Use of Diagnostic Laparoscopy in a Patient with Gastric Pneumatosis and Portal Venous Gas
A vigorous 84-year-old man presented with recurrent adenocarcinoma and a solitary hepatic metastasis several years after laparoscopic right hemicolectomy. A wedge excision of a 1.8 cm lesion in segment 7 of the liver was performed after resecting en bloc a 3.5 cm mass at the ileo-colonic anastomosis that invaded the retroperitoneum and the serosa of the third portion of the duodenum.\nAfter recovering from adynamic ileus, the patient was sent home on postoperative day 9 to return soon after with nausea and severe vomiting. On arrival, he had normal vital signs except for tachycardia that resolved after rehydration. Placement of a nasogastric tube returned 150 ml of clotted blood. His abdomen was mildly distended and non-tender to palpation. He had normal labs except for leukocytosis (WBC: 20,400). An abdominal X-ray was performed and showed an atypical gas pattern involving the stomach. There were also signs of gastric pneumatosis and portal venous gas. Computed tomography of the abdomen with oral and intravenous contrast was obtained (fig. ) which showed gastric distention and pneumatosis with portal venous gas. Esophagogastroduodenoscopy confirmed the gastric mucosal findings (fig. ). It showed areas of mucosal color changes in patchy distribution, along with edematous and friable areas suggesting necrosis. Biopsy was not obtained because of concern of full thickness necrosis and perforation.\nGastric pneumatosis with portal venous air and endoscopic concern for gastric ischemia prompted urgent diagnostic laparoscopy. This demonstrated completely normal-appearing gastric serosa with no signs suggesting full thickness infarction or distal obstruction (fig. ). The patient was treated conservatively with intravenous antibiotics covering aerobic and anaerobic bacteria, nasogastric decompression and parenteral nutrition. He recovered well with this conservative approach and was discharged home in a stable condition. On follow-up, he was able to tolerate a regular diet.