulmonary arrest occurred. Death was due to massive pulmonary air embolism. Cerebral air embolism was also found. Autopsy was performed. A spontaneous duodenobiliary fistula was found. On the basis of bench radiologic investigation (retrograde suprahepatic venography and anterograde portography), it was demonstrated that the air insufflated during duodenal endoscopy, which entered through the spontaneous duodeno-biliary fistula, penetrated into intrahepatic vein radicles injured secondarily to prolonged impaction of biliary sand and stones and infection, resulting in portal and hepatic venous gas and systemic air embolism.

[Linear or bubbly: a pictorial review of CT features of intestinal pneumatosis in adults]

Pneumatosis intestinalis is a rare condition, which is defined by the presence of gas within the bowel wall. In adult patients, pneumatosis intestinalis can be depicted in various circumstances. Owing to the routine use of CT to investigate patients with abdominal pain, pneumatosis intestinalis can be seen as an incidental finding or can be observed in association with a life-threatening disease such as bowel infarction. On CT images, pneumatosis intestinalis can display two different appearances; one that has a cystic or bubbly appearance can be considered as a chronic pneumatosis and is suggestive for a benign cause while the other, which has a linear appearance can be considered as a symptom and is more frequently secondary to a life-threatening cause. However, none of these two CT characteristics can be considered pathognomonic for any of these two categories of causes. In such situations, the analysis of the location, extent and, if any, associated findings may help to differentiate between benign and life-threatening causes. In these patients who present with abdominal signs that mimic symptoms that would warrant surgical exploration, the analysis of associated findings is critical to rule out a life-threatening cause of pneumatosis intestinalis and to obviate the need for unnecessary laparotomy. In adult patients with a known specific disease such as celiac disease, chronic pseudointestinal obstruction or other chronic diseases, even with accompanying pneumoperitoneum, pneumatosis intestinalis does not uniformly mandate surgical exploration. This pictorial review presents the more and the less common pneumatosis intestinalis CT features in adult patients, with the aim of making the reader more familiar with this potentially misleading sign.

Flaming portal vein as a new color Doppler sign of portal gas: report of two cases

Portal gas is relatively rare, and the majority of reported cases have shown it to have a close relation to bowel diseases. At present, portal exploration usually begins with color Doppler sonography, and clinicians now possess a good understanding of color Doppler findings of a wide spectrum of portal abnormalities. However, the color Doppler sign we present in this article has not been reported before. We report two cases of ischemic bowel disease in which B-mode ultrasound showed multiple hyperechoic spots moving in the portal vein; the color Doppler appearance was as if the portal vein was on fire (flaming portal vein sign). Knowledge of this simple color Doppler sign helps to improve the diagnostic strategies in patients with portal gas.

Portal vein gas in emergency surgery

Background

Portal vein gas is an ominous radiological sign, which indicates a serious gastrointestinal problem in the majority of patients. Many causes have been identified and the most important was bowel ischemia and mesenteric vascular accident. The presentation of patients is varied and the diagnosis of the underlying problem depends mainly on the radiological findings and clinical signs. The aim of this article is to show the clinical importance of portal vein gas and its management in emergency surgery.

Methods

A computerised search was made of the Medline for publications discussing portal vein gas through March 2008. Sixty articles were identified and selected for this review because of their relevance. These articles cover a period from 1975–2008.

Results

Two hundreds and seventy-five patients with gas in the portal venous system were reported. The commonest cause for portal vein gas was bowel ischemia and mesenteric vascular pathology (61.44%). This was followed by inflammation of the gastrointestinal tract (16.26%), obstruction and dilatation (9.03%), sepsis (6.6%), iatrogenic injury and trauma (3.01%) and cancer (1.8%). Idiopathic portal vein gas was also reported (1.8%).

Conclusion

Portal vein gas is a diagnostic sign, which indicates a serious intra-abdominal pathology requiring emergency surgery in the majority of patients. Portal vein gas due to simple and benign cause can be treated conservatively. Correlation between clinical and diagnostic findings is important to set the management plan.

