Portomesenteric gas – emergent operation not always required

R. Wyss, H. Gelpke, F. Grieder, S. Breitenstein

Objective

Hepatic portal venous gas is usually associated with necrosis of the bowel and represents a life threatening situation. Mortality rates of more than 50% are described. Prognosis depends on pathogenesis and distribution of gas within the venous system. Immediate operation with bowel resection is required in the vast majority of cases. We present a case with successful delayed surgery in a semi-elective setting.

Methods

We present the case of a 62-year-old female with an acute intra- and retromesocolic perforated diverticulitis. As a comorbidity retroperitoneal fibrosis (M. Osmond) was known and treated with corticosteroids for several years.

Results

Due to slight unspecific abdominal pain during 5 days, the patient was admitted to our hospital. The general condition of the patient was normal. Abdominal symptoms (cramps) were very weak. Clinical examination showed no peritonitis and lab values showed a slight systemic inflammation: Leucocytes 3.1 x10^9, C-reactive protein (CRP) was 117 mg/l. Surprisingly excessive gas accumulation in the inferior mesenteric vein and the hepatic portal system was identified by the computed tomography (CT).

A conservative therapeutic approach with antibiotics was performed and a close monitoring was installed. Thereby an emergency operation could be prevented. After three days the gas accumulation in the hepatic portal venous system completely dissolved. In the further course, the patient remained stable and oligosymptomatic. However, after 8 days the patient felt aggravation of pain in the left lower quadrant and the CT-Scan showed an increase in air accumulation in the mesenteric venous system and a significantly elevated Procalcitonin Level. Therefore, we decided to perform a semi-elective open rectosigmoidectomy with descendorectostomy and diverting loop ileostomy. The perioperative course was uneventful, the patient was discharged 9 days postoperatively. The Ileostomy was restored after 3 Months.

Conclusion

Surgical treatment in case of gas in the portomesenteric system can be delayed in selective cases in order to prevent an emergency operation and install antibiotic treatment. Further studies are required to stratify the risk of mortality and adapt medical and surgical treatment accordingly.

Figure 1: excessive gas accumulation in the inferior mesenteric vein and the hepatic portal system
Figure 2: intra- and retromesocolic perforated diverticulitis
Figure 3: completely dissolved intrahepatic gas accumulation after 3 days
Figure 4: labor showing significant increase of Procalcitonin on the 8th day
Figure 5 and 6: recurrent air accumulation in the inferior mesenteric vein and pericolic