A rare case of ischaemic pneumatosis intestinalis and hepatic portal venous gas in an elderly patient with good outcome following conservative management

• PI and HPVG caused by ischaemia usually results in death if conservatively managed.
• A 93 year old male survived this despite non-operative management.
• Aggressive surgical intervention is not always in the patients’ best interest.
• Further work is needed to identify patients who may survive conservative treatment.

IntroductionPneumatosis intestinalis (PI) and hepatic portal venous gas (HPVG) are typically associated and are likely to represent a spectrum of the same disease. The causes of both entities range from benign to life-threatening conditions. Ischaemic causes are known to be fatal without emergency surgical intervention.Presentation of caseIn this case a 93 year old male experienced acute abdominal pain radiating to his back, with nausea and vomiting and a 2-week history of altered bowel habit. Examination revealed abdominal tenderness and distension. He had deranged white cell count (WCC) and renal function. Computed tomography (CT) revealed PI with associated HPVG. The cause was due to ischaemic pathology. The patient was managed conservatively with antibiotics and was discharged 7 days later with resolution of his abdominal pain and WCC.DiscussionThe pathogenesis of HPVG secondary to PI is poorly understood but usually indicates intestinal ischaemia, thought to carry a mortality of around 75%. HPVG in the older patient usually necessitates emergency surgery however this is not always in the patient’s best interest.ConclusionThere are few reported cases of patient survival following conservative management of PI and HPVG secondary to ischaemic pathology. This case demonstrates the possibility of managing this condition without aggressive surgical intervention especially when surgery would likely result in mortality due to frailty and morbidity. Further work is required to identify suitable patients.