A case of portal venous gas after extracorporeal shockwave lithotripsy and obstructive pyelonephritis

The presence of gas in the portal venous system is considered an ominous sign often mandating immediate exploratory laparotomy; however, there are numerous reports of benign incidences of this finding. This report describes a case of portal venous gas after extracorporeal shockwave lithotripsy. The patient had the rare complication of obstructive pyleonephritis that progressed to sepsis and subsequently underwent a negative exploratory laparotomy. It is suggested that the radiographic finding of portal venous gas should be correlated with the likely cause and overall clinical picture.

Phenotyping Clostridium septicum infection: a surgeon's infectious disease

BACKGROUND

Clostridium septicum infection is associated with malignancy. Whether disease phenotype is affected by malignant status is not known. Surgical treatment is used frequently but its impact on survival has not been examined in a cohort >30 patients.

METHODS

A PubMed search of English language journal articles yielded 320 cases. Full information (infection location, cancer type, operative intervention, and survival) was available for 224 cases + 7 at our institution not previously reported.

RESULTS

Seventy-two percent of patients had malignancy or malady of the gastrointestinal (GI) or hematologic (HEME) organ systems. HEME survival was inferior to GI survival (35% versus 55%, P = 0.03). Overall, patients who underwent operation had improved survival (57% versus 26%; P < 0.0001) and this association was maintained within GI and HEME cohorts (P = 0.002 and 0.005, respectively). More GI than HEME patients underwent operation (81% versus 51%, P < 0.001). GI patients were more likely than HEME patients to experience infection of skin and soft tissues (SSTI, P = 0.006). Diabetics were more likely to experience SSTI than nondiabetics (77% versus 45%, P < 0.001).

CONCLUSIONS

C. septicum infectious phenotype varies with host milieu. The SSTI phenotype is more common in GI and diabetic patients. This recognition may aid in directing the search for occult malignancy, which must be performed given the >70% incidence of concomitant cancer. This infection is more fatal in HEME versus GI patients, perhaps due in part to less HEME group operative intervention. Primary surgical therapy should be considered in GI or HEME patients as operative intervention benefits both groups.

Portal gas in a patient with acute obstructive cholangitis: report of a case with emphasis on US findings

Portal gas is relatively rare, and its relationship to ischemic bowel diseases has been emphasized. We report the case of a 70-year-old woman with acute obstructive cholangitis in whom portal gas was detected by ultrasonography (US) but not by computed tomography (CT). The former showed multiple echo spots moving in the portal vein. Doppler signals confirmed them to be bidirectional and spiky, which immediately led to the diagnosis of portal gas. Immediate appropriate antibiotic treatment and biliary drainage yielded the disappearance of the portal gas. We stress the usefulness of US and Doppler US for detecting and diagnosing portal gas. Our observation suggests that when portal gas is detected by US, the possibility of cholangitis should be included in the differential diagnosis.

Intermittent hepatic portal vein gas complicating diverticulitis--a case report and literature review

CASE REPORT

This report describes a case of intermittent hepatic portal venous gas (HPVG) because of colonic diverticulitis in a 48-year-old man, who was successfully treated by surgery.

CONCLUSION

Based on an extensive literature search, which produced 21 observations, the etiology, symptoms, imaging features, clinical significance, treatment strategy, and outcome of HPVG because of colonic diverticulitis are evaluated: While observations with an underlying intramesocolic abscess carry a favorable prognosis, the prognosis of observations because of septic thrombophlebitis with gas forming germs is poor.

