Veeshal Modi, MD
Assistant Professor of Medicine
University of South Florida Morsani College of Medicine, United States
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Title: Medical Management of Portal Venous Gas and Pneumatosis Intestinalis
Introduction: Portal venous gas and pneumatosis intestinalis are radiologic findings most commonly associated with bowel ischemia and necrosis. Given the high mortality rate associated with bowel necrosis, many patients are immediately evaluated for exploratory laparotomy. The following case represents a rare example of benign portal venous gas and pneumatosis intestinalis and describes the medical management thereof.
Summary: A 70-year-old male with past medical history of COPD, multiple abdominal surgeries, and squamous cell carcinoma status post laryngeal resection, presented 6 days after cisplatin administration with severe abdominal pain. Vitals: BP 112/61, HR 113, Temperature 99.2F. Physical exam demonstrated marked abdominal distention and pain out of proportion to exam. Aside from chemotherapy induced leukopenia and a mild acute kidney injury, his laboratory studies were unremarkable. Abdominal CT demonstrated extensive intrahepatic portal venous gas and areas of pneumatosis within the small intestine. Given great concern for acute mesenteric ischemia, general surgery was consulted, but recommended palliative care as the patient was too high risk for surgical intervention. However, the patient opted to continue aggressive medical management. He was placed on strict bowel rest with his G-tube to low intermittent suction. TPN was initiated and continued for 11 days, at which point his G-tube had minimal output. Zosyn was prophylactically administered over 7 days for anaerobic bacterial coverage. Repeat CT abdomen on day 6 demonstrated resolved pneumatosis and 2 small foci of portal venous gas remaining. Prior to discharge, the patient was transitioned back to his full home-based tube feeding regimen.
Discussion: Portal venous gas and pneumatosis intestinalis are often classified as surgical emergencies given their high correlation with bowel ischemia and necrosis. However, these radiologic findings can be caused by nonischemic etiologies (i.e. platinum-based chemotherapy, small bowel obstruction, COPD exacerbation) and occasionally managed medically. This case signifies the importance of adequately correlating acute findings with a patient’s clinical history, vital signs, and laboratory studies in order to safely differentiate the need for medical versus surgical management.