Acute mesenteric ischemia with pneumatosis intestinalis and hepatic portal venous gas: a case report

Abstract

Acute mesenteric ischemia (AMI) is a life-threatening condition requiring early diagnosis and intervention. This case represents a rare presentation of AMI with pneumatosis intestinalis and hepatic portal venous gas, requiring emergent surgical intervention. A 79-year-old female with a history of chronic obstructive pulmonary disease (COPD) and autoimmune thyroiditis presented with worsening dyspnea and intermittent chest pain. She was initially treated for non-ST elevation myocardial infarction (NSTEMI) due to ECG T inversions in V2-6 and an elevated troponin level of 76. Coronary angiography was performed and showed no acute occlusions or significant stenoses, with no complications observed. However, on the second day of hospitalization, she developed hypotension and worsening abdominal pain. Imaging revealed pneumatosis intestinalis and hepatic portal venous gas, indicating ischemic bowel disease. Despite initial reluctance, the patient consented to surgery, and a right hemicolectomy with ileotransverse anastomosis was performed. AMI often presents with non-specific symptoms, leading to delayed diagnosis. In this case, pneumatosis intestinalis and hepatic portal venous gas on computed tomography (CT) were key signs of transmural bowel infarction. The surgical findings confirmed extensive necrosis of the ascending and transverse colon. Early recognition and prompt surgical intervention significantly impacted the outcome. Postoperatively, the patient required intensive care support, including vasopressors, oxygen therapy, and antibiotic treatment for sepsis. Despite initial instability, she gradually improved and was transferred to the general ward. This case highlights the importance of early recognition of AMI, particularly in patients with non-specific symptoms. The presence of pneumatosis intestinalis and hepatic portal venous gas on imaging should indicate immediate surgical consultation. A high index of suspicion, timely surgical intervention, and intensive postoperative care are crucial for improving survival in these critically ill patients.