Images in Clinical Medicine
Air in the Portal and Mesenteric Veins
N Engl J Med 2009; 361:2079November 19, 2009
- Article
A 73-year-old man with history of smoking, hypertension, chronic obstructive pulmonary disease, and type 2 diabetes mellitus presented with respiratory distress. The trachea was intubated, and the patient was admitted to the intensive care unit. On the eighth day of hospitalization, atrial fibrillation developed, with associated hypotension, lactic acidosis, and mild elevation of liver enzymes (alanine aminotransferase, 190 U per liter; aspartate aminotransferase, 220 U per liter) and plasma amylase (140 mg per deciliter). The physical examination showed abdominal distention and regurgitation of enteral-tube nutrients. Computed tomography of the abdomen showed gas in the intrahepatic portal veins (Panel A, arrows), the superior mesenteric veins (Panel B, arrows), and the jejunal wall (Panel B, arrowheads), findings that were strongly suggestive of mesenteric ischemia. The superior mesenteric artery showed severe calcification, but there was no evidence of occlusion or thrombosis. Emergency laparotomy confirmed bowel ischemia, and a 150-cm segment of necrotic jejunum was resected. The patient died from multiple-organ failure 3 days after surgery.
Diego de Mendoza-Asensi, M.D.
Kenneth Planas, M.D.
Joan XXIII University Hospital, Tarragona, Spain
kplanas@gmail.com
