Extensive Portal Venous Gas and Pneumatosis Intestinalis in the Absence of Small Bowel Ischemia or Infarction

Abstract Background Pneumatosis intestinalis has long been a marker of advanced bowel ischemia and prompts urgent laparotomy. In post-operative settings, the presence of pneumatosis represents a significant management dilemma. We share a case-series of post-esophagectomy patients with pneumatosis intestinalis and no corollary intra-abdominal pathologic findings on re-exploration. Methods January 2000 to December 2017, 1760 patients underwent Ivor-Lewis esophagectomy or gastrectomy with jejunostomy-tube placement. Charts were reviewed retrospectively to identify patients with pneumatosis intestinalis discovered in the post-operative period. Demographic data, operative details and postoperative course were reviewed including incidence and details of re-exploration. Results Eleven patients met inclusion criteria. Nine were male (81.8%) and mean age was 69 years. All patients had radiographic confirmation of pneumatosis intestinalis and in many cases portal venous gas (Figure 1). Clinical course was variable without discernable trends in vitals or laboratory values. Development of significant postoperative ileus along with delivery of enteral tube feeds through a jejunostomy tube preceded development of the pneumatosis in all patients. Nine patients were re-explored and none had evidence of bowel ischemia. Conclusion The finding of pneumatosis intestinalis in the post-operative setting can be alarming and pose a management dilemma. With the advent of improved and readily available imaging, there has been an increase in findings that have no corollary physical symptomatology. In this series of patients, despite dramatic radiographic findings, none had ischemic bowel. Pneumatosis intestinalis alone in patients who have undergone esophagectomy should not be considered an indication for emergency re-exploration. Disclosure All authors have declared no conflicts of interest.

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Pneumatosis Intestinalis Presenting as Small Bowel Obstruction without Bowel Ischemia after Mechanical Ventilation

Acute and Critical Care ◽

10.4266/acc.2016.00311 ◽

2019 ◽

Vol 34 (1) ◽

pp. 81-85

Author(s):

Dong Joon Kim ◽

Yong Joon Choi ◽

Young Sun Yoo

Keyword(s):

Mechanical Ventilation ◽

Small Bowel ◽

Small Bowel Obstruction ◽

Bowel Obstruction ◽

Pneumatosis Intestinalis ◽

Bowel Ischemia

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Massive Portal Venous Gas Related to Small Bowel Ischemia

The American Journal of Gastroenterology ◽

10.14309/00000434-201110002-00729 ◽

2011 ◽

Vol 106 ◽

pp. S275

Author(s):

Noel Yarze ◽

Joseph Yarze

Keyword(s):

Small Bowel ◽

Bowel Ischemia ◽

Portal Venous Gas

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Portomesenteric Venous System Gas after CT Colonography: A Case Report

Case Reports in Radiology ◽

10.1155/2012/420901 ◽

2012 ◽

Vol 2012 ◽

pp. 1-3

Author(s):

Ilaria Sansoni ◽

Claudia Lucia Piccolo ◽

Ilenia Di Giampietro ◽

Matteo Polacco ◽

Bruno Beomonte Zobel

Keyword(s):

Ct Scan ◽

Ct Colonography ◽

Pneumatosis Intestinalis ◽

Clinical Findings ◽

Bowel Ischemia ◽

Colonic Perforation ◽

Venous System ◽

Portal Venous System ◽

Portal Venous Gas ◽

Mucosal Integrity

Portomesenteric vein gas can occur owing to a variety of interraleted factors such as loss of mucosal integrity and intraluminal overpressure, and the most common and serious cause is bowel ischemia, which requires urgent laparotomy. Nevertheless, when portal venous gas is caused by nonischemic causes, surgery is not required and it can be treated conservatively. So, its features should be carefully evaluated at CT scan, together with clinical findings. The authors report a case of an old male with portomesenteric venous system gas after CT colonography, without evidence of pneumatosis intestinalis or colonic perforation. A CT scan without enema was required after 24 hours in absence of worsened patient conditions, revealing the disappearance of gas in mesenteric vein and in the portal venous system.

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Pneumatosis Intestinalis and Portal Venous Gas Without Bowel Ischemia in a Patient Treated with Irinotecan and Cisplatin

Digestive Diseases and Sciences ◽

10.1007/s10620-007-9846-9 ◽

2007 ◽

Vol 53 (1) ◽

pp. 217-219 ◽

Cited By ~ 19

Author(s):

David Kung ◽

Daniel T Ruan ◽

Rodney K. Chan ◽

Melissa L. Ericsson ◽

Mandeep S. Saund

Keyword(s):

Pneumatosis Intestinalis ◽

Bowel Ischemia ◽

Portal Venous Gas

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Association of Contrast-Enhanced CT Findings with Etiology and Outcome in Patients with Portal Venous Gas and Pneumatosis Intestinalis: A Single Center Case Series Study

10.21203/rs.3.rs-533515/v1 ◽

2021 ◽

Author(s):

Naohiro Yoshida ◽

Yoshihiko Sadakari ◽

Kazuhito Tamehiro ◽

Kazuma Ohkawara ◽

Hiroyuki Nakane ◽

...

Keyword(s):

Surgical Treatment ◽

Pneumatosis Intestinalis ◽

Bowel Ischemia ◽

Portal Venous Gas ◽

Ct Findings ◽

Contrast Enhanced Ct ◽

Contrast Enhanced ◽

Enhanced Ct ◽

The Relationship ◽

Group 1

Abstract Background: Contrast-enhanced computed tomography (CT) is a reliable diagnostic tool often used to investigate the etiology of portal venous gas (PVG) and pneumatosis intestinalis (PI). However, there are few reports that offer an analysis of the relationship between particular CT findings and clinical outcomes. In this paper, we sought to close that gap and present the results of our analyses that reveal which CT findings are correlated with life-threatening cases.Methods: 39 patients were diagnosed with PVG or PI from contrast-enhanced CT scans and underwent treatment at St. Mary’s Hospital from January 2009 to December 2018. We reviewed patients’ medical charts, laboratory data, and CT scan images retrospectively. We defined cases resulting in operation or death as group 1, and patients with conservative treatment who survived as group 2. We then analyzed the relationship between each CT finding and clinical feature.Results: The primary underlying diseases identified for PVG and PI were bowel ischemia (13/39), enteritis (9/39), constipation (5/39), iatrogenic disease (4/39), and hemodialysis (3/39). Poor enhancement of the intestinal wall and extrahepatic venous gas were correlated with bowel ischemia (p=0.0002 and p=0.0003, respectively). Free air was less correlated with bowel ischemia (p=0.02). Wall thickness was correlated with enteritis (p=0.02). Mortality in cases with bowel ischemia and perforation was quite high (60%) even if patients underwent surgery (33.3%). Conversely, patients with enteritis, constipation, hemodialysis and gastric dilatation who did not require surgery resulted in more favorable outcomes with conservative treatment. In the multivariate analysis, extra hepatic venous gas was the only solitary factor correlated with group 1 (p=0.0008).Conclusions: Extra hepatic venous gas was the strongest predictive factor of clinical outcome in contrast-enhanced CT findings correlated with bowel ischemia and required surgical treatment. The other CT findings were useful in diagnosing the underlying disease, but were not correlated with clinical outcomes. The necessity for surgical treatment remains dependent on the root cause.

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