Education and imaging. Gastrointestinal: massive portal venous gas and pneumatosis intestinalis.

摘要

A 64-year-old schizophrenic man residing for 18 years in a psychiatric unit complained of acute abdominal pain. Because the patient was quite constipated and had impressive amounts of stool in his colon, a glycerol enema was given. The following day, as signs of shock were becoming evident, the patient was referred to us. The physical examination of abdomen did not show abnormal findings except for reduced abdominal sounds. Laboratory tests indicated slight anemia (hemoglobin, 10.9 g/dL) and acidosis (pH, 7.391; base excess, -3.2 mmol/L), an elevated white blood cell count (10,900/mm3) and creatine kinase (1342 U/L). An abdominal radiograph revealed massive small bowel gas and an abdominal computed tomography (CT) showed massive intra- (thin arrow in Figure 1 and 2) and extra- (thick arrow in Figure 2) hepatic gas, cholelithiasis (circle in Figure 2) and distended small bowel (Figure 3). Free air was not detected. Based on a diagnosis of massive portal and superior mesenteric venous gas, possibility of bowel ischemia and cholangitis with pneumobilia, emergency lap-arotomy was performed. It revealed serous ascites, edematous changes of the jejunal serosa and portal venous gas. Considering the possibility of pneumobilia, therefore, we performed a chole-cystectomy with cystic tube drainage and intra-abdominal-lavage. The patient had an uneventful postoperative course. Follow-up CT, performed 3 days postoperatively, confirmed resolution of the portal venous gas. Cultures of bile and ascites that were extracted intraoperatively were negative.