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Images of Memorable Cases: Case 37

Module by: Herbert L. Fred, MD, Hendrik A. van Dijk. E-mail the authorsEdited By: Frederick Moody

http://rup.rice.edu/memcases-button.jpg

Case_37-pres1-1.jpg

Plain abdominal radiograph of a 60-year-old woman with progressive periumbilical pain and abdominal distention of three days’ duration.

The radiographic hallmark of this condition is a spidery pattern of tubular radiolucencies branching toward the liver edge (image below). Gas in the biliary tract is located more centrally and may appear in the gallbladder and extrahepatic biliary ducts as well.

Case_37-diag1-1.jpg

Hepatic portal venous gas usually indicates necrotic bowel in adults and necrotizing enterocolitis in infants. Emergency celiotomy in this patient demonstrated gangrene of the jejunum and gas in the portal vein. Blood cultures grew Klebsiella and Enterococcus species. The patient died 10 days after surgery.

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