Portomesenteric Vein Gas: Pathologic Mechanisms, CT Findings, and Prognosis1
Carmen Sebastià, MD,
Sergi Quiroga, MD,
Eloy Espin, MD,
Rosa Boyé, MD,
Agustí Alvarez-Castells, MD and
Manel Armengol, MD
1 From the Departments of Radiology I.D.I. (C.S., S.Q., R.B., A.A.C.) and Surgery (E.E., M.A.), Hospital General Universitari Vall d'Hebron, Pg Vall d'Hebron 119-129, Barcelona 08015, Spain. Recipient of a Certificate of Merit award for a scientific exhibit at the 1999 RSNA scientific assembly. Received February 28, 2000; revision requested March 15 and received May 4; accepted May 4. Address correspondence to C.S.
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Figure 1a. Portal vein gas. Contrast material-enhanced CT scans obtained at the top (a) and in the middle (b) of the liver show tubular areas of decreased attenuation in the periphery of the liver (arrows), findings that are consistent with gas in the intrahepatic portal veins.
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Figure 1b. Portal vein gas. Contrast material-enhanced CT scans obtained at the top (a) and in the middle (b) of the liver show tubular areas of decreased attenuation in the periphery of the liver (arrows), findings that are consistent with gas in the intrahepatic portal veins.
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Figure 2a. Pneumobilia. Contrast-enhanced CT scans obtained at the top (a) and in the middle (b) of the liver show tubular areas of low attenuation in the biliary tree (arrows). Note the central location of the air, which does not extend to within 2 cm of the liver capsule (cf Fig 1).
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Figure 2b. Pneumobilia. Contrast-enhanced CT scans obtained at the top (a) and in the middle (b) of the liver show tubular areas of low attenuation in the biliary tree (arrows). Note the central location of the air, which does not extend to within 2 cm of the liver capsule (cf Fig 1).
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Figure 3a. Mesenteric vein gas. (a) Contrast-enhanced CT scan depicts gas in the gastrocolic venous trunk (arrow) and superior mesenteric vein (arrowhead). The marked enhancement of the vein demonstrates the vascular nature of the affected structure. (b) Contrast-enhanced CT scan obtained in a patient with diverticulitis of the sigmoid colon demonstrates gas in the inferior mesenteric vein (arrow). (c) Contrast-enhanced CT scan demonstrates multiple tubular areas of low attenuation in the mesentery (arrows), findings that are consistent with gas in the small mesenteric veins.
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Figure 3b. Mesenteric vein gas. (a) Contrast-enhanced CT scan depicts gas in the gastrocolic venous trunk (arrow) and superior mesenteric vein (arrowhead). The marked enhancement of the vein demonstrates the vascular nature of the affected structure. (b) Contrast-enhanced CT scan obtained in a patient with diverticulitis of the sigmoid colon demonstrates gas in the inferior mesenteric vein (arrow). (c) Contrast-enhanced CT scan demonstrates multiple tubular areas of low attenuation in the mesentery (arrows), findings that are consistent with gas in the small mesenteric veins.
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Figure 3c. Mesenteric vein gas. (a) Contrast-enhanced CT scan depicts gas in the gastrocolic venous trunk (arrow) and superior mesenteric vein (arrowhead). The marked enhancement of the vein demonstrates the vascular nature of the affected structure. (b) Contrast-enhanced CT scan obtained in a patient with diverticulitis of the sigmoid colon demonstrates gas in the inferior mesenteric vein (arrow). (c) Contrast-enhanced CT scan demonstrates multiple tubular areas of low attenuation in the mesentery (arrows), findings that are consistent with gas in the small mesenteric veins.
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Figure 4. Pneumoperitoneum. Contrast-enhanced CT scan depicts extraluminal air in the peritoneal cavity due to a perforated hollow viscus. The air is located between the antimesenteric border of the bowel and the parietal peritoneum (arrows). Air in this location cannot be seen in cases of venous mesenteric air.
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Figure 5. Air in the appendix. Contrast-enhanced CT scan shows air in the appendix mimicking mesenteric vein gas (thick arrow). The walls of the appendix and its attachment to the cecum (thin arrow) are clearly seen.
