POCUS Finding of Portal Venous Gas: An Unusual Consequence of an Amyloid Dysmotility Related Bezoar

Abstract

A 73-year-old male with a recent finding of pericardial effusion and syncope was evaluated with point of care ultrasound for recurrent effusion. A thickened left ventricle and recurrent pericardial effusion were found. Unexpectedly, on scanning the inferior vena cava (IVC), extensive portal venous gas was identified, a finding previously described as a "meteor shower". Subsequent imaging by computed tomography (CT) identified gastric edema and peri-gastric vessel gas as the source of the portal gas, attributed to a large bezoar. The bezoar was later classified as a phytobezoar and the patient was found to have both cardiac and gastrointestinal manifestations of light chain amyloidosis. The gastrointestinal amyloidosis predisposed the patient to bezoar formation owing to associated dysmotility, a rare complication of an unusual manifestation of systemic amyloid.

Keywords: POCUS; Portal gas.

Figure 1. Parasternal long axis (left) and apical four chamber view (right). The left image shows a moderate sized pericardial effusion. In both images the walls were thickened and function was depressed towards the base of the heart. A subsequent echocardiogram described the findings as concerning for amyloid cardiomyopathy.

Figure 2. The left image shows the patient’s IVC, which was plethoric, but also notable for scattered hyperechoic areas. The hyperechoic areas were confirmed in subsequent views of the liver (right) and lead to further investigation, as they are indicative of extensive portal venous gas.

Figure 3. CT Abdomen showing gastric wall edema and gas in the peri-gastric vessels, some of which is highlighted in red.

Figure 4. CT Abdomen showing the large amount of gastric contents consistent with a bezoar, later confirmed to be a phytobezoar.