IMAGES IN CLINICAL MEDICINE

Portal Venous Gas

Ming Cui, and Xin Lu

N Engl J Med 2018; 379:e37

DOI: 10.1056/NEJMicm1806082

A 72-year-old man presented to the emergency department with an 11-hour history of periumbilical abdominal pain and inability to pass flatus. His medical history included chronic lymphocytic leukemia (for which he had been taking ibrutinib), type 2 diabetes, and chronic hepatitis B virus infection. The pulse was 155 beats per minute, and the blood pressure 83/52 mm Hg. 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 appearance 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 procedure. 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 presentation.

一名72岁男性患者因脐周疼痛、不能排气11小时到急诊就诊。患者既往罹患慢性淋巴细胞白血病（服用伊布替尼），2型糖尿病及慢性乙肝病毒感染。脉搏155次/分，血压83/52 mmHg。体检发现，腹部弥漫性压痛，最严重部位位于右上腹。初始实验室检查发现白细胞计数22,570/ml（正常值范围4000-10,000），动脉血pH 7.27（正常值范围7.35-7.45），乳酸8 mmol/L（72 mg/dl）（正常值范围0.5-1.7 mmol/L [4.5-15.3 mg/dl]）。腹部CT显示门静脉及肠壁大量积气，符合肠缺血表现。门脉积气常伴随肠缺血，提示预后不良；然而，门脉积气也可发生于其他病因的患者，如感染或炎性肠病，或在治疗后出现。患者接受液体复苏，静脉广谱抗生素及升压药治疗，并计划进行急诊手术。然而，患者病情迅速恶化，2小时后去世。