Portal Venous Gas
A 72-year-old man presented to the emergency department with an 11-hour history of periumbilical abdominal pain and inability to pass flatus. His medical history included chronic lymphocytic leukemia (for which he had been taking ibrutinib), type 2 diabetes, and chronic hepatitis B virus infection. The pulse was 155 beats per minute, and the blood pressure 83/52 mm Hg. On physical examination, his abdomen was diffusely tender, with the most severe pain in the right upper quadrant. Initial laboratory studies of the blood revealed a white-cell count of 22,570 per cubic millimeter (reference range, 4000 to 10,000), an arterial blood pH of 7.27 (reference range, 7.35 to 7.45), and a lactate level of 8 mmol per liter (72 mg per deciliter) (reference range, 0.5 to 1.7 mmol per liter [4.5 to 15.3 mg per deciliter]). Computed tomography of the abdomen revealed extensive portal venous gas, as well as gas in the bowel wall, which had an appearance consistent with ischemic bowel. Portal venous gas is most commonly associated with bowel ischemia and is a poor prognostic sign in patients with that condition; however, it can also develop in patients with other conditions, such as infection or inflammatory bowel disease, or as a result of an interventional procedure. Treatment was initiated with fluid resuscitation, broad-spectrum intravenous antibiotics, and vasopressors, and an urgent laparotomy was planned. However, the patientโs clinical condition deteriorated rapidly, and he died 2 hours after presentation.