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Portal Venous Gas and Pneumatosis Intestinalis in Necrotizing Pancreatitis
ELECTRONIC IMAGE OF THE MONTH Portal Venous Gas and Pneumatosis Intestinalis in Necrotizing Pancreatitis Albert C. Y. Chan* and Ronnie T. P. Poon*,‡ *Division of Hepatobiliary and Pancreatic Surgery and Liver Transplantation, Department of Surgery, and ‡State Key Laboratory for Liver Research, The University of Hong Kong, Hong Kong
75-year-old man presented with acute epigastric pain. The physical examination revealed epigastric tenderness. The complete blood profile revealed a white cell count of 1.05 109/L and a platelet count of 18 109/L. His serum amylase was 2298 U/L, lipase was 4000 U/L, and lactate dehydrogenase was 256 U/L. The Glasgow score was 4. Computed tomography showed necrosis in the body of the pancreas (Figure A, arrow) and gas in the terminal branch of right portal vein (Figure B, arrow). The stomach (Figure C) and small bowels (Figure D, arrow) were also filled with an abundant subserosal layer of gas. Because of increasing generalized peritonitis, laparotomy was performed, which confirmed fresh necrosis at the body of the pancreas with saponification of the root of small bowel
A
mesentery (Figure E, arrow). The stomach and the entire small bowel, however, were completely viable. Peritoneal lavage was subsequently performed, and the patient gradually recovered after the operation. Pneumatosis intestinalis is defined as gas in the bowel wall and is regarded as a sign rather than a diagnosis. The presence of hepatic portal venous gas in conjunction with pneumatosis intestinalis often signifies full-thickness bowel wall infarction. However, they are also associated with a variety of nonischemic conditions, such as mesenteric abscess, inflammatory bowel disease, diverticulitis, and trauma.1 Its association with necrotizing pancreatitis is uncommon but confers high mortality.2,3 Management should depend on the patient’s general condition rather than the radiologic findings and Clinical Gastroenterology and Hepatology 2014;-:-–-
ELECTRONIC IMAGE OF THE MONTH, continued mandates surgery to exclude gut ischemia if the condition deteriorates.
3.
Park HC, Lee WS, Joo SY, et al. Hepatic portal venous gas associated with acute pancreatitis: reports of two cases and review of literature. Korean J Gastroenterol 2007;50:131–135.
References 1.
Ho LM, Paulson EK, Thompson WM. Pneumatosis intestinalis in the adult: benign to life-threatening causes. AJR Am J Roentgenol 2007;188:1604–1613.
2.
Wu JM, Wang MY. Hepatic portal venous gas in necrotizing pancreatitis. Dig Surg 2009;26:119–120.
e2
Conflicts of interest The authors disclose no conflicts. © 2014 by the AGA Institute 1542-3565/$36.00 http://dx.doi.org/10.1016/j.cgh.2013.10.010
75-year-old man presented with acute epigastric pain. The physical examination revealed epigastric tenderness. The complete blood profile revealed a white cell count of 1.05 109/L and a platelet count of 18 109/L. His serum amylase was 2298 U/L, lipase was 4000 U/L, and lactate dehydrogenase was 256 U/L. The Glasgow score was 4. Computed tomography showed necrosis in the body of the pancreas (Figure A, arrow) and gas in the terminal branch of right portal vein (Figure B, arrow). The stomach (Figure C) and small bowels (Figure D, arrow) were also filled with an abundant subserosal layer of gas. Because of increasing generalized peritonitis, laparotomy was performed, which confirmed fresh necrosis at the body of the pancreas with saponification of the root of small bowel
A
mesentery (Figure E, arrow). The stomach and the entire small bowel, however, were completely viable. Peritoneal lavage was subsequently performed, and the patient gradually recovered after the operation. Pneumatosis intestinalis is defined as gas in the bowel wall and is regarded as a sign rather than a diagnosis. The presence of hepatic portal venous gas in conjunction with pneumatosis intestinalis often signifies full-thickness bowel wall infarction. However, they are also associated with a variety of nonischemic conditions, such as mesenteric abscess, inflammatory bowel disease, diverticulitis, and trauma.1 Its association with necrotizing pancreatitis is uncommon but confers high mortality.2,3 Management should depend on the patient’s general condition rather than the radiologic findings and Clinical Gastroenterology and Hepatology 2014;-:-–-
ELECTRONIC IMAGE OF THE MONTH, continued mandates surgery to exclude gut ischemia if the condition deteriorates.
3.
Park HC, Lee WS, Joo SY, et al. Hepatic portal venous gas associated with acute pancreatitis: reports of two cases and review of literature. Korean J Gastroenterol 2007;50:131–135.
References 1.
Ho LM, Paulson EK, Thompson WM. Pneumatosis intestinalis in the adult: benign to life-threatening causes. AJR Am J Roentgenol 2007;188:1604–1613.
2.
Wu JM, Wang MY. Hepatic portal venous gas in necrotizing pancreatitis. Dig Surg 2009;26:119–120.
e2
Conflicts of interest The authors disclose no conflicts. © 2014 by the AGA Institute 1542-3565/$36.00 http://dx.doi.org/10.1016/j.cgh.2013.10.010