The n e w e ng l a n d j o u r na l of m e dic i n e

Images in Clinical Medicine

Chana A. Sacks, M.D., Editor

Portal Venous Gas

17 cm

A
72-year-old man presented to the emergency department with Ming Cui, M.D.
an 11-hour history of periumbilical abdominal pain and inability to pass Xin Lu, M.D.
flatus. His medical history included chronic lymphocytic leukemia (for Peking Union Medical College Hospital
which he had been taking ibrutinib), type 2 diabetes, and chronic hepatitis B virus Beijing, China
infection. The pulse was 155 beats per minute, and the blood pressure 83/52 mm Hg. luxinln@163.com
On physical examination, his abdomen was diffusely tender, with the most severe
pain in the right upper quadrant. Initial laboratory studies of the blood revealed a
white-cell count of 22,570 per cubic millimeter (reference range, 4000 to 10,000),
an arterial blood pH of 7.27 (reference range, 7.35 to 7.45), and a lactate level of
8 mmol per liter (72 mg per deciliter) (reference range, 0.5 to 1.7 mmol per liter
[4.5 to 15.3 mg per deciliter]). Computed tomography of the abdomen revealed
extensive portal venous gas, as well as gas in the bowel wall, which had an ap-
pearance consistent with ischemic bowel. Portal venous gas is most commonly
associated with bowel ischemia and is a poor prognostic sign in patients with that
condition; however, it can also develop in patients with other conditions, such as
infection or inflammatory bowel disease, or as a result of an interventional proce-
dure. Treatment was initiated with fluid resuscitation, broad-spectrum intravenous
antibiotics, and vasopressors, and an urgent laparotomy was planned. However,
the patient’s clinical condition deteriorated rapidly, and he died 2 hours after pre-
sentation.
DOI: 10.1056/NEJMicm1806082
Copyright © 2018 Massachusetts Medical Society.

n engl j med 379;21 nejm.org November 22, 2018 e37

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