Hepatic portal venous gas: a report of two cases and a review of the epidemiology, pathogenesis, diagnosis and approach to management

BACKGROUND

Hepatic portal venous gas (HPVG) is a rare condition that occurs when intraluminal gas and/or gas produced by intestinal bacteria enters the portal venous circulation. The most common precipitating factors include ischemia, intra-abdominal abscesses and inflammatory bowel disease. However, HPVG has recently been recognized as a rare complication of endoscopic and radiological procedures. Earlier studies advised immediate surgical intervention, but according to current recommendations, in some settings, HPVG can be managed conservatively. The present study reports two cases of HPVG; one that occurred following colonoscopy in a patient with severe Crohn's disease and one in a patient with graft-versus-host disease.

METHODS

The epidemiology, pathogenesis, diagnosis and management of HPVG are reviewed. Two case reports are presented, followed by the development of a management algorithm.

RESULTS

Of the two patients that developed HPVG, one was an outpatient undergoing a colonoscopy for assessment of Crohn's disease activity and the other was an inpatient with graft-versus-host disease. Once the diagnosis of HPVG was made, both patients were managed conservatively with antibiotic therapy and management of their underlying disease.

CONCLUSIONS

HPVG can occur in the setting of severe gastrointestinal disease states and following endoscopic procedures. It is critical that gastroenterologists are aware of the differential diagnosis, pathogenesis, diagnostic approach and management of HPVG.

Pneumatosis intestinalis in the adult: benign to life-threatening causes

OBJECTIVE

The frequency of detection of pneumatosis intestinalis (PI) appears to be increasing. This increase may be the result of increased CT use. New medications and surgical procedures have been reported to be associated with an increase in the incidence of PI. The purpose of this review is to provide an update on the imaging features and clinical conditions associated with PI.

CONCLUSION

This article illustrates the imaging findings of PI due to benign and life-threatening causes, with emphasis placed on describing newly associated conditions and also the imaging appearance on CT.

Portal venous gas--case report and review of the literature

A 74-year-old man with chronic renal failure was admitted to the renal unit with non-specific symptoms and positive blood cultures. He later deteriorated and was admitted to the Intensive Care Unit with septic shock, respiratory failure and deranged liver function. Initial improvement was followed by abdominal distension and discomfort. Portal venous gas (PVG) and thrombosis were diagnosed on computed tomography. A conservative line of management was adopted. Improvement was soon followed by deterioration with septic shock. Extensive portal venous gas and free intra-abdominal gas were now evident on repeat computed tomography. The patient was too unwell to withstand surgery and a decision was made not to escalate therapy. He died on day 16. Portal venous gas is not a disease; it is a diagnostic clue in patients who may be harbouring an intra-abdominal catastrophe. Successful management of these cases requires early identification of the underlying pathology and can range from simple observation to extensive surgical intervention.

[Hepatic portal venous gas. Clinical significance and review of the literature]

Hepatic portal venous gas in adults is a rare entity. The most frequent cause is intestinal ischemia. However, an increasing number of cases associated with benign conditions suitable for conservative treatment are being reported. We review the literature to define the clinical significance of portal venous gas, the role of computed tomography, and the need to perform emergency exploratory laparotomy.

Detection of hepatic portal venous gas: its clinical impact and outcome

The clinical impact and outcome of a rare radiographic finding of hepatic portal venous gas (HPVG) as well as the effectiveness of computed tomography (CT), CT scanogram, and conventional radiography in the detection of HPVG were retrospectively analyzed. CT scans, CT scanogram, and plain film radiographs of 11 patients with HPVG were reviewed and compared with their medical records and surgical and pathology reports. Eight of the 11 patients underwent plain film radiographs 1 day before or after the CT scan. HPVG was detected at CT in all 11 patients, on CT scanogram in three (3 of 11, 27.3%), and on plain films in one (one of eight, 12.5%). In nine of 11 patients (81.8%), CT revealed an associated pneumatosis intestinalis. In six of the 11 patients (54.6%), acute mesenteric ischemia was the underlying disease for HPVG. Seven patients (63.6%) underwent emergency exploratory laparotomy. The mortality rate for HPVG alone was 27.3% (3 of 11) and for HPVG related to mesenteric bowel disease 50% (three of six). Acute mesenteric ischemia is the most common cause of HPVG, which continues to have a predictably higher mortality. CT is superior to CT scanograms and radiographs in the detection of HPVG and its underlying diseases and, therefore, should be used as the primary diagnostic tool.

