A Case of Intratumoral and Hepatic Portal Venous Gas in Patient with Gastric Cancer Liver Metastases

Background: Hepatic portal venous gas [HPVG] is not a common finding in daily practice. It is usually associated with mesenteric ischemia and bowel necrosis in adults. Combination of intratumoral gas in metastatic liver lesions with HPVG is quite rare and thought to be associated with chemotherapy-induced necrosis and infection of the necrotized metastasis. Objective: Here we present a case of gastric adenocarcinoma with portal venous and intratumoral gas in metastatic liver lesions due to the infected necrosis. Case Presentation: The patient was presented to the emergency room with severe abdominal pain and septic condition after the second round of chemotherapy. Hepatic portal venous and intratumoral gas in metastatic liver lesions due to the infected necrosis of liver metastasis was detected in computed tomography images. There were no findings of mesenteric ischemia both clinically and radiologically. Massive intratumoral infected necrosis in metastatic liver lesions and fistulization to the right portal vein branches were detected on abdominopelvic CT. Secondary infection of the necrotic metastases and fistulization to portal vein branches was believed to cause the air in metastatic liver masses and portal venous gas. Conclusion: Infected necrosis of metastatic liver lesions and fistulizations to the portal venous structures is extremely rare. Clinicians and radiologists should be aware of such a rare complication because early detection is crucial for patient management.

SP3.1.17 Assessment of the utility of CT to predict the requirement for resection at laparotomy in patients presenting with acute mesenteric arterial insufficiency

Introduction Mesenteric ischaemia as a consequence of arterial atherosclerosis is associated with significant morbidity and mortality. Practice has been influenced by the rise in cross-sectional imaging. In Glasgow a policy of laparotomy for patients presenting with acute mesenteric ischaemia at the time of mesenteric revascularisation has been adopted. We have sought to define whether CT can predict visceral necrosis and a requirement for tissue resection at the primary revascularisation. Methods This was a retrospective review of interventions performed for mesenteric ischaemia. Radiological variables described in the context of mesenteric ischaemia were defined. The primary CT report was reviewed to define whether these features were recorded and whether a diagnosis of mesenteric ischaemia was suggested. Imaging was then retrospectively reviewed with reference to the dataset by a radiologist. The radiologist was asked to offer a subjective opinion as to whether there was mesenteric infarction. These data were compared with laparotomy findings. Results There were 129 interventions performed for mesenteric ischaemia over the study period and 147 laparotomies. There was no specific radiological variable that was consistently reported in the primary or secondary CT review. However when bowel wall thinning, hypoattenuation or portal venous gas reported (independently) they seemed to be specific as in each case there was mesenteric infarction at laparotomy. Conclusion Even with retrospective radiological assessment there is no reliable feature that will predict mesenteric infarction and a requirement for tissue resection. As such a policy of laparotomy in patients who considered physiologically well enough would appear to be justified.