Lubin, Jeffrey S.

International Journal of Emergency Medicine

English

PubMed

Springer - Publisher Connector

CLINICAL IMAGES
Portomesenteric air from acute necrotizing appendicitis
Jeffrey S. Lubin
Received: 2 January 2009 /Accepted: 18 January 2009 /Published online: 24 February 2009
# Springer-Verlag London Ltd 2009
A 75-year-old man presented to the emergency department
(ED) with a history of 2 days of abdominal distention. He
complained of mild nausea with vomiting but no abdominal
pain or reported fevers. His temperature was 94.8°F (34.9°C),
pulse was 106, and blood pressure was 99/59. He was awake
and alert and did not appear toxic. His abdomen was firm
and distended without significant tenderness. Initial labora-
tory tests, including white blood cell count, were essentially
normal.
Figure 1 shows branching lucencies in the liver, suggest-
ing either pneumobilia or portomesenteric venous gas. The
presence of air in the left lobe of the liver extending beyond
2 cm from the liver capsule, as seen in the abdominal
computed tomography (CT) scan shown in Fig. 2, confirms
mesenteric and portal venous gas. This feature differs from
pneumobilia, which is centrally located. His CT scan also
demonstrated extensive pneumatosis involving the esopha-
gus, stomach, and large portions of the bowel. The patient
received broad-spectrum antibiotics in the ED and the
general surgery department was consulted. His condition
rapidly deteriorated, and he was resuscitated from cardiac
arrest twice but ultimately died. Autopsy revealed acute
necrotizing appendicitis, which led to sepsis and resulted in
his death.
Morbidity and mortality in elderly patients with appen-
dicitis ranges as high as 70% versus approximately 1% in
the general population [1]. It is a difficult diagnosis to make
since more than one half of elderly patients do not present
with fever or leukocytosis. In addition, approximately one
third do not localize pain to the right lower quadrant and
one quarter do not have appreciable right lower quadrant
tenderness. Portomesenteric gas is rare, but is often
associated with fatal outcome [2].
References
1. Storm-Dickerson TL, Horattas MC (2003) What have we learned
over the past 20 years about appendicitis in the elderly? Am J Surg
185(3):198–201
2. Sebastià C, Quiroga S, Espin E, Boyé R, Alvarez-Castells A,
Armengol M (2000) Portomesenteric vein gas: pathologic mecha-
nisms, CT findings, and prognosis. Radiographics 20(5):1213–1224
Int J Emerg Med (2009) 2:123–124
DOI 10.1007/s12245-009-0090-2
The views expressed in this paper are those of the author(s) and not
those of the editors, editorial board or publisher.
J. S. Lubin (*)
Department of Emergency Medicine,
University Hospitals Case Medical Center,
Case Western Reserve University School of Medicine,
11100 Euclid Ave, Bolwell 3700,
Cleveland, OH 44106, USA
e-mail: Jeffrey.Lubin@uhhospitals.org
Fig. 2 CT scan demonstrating the presence of air in the left lobe of
the liver extending beyond 2 cm from the liver capsule
Fig. 1 Visualization of branching lucencies in the liver
124 Int J Emerg Med (2009) 2:123–124


Portomesenteric air from acute necrotizing appendicitis

Jeffrey S. Lubin

What have we learned over the past 20 years about appendicitis in the elderly? Am J Surg 185(3):198–201 2. Sebastià C,

file:///data/remote/core/dit/data/Springer-OA/pdf/c64/aHR0cDovL2xpbmsuc3ByaW5nZXIuY29tLzEwLjEwMDcvczEyMjQ1LTAwOS0wMDkwLTIucGRm.pdf

Portomesenteric air from acute necrotizing appendicitis

Abstract

Similar works

Full text

Available Versions

Springer - Publisher Connector

Springer - Publisher Connector