Sister Joseph's Nodule and pneumatosis: A rare presentation of ovarian cancer

BACKGROUND

The condition of pneumatosis intestinalis is characterized by gas in the intestinal wall, with a variety of causes.

CASE

A septic patient with intestinal pneumatosis, locally advanced ovarian cancer, and Sister Joseph's Nodule.

CONCLUSION

The clinical significance of this rare combination of symptoms and signs is discussed.

Hepatic portal venous gas: clinical significance of computed tomography findings

Hepatic portal venous gas (HPVG) is a rare radiographic finding of significance. Most cases with HPVG are related to mesenteric ischemia that have been associated with extended bowel necrosis and fatal outcome. With the help of computed tomography (CT) in early diagnosis of HPVG, the clinical outcome of patients with mesenteric ischemia has improved. There has been also an increasing rate of detection of HPVG with certain nonischemic conditions. In this report, we present two cases demonstrating HPVG unrelated to mesenteric ischemia. One patient with cholangitis presented abdominal pain with local peritonitis and survived after appropriate antibiotic treatment. Laparotomy was avoided as a result of lack of CT evidence of ischemic bowel disease besides the presence of HPVG. The other case had severe enteritis. Although his CT finding preluded ischemic bowel disease, conservative treatment was implemented because of the absence of peritoneal signs or clinical toxic symptoms. Therefore, whenever HPVG is detected on CT, urgent exploratory laparotomy is only mandatory in a patient with whom intestinal ischemia or infarction is suspected on the basis of radiologic and clinical findings. On the other hand, unnecessary exploratory laparotomy should be avoided in nonischemic conditions that are usually associated with a better clinical outcome if appropriate therapy is prompted for the underlying diseases. Patients with radiographic diagnosis of HPVG should receive a detailed history review and physical examination. The patient's underlying condition should be determined to provide a solid ground for exploratory laparotomy. A flow chart is presented for facilitating the management of patients with HPVG in the ED.

Case report. Hepatic portal venous gas: transient radiographic finding associated with colchicine toxicity

Hepatic portal venous gas has traditionally been associated with a grave prognosis and high mortality. However, with the advent of ultrasound and CT, numerous less serious causes have been associated with this dramatic radiological finding. We present a previously unreported association with colchicine toxicity. The patient ingested a large dose of colchicine and was subsequently found to have portal venous gas on CT. The source of gas was felt to be intestinal gas penetrating through the demonstrated bowel injury. No surgical intervention was deemed necessary and the finding resolved spontaneously.

Acute small bowel ischemia: CT imaging findings

Small bowel ischemia is a disorder related to a variety of conditions resulting in interruption or reduction of the blood supply of the small intestine. It may present with various clinical and radiologic manifestations, and ranges pathologically from localized transient ischemia to catastrophic necrosis of the intestinal tract. The primary causes of insufficient blood flow to the small intestine are various and include thromboembolism (50% of cases), nonocclusive causes, bowel obstruction, neoplasms, vasculitis, abdominal inflammatory conditions, trauma, chemotherapy, radiation, and corrosive injury. Computed tomography (CT) can demonstrate changes because of ischemic bowel accurately, may be helpful in determining the primary cause of ischemia, and can demonstrate important coexistent findings or complications. However, common CT findings in acute small bowel ischemia are not specific and, therefore, it is often a combination of clinical, laboratory and radiologic signs that may lead to a correct diagnosis. Understanding the pathogenesis of various conditions leading to mesenteric ischemia and being familiar with the spectrum of diagnostic CT signs may help the radiologist recognize ischemic small bowel disease and avoid delayed diagnosis. The aim of this article is to provide a review of the pathogenesis and various causes of acute small bowel ischemia and to demonstrate the contribution of CT in the diagnosis of this complex disease.