Ultrasound Detection of Portomesenteric Venous Gas Is an Early Sign of Bowel Ischaemia in Non-Traumatic Abdominal Pain: Old Dogs, New Tricks-Four Cases Report

Abstract

Acute bowel ischemia is a severe disease often with a poor outcome. Early diagnosis can improve outcome, but atypical clinical manifestations and nonspecific laboratory and instrumental diagnostic findings may delay computed tomographic angiography (CTA). Portomesenteric venous gas (PVG), indirect sign of pneumatosis intestinalis, is considered a late finding with poor prognosis. We report four cases where PVG, easily identified through point-of-care ultrasonography (POCUS), was an early sign of bowel ischemia leading to a precocious diagnosis confirmed at CTA. In acute non-traumatic abdominal pain, an evidence of PVG could be an early ultrasonographic finding of bowel ischemia in the emergency department.

Figure 1

POCUS and CTA of case 1. (a) POCUS shows portal vein at hepatic hilum (asterisk) with multiple hyperechogenic spots into the lumen. White arrows indicate air in intrahepatic portal vessels with altered liver ultrasonographic structure. (b) A CTA scan confirms air into the liver (white arrows), while air is not easily identified into portal vein. (c) CTA confirms a little area of pneumatosis intestinalis (white arrow). POCUS stands for point-of-care ultrasonography; CTA stands for computed tomographic angiography.

Figure 2

POCUS and CTA of case 2. (a) POCUS shows a right portal branch (asterisk) with some air bubbles into the lumen (black arrow). White arrows indicate some air in intrahepatic portal vessels. (b) CTA showing pneumatosis intestinalis (white arrow). (c) CTA shows the air flowing within the intestinal vessels (white arrow), as it is drained from the pneumatosis intestinalis, that will reach the portal vein. POCUS stands for point-of-care ultrasonography; CTA stands for computed tomographic angiography.