Massive Portomesenteric Gas and Intestinal Pneumatosis

An 84-year-old woman with a history of hypertension and carotid artery atherosclerosis presented to the Emergency Department with abdominal pain and hypotension. Her sons reported that in the last year she had suffered from increasingly frequent episodes of abdominal pain after eating. On initial assessment, the patient appeared dehydrated, confused, tachycardic (120 beats/min), and tachypneic (24 breaths/min), and the blood pressure was not obtainable. Her abdomen was enlarged with diffuse rebound tenderness. Bowel sounds were absent. The extremities were cold, and the skin of the abdomen presented a diffuse cyanotic discoloration. She had severe metabolic acidosis (blood pH 7.25,base excess 12 mEq/L) and her blood tests showed a white blood cell count of 16.5 103/mL (normal: 4.1–9.8 103/mL) with 81% neutrophils (40–74%), and a hematocrit of 49% (37–47%) and markedly elevated lactate levels (14.5 mmol/L, normal value 0.7–2.1 mmol/L). Her liver and renal function tests were normal. She underwent fluid resuscitation and when she was hemodynamically stable, a computed tomography (CT) scan of the abdomen with intravenous contrast was performed to investigate signs of peritonitis. The CT scan showed extensive gas in the intrahepatic portal venous system, in the spleen, and in the superior mesenteric vein (Figure 1A and 1B) with a diffuse pneumatosis intestinalis (i.e., air within the intestinal wall) throughout the stomach and the small intestine. e superior mesenteric artery showed severe calcification at its origin, with a complete stenosis (Figure 1D). Moreover, a severe stenosis of the celiac axis with narrowing of its main branches was noted. In this patient the clinical and radiological findings were consistent with massive bowel ischemia. The patient’s clinical condition deteriorated rapidly. Only palliative measures were established and the patient died 4 h after presentation