Portal venous gas (PVG) and postoperative necrotising enterocolitis in an adult (ECNA) following radical cystectomy

Description

Portal venous gas (PVG) is an infrequent radiological finding of ominous clinical significance. It is more common in premature infants but can also be seen in adults with necrotising enterocolitis (ECNA) or non-occlusive mesenteric ischaemia. ECNA is a cause of PVG with very few cases described in literature and with high mortality. It is a multifactorial condition and the eliciting factors include infection, ischaemia and protracted ileus.¹ The radiographical findings are impressive since it is very difficult to suspect it straightforward and diagnosis comes when the presentation is fulminant.²

Our case is a 67-year-old male retired painter diagnosed with pT2N0M0 bladder urothelial carcinoma, with a medical history of type 2 diabetes and rheumatoid arthritis on methotrexate. Discussion in joint Multidisciplinary Team recommended radical cystectomy with no neoadjuvant chemotherapