Radiology Rounds 57 Yo Male In Icu

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Information about Radiology Rounds 57 Yo Male In Icu

Published on June 24, 2008

Author: radrounds



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57 yo male in ICU Laura Avery, MD Massachusetts General Hospital Harvard Medical School Boston, MA, USA

Air overlying the liver DDX • Biliary tract • Portal venous air

What do you think? Peripheral air Air in SMV/PV Pneumatosis Note dependent location

Portal venous gas vs. biliary tract gas • They represent two entirely different clinical entities: – Pneumobilia is associated with biliary-enteric fistula, incompetent sphincter of Oddi, and emphysematous cholecystitis, and is commonly seen following biliary bypass operations. – The finding of portal venous air requires urgent surgical exploration. The list of causes of portal venous gas is long, but ischemic bowel with infarction and necrosis is by far the most common etiology and carries a grave prognosis. In one study, necrotic bowel accounted for 72% of cases, ulcerative colitis for 8%, abdominal abscess for 6%, small bowel obstruction for 3%, and gastric ulcer for 3%. • It has been suggested that the anatomic distribution of portal venous air and biliary air within the liver allows one to distinguish between these two entities. – The centrifugal flow of portal venous blood distributes air in this system to a peripheral location, adjacent to the liver capsule. Air within 2 cm of the liver capsule generally corresponds to air in the portal system. – In contrast, biliary air is usually kept in a more central location by the continuous centripetal flow of secreted bile. • Another important discriminator between portal venous and biliary air is the transiency of air within the portal system, important finding on real time ultrasound. Because of the nature of flowing blood, air within the portal veins is likely to be evanescent. Lack of change in the pattern of air over several hours is more consistent with biliary tract air rather than portal venous air.

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