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Figure 6a. Causes of mesenteric ischemia. (a) Contrast-enhanced CT scan demonstrates a thrombus in the superior mesenteric artery (arrow). (b) Contrast-enhanced CT scan obtained in a different patient shows a thrombus in the superior mesenteric vein (arrow). Gas is also seen in other mesenteric veins (cf Fig 7d). (c) Contrast-enhanced CT scan obtained in yet another patient depicts gas in the mesenteric veins (white arrow) due to mesenteric ischemia secondary to abdominal aortic dissection (black arrow).
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Figure 6b. Causes of mesenteric ischemia. (a) Contrast-enhanced CT scan demonstrates a thrombus in the superior mesenteric artery (arrow). (b) Contrast-enhanced CT scan obtained in a different patient shows a thrombus in the superior mesenteric vein (arrow). Gas is also seen in other mesenteric veins (cf Fig 7d). (c) Contrast-enhanced CT scan obtained in yet another patient depicts gas in the mesenteric veins (white arrow) due to mesenteric ischemia secondary to abdominal aortic dissection (black arrow).
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Figure 6c. Causes of mesenteric ischemia. (a) Contrast-enhanced CT scan demonstrates a thrombus in the superior mesenteric artery (arrow). (b) Contrast-enhanced CT scan obtained in a different patient shows a thrombus in the superior mesenteric vein (arrow). Gas is also seen in other mesenteric veins (cf Fig 7d). (c) Contrast-enhanced CT scan obtained in yet another patient depicts gas in the mesenteric veins (white arrow) due to mesenteric ischemia secondary to abdominal aortic dissection (black arrow).
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Figure 7a. Mesenteric ischemia. (a) CT scan demonstrates bowel dilatation (arrowheads) and mesenteric infiltration (arrows). (b) CT scan shows pneumatosis intestinalis (arrow) and venous mesenteric gas (arrowhead). (c) CT scan demonstrates absence of enhancement of the bowel wall (arrow). (d) CT scan obtained in the same patient as in Figure 6b shows mesenteric edema (straight arrow), bowel wall thickening (curved arrow), and air in the small mesenteric veins (arrowheads). (e) CT scan demonstrates renal and hepatic infarcts (arrows) and hepatic portal vein gas (arrowhead).
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Figure 7b. Mesenteric ischemia. (a) CT scan demonstrates bowel dilatation (arrowheads) and mesenteric infiltration (arrows). (b) CT scan shows pneumatosis intestinalis (arrow) and venous mesenteric gas (arrowhead). (c) CT scan demonstrates absence of enhancement of the bowel wall (arrow). (d) CT scan obtained in the same patient as in Figure 6b shows mesenteric edema (straight arrow), bowel wall thickening (curved arrow), and air in the small mesenteric veins (arrowheads). (e) CT scan demonstrates renal and hepatic infarcts (arrows) and hepatic portal vein gas (arrowhead).
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Figure 7c. Mesenteric ischemia. (a) CT scan demonstrates bowel dilatation (arrowheads) and mesenteric infiltration (arrows). (b) CT scan shows pneumatosis intestinalis (arrow) and venous mesenteric gas (arrowhead). (c) CT scan demonstrates absence of enhancement of the bowel wall (arrow). (d) CT scan obtained in the same patient as in Figure 6b shows mesenteric edema (straight arrow), bowel wall thickening (curved arrow), and air in the small mesenteric veins (arrowheads). (e) CT scan demonstrates renal and hepatic infarcts (arrows) and hepatic portal vein gas (arrowhead).
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Figure 7d. Mesenteric ischemia. (a) CT scan demonstrates bowel dilatation (arrowheads) and mesenteric infiltration (arrows). (b) CT scan shows pneumatosis intestinalis (arrow) and venous mesenteric gas (arrowhead). (c) CT scan demonstrates absence of enhancement of the bowel wall (arrow). (d) CT scan obtained in the same patient as in Figure 6b shows mesenteric edema (straight arrow), bowel wall thickening (curved arrow), and air in the small mesenteric veins (arrowheads). (e) CT scan demonstrates renal and hepatic infarcts (arrows) and hepatic portal vein gas (arrowhead).
