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Websurg, e-Surgery 關於腹腔鏡手術
Clinical Case
AIR IN THE PORTAL VEIN SECONDARY TO ISCHEMIC BOWELS Vartolomei, MD, M Smith, MD , Hôpitaux Universitaires de Strasbourg, Strasbourg, France 1. Description This clinical case presents radiographic evidence of portal vein gas. This may occur spontaneously or iatrogenically and is rarely discovered. The diagnosis may be made by plain X-ray, ultrasound or CT scan. Its discovery requires urgent surgical intervention in the context of an acute abdomen. 2. KeywordsColon, portal vein, liver, ischemia, emergency 3. PatientFemale, 82-year-old 4. Past medical history- hypertension; - supraventricular cardiac arrhythmia; - cardiac ischemia (myocardial infarct 8 years before); - ectopic pregnancy; - facial paralysis. 5. History of present illnessThe patient is admitted via the emergency room for the acute onset of severe abdominal pain. The patient had a sensation of postprandial bloating 3 days before admission, and continuous abdominal pain, which started 12 hours before admission and became progressively worse. 6. Clinical examination- generalized abdominal defense; - beginning of rebound. 7. Lab work- CRP = 15 mg/l; - WBC= 11 000 / mm3; - lactate = 3.77 UI (elevated); - hypoxia (pO2 = 57 mm Hg), hypocapnia. 8. Plain AXRDilatation of the small bowel (right: flat plate), with diffuse air fluid levels of the small bowel (left: upright) 9. Abdominal ultrasoundLiver is heterogeneous, with multiple punctiform elements realizing a sparkling of the peripheral parenchyma, giving typical image of air in the portal vein. 10. Abdominal CT scan 1Confirmation of portal vein air with the presence of hypodense images essentially in the periphery of the liver parenchyma, corresponding to the presence of gas in the distal branches of the portal vein. 11. Abdominal CT scan 2Demonstrates a moderate peritoneal fluid effusion, distal small bowel distension and a thickening of the terminal small bowel and cecum with mesenteric infiltration (suggests an intestinal necrosis). 12. Urgent explorationEmergent exploratory laparotomy: - diagnosis: ischemic bowel on the verge of necrosis involving the last 70 centimeters of small bowel and the cecum with a perforation secondary to necrosis; - operation: partial resection of the ileum with a right hemicolectomy. Immediate re-establishment of continuity by an ileo-transverse side-to-side anastomosis with stapler. 13. Clinical courseUncomplicated, with a rapid return of bowel function and discharge of the patient on the 12th postoperative day. 14. DiscussionAir in the portal vein is defined by the presence of gas in the portal vein system. The diagnosis of the portal vein gas, which is a rare occurrence, is most often diagnosed by an abdominal CT scan in the workup of an acute abdomen. The portal vein gas can also be diagnosed by an abdominal ultrasound, which typically demonstrates peripheral aspects of sparkling. The CT scan shows hypodense images in the peripheral liver tissue, corresponding to gas in the distal branches of the portal vein trunk, and shows an image of portal vein distribution. The direction of portal blood flow explains the presence of gas in the liver periphery, and differentiates this diagnosis from aerobilia, which is located centrally. The first cuts of the CT scan must be performed without injection of iodinated contrast, which could mask the presence of a small quantity of gas in the portal vessels. It presents a rare radiologic diagnosis but which is being diagnosed more and more frequently due to the improved quality of imaging techniques. In a patient in a state of good general health, undergoing an invasive exam (such as colonoscopy, or barium enema) a simple surveillance is useful. In the case of acute abdominal symptoms (trauma, inflammatory illness, bowel ischemia) and in the absence of rapid recovery with medical treatment, an emergency surgical intervention is necessary. The most common causes are due to Crohn's disease, liver transplantation, and bowel necrosis. The prognosis of a complicated bowel necrosis with portal vein air is grave with a mortality between 75% and 90%. The prognosis is linked to the cause and the nature of bacterial contamination. 15. References
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