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Figure 7e. Mesenteric ischemia. (a) CT scan demonstrates bowel dilatation (arrowheads) and mesenteric infiltration (arrows). (b) CT scan shows pneumatosis intestinalis (arrow) and venous mesenteric gas (arrowhead). (c) CT scan demonstrates absence of enhancement of the bowel wall (arrow). (d) CT scan obtained in the same patient as in Figure 6b shows mesenteric edema (straight arrow), bowel wall thickening (curved arrow), and air in the small mesenteric veins (arrowheads). (e) CT scan demonstrates renal and hepatic infarcts (arrows) and hepatic portal vein gas (arrowhead).
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Figure 8a. Portomesenteric vein gas due to mesenteric ischemia. (a) Contrast-enhanced CT scan depicts mural thickening of the colon (arrows), mesenteric edema, and gas in the mesenteric vessels (arrowheads). Note also the presence of polycystic renal disease. (b) Contrast-enhanced CT scan demonstrates portal vein gas (arrows), a finding that caused suspicion for mesenteric ischemia. At surgery, the right side of the colon demonstrated necrosis, and hemicolectomy was performed. Follow-up CT performed 15 days later demonstrated resolution of the portomesenteric vein gas. The patient's recovery was uneventful.
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Figure 8b. Portomesenteric vein gas due to mesenteric ischemia. (a) Contrast-enhanced CT scan depicts mural thickening of the colon (arrows), mesenteric edema, and gas in the mesenteric vessels (arrowheads). Note also the presence of polycystic renal disease. (b) Contrast-enhanced CT scan demonstrates portal vein gas (arrows), a finding that caused suspicion for mesenteric ischemia. At surgery, the right side of the colon demonstrated necrosis, and hemicolectomy was performed. Follow-up CT performed 15 days later demonstrated resolution of the portomesenteric vein gas. The patient's recovery was uneventful.
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Figure 9. Mesenteric vein gas due to mesenteric ischemia. Contrast-enhanced CT scan demonstrates gas in the mesenteric veins (arrow) and thickening of the cecum (arrowhead). Although only a small amount of portomesenteric vein gas was found at CT, the patient had massive mesenteric ischemia and died immediately after surgery.
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Figure 10a. Portomesenteric vein gas in a patient who presented with abdominal pain and distention. The patient had undergone colonoscopy 10 hours earlier. CT was performed for suspected colon perforation. (a) Scanogram shows marked distention of the colon. (b) Unenhanced CT scan demonstrates portomesenteric vein gas (arrows). The nasogastric tube can also be seen. The patient was treated conservatively and had an uneventful recovery.
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Figure 10b. Portomesenteric vein gas in a patient who presented with abdominal pain and distention. The patient had undergone colonoscopy 10 hours earlier. CT was performed for suspected colon perforation. (a) Scanogram shows marked distention of the colon. (b) Unenhanced CT scan demonstrates portomesenteric vein gas (arrows). The nasogastric tube can also be seen. The patient was treated conservatively and had an uneventful recovery.
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Figure 11a. Portomesenteric vein gas associated with paralytic ileus secondary to bronchial artery embolization in a patient who presented with abdominal pain and distention. CT was performed 24 hours after embolization. (a) Contrast-enhanced CT scan shows intrahepatic portal vein gas (arrows). (b) Contrast-enhanced CT scan depicts bowel distention with mural air (arrowheads). Mesenteric ischemia was suspected, and the patient underwent surgery. No ischemic bowel was found. Contrast-enhanced follow-up CT performed 20 days later demonstrated resolution of the hepatic portal vein gas.
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Figure 11b. Portomesenteric vein gas associated with paralytic ileus secondary to bronchial artery embolization in a patient who presented with abdominal pain and distention. CT was performed 24 hours after embolization. (a) Contrast-enhanced CT scan shows intrahepatic portal vein gas (arrows). (b) Contrast-enhanced CT scan depicts bowel distention with mural air (arrowheads). Mesenteric ischemia was suspected, and the patient underwent surgery. No ischemic bowel was found. Contrast-enhanced follow-up CT performed 20 days later demonstrated resolution of the hepatic portal vein gas.
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Figure 12a. Portomesenteric vein gas associated with diverticulitis and mesocolic abscess. (a) Contrast-enhanced CT scan shows branched areas of decreased attenuation in the left hepatic lobe (arrows), findings that are consistent with portal vein gas. (b) Contrast-enhanced CT scan depicts sigmoid bowel thickening (arrowhead) and a mesosigmoid abscess (arrows). Surgical findings confirmed acute diverticulitis and abscess. Colostomy and abscess drainage were performed. Contrast-enhanced follow-up CT demonstrated resolution of the portal vein gas.
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Figure 12b. Portomesenteric vein gas associated with diverticulitis and mesocolic abscess. (a) Contrast-enhanced CT scan shows branched areas of decreased attenuation in the left hepatic lobe (arrows), findings that are consistent with portal vein gas. (b) Contrast-enhanced CT scan depicts sigmoid bowel thickening (arrowhead) and a mesosigmoid abscess (arrows). Surgical findings confirmed acute diverticulitis and abscess. Colostomy and abscess drainage were performed. Contrast-enhanced follow-up CT demonstrated resolution of the portal vein gas.
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Figure 13. Abdominal wall gangrene with portomesenteric vein gas. Contrast-enhanced CT scan shows subcutaneous and mesenteric gas (arrows), a finding that is consistent with abdominal wall gangrene. Note also the presence of gas in the mesenteric vein (arrowhead). Surgical findings confirmed the diagnosis, and the patient died 3 days later in the intensive care unit.
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Figure 14a. Pylephlebitis due to tuberculosis in a man with non-Hodgkin lymphoma who presented with fever and abdominal pain. (a) Contrast-enhanced CT scan depicts peripancreatic nodes with a hypoattenuating center (arrows). (b) Contrast-enhanced CT scan demonstrates gas in the extrahepatic portal vein (arrow). CT-guided biopsy of the nodes was performed, and Mycobacterium tuberculosis was cultured. Follow-up CT performed 6 months later after completion of treatment for tuberculosis demonstrated decreased peripancreatic adenopathy and resolution of the portal vein gas.
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Figure 14b. Pylephlebitis due to tuberculosis in a man with non-Hodgkin lymphoma who presented with fever and abdominal pain. (a) Contrast-enhanced CT scan depicts peripancreatic nodes with a hypoattenuating center (arrows). (b) Contrast-enhanced CT scan demonstrates gas in the extrahepatic portal vein (arrow). CT-guided biopsy of the nodes was performed, and Mycobacterium tuberculosis was cultured. Follow-up CT performed 6 months later after completion of treatment for tuberculosis demonstrated decreased peripancreatic adenopathy and resolution of the portal vein gas.
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Figure 15a. Pneumatosis intestinalis with portomesenteric vein gas in a patient with asthma and non-Hodgkin lymphoma who was undergoing corticoid therapy. Routine abdominal radiography demonstrated intramural bowel gas, and CT was performed. (a) Scanogram demonstrates pneumatosis intestinalis (arrows). (b) Contrast-enhanced CT scan (lung window) shows intramural bowel gas (arrowhead) and mesenteric vein gas (arrows). The patient had no abdominal symptoms and made a full recovery without having to undergo surgery.
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Figure 15b. Pneumatosis intestinalis with portomesenteric vein gas in a patient with asthma and non-Hodgkin lymphoma who was undergoing corticoid therapy. Routine abdominal radiography demonstrated intramural bowel gas, and CT was performed. (a) Scanogram demonstrates pneumatosis intestinalis (arrows). (b) Contrast-enhanced CT scan (lung window) shows intramural bowel gas (arrowhead) and mesenteric vein gas (arrows). The patient had no abdominal symptoms and made a full recovery without having to undergo surgery.
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Figure 16. Portomesenteric vein gas associated with hepatic transplantation. Contrast-enhanced CT scan obtained 10 days after surgery demonstrates portal vein gas (arrow). There were no complications at that time. Unenhanced CT performed 10 days later showed resolution of the portal vein gas.
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Copyright © 2000 by the Radiological Society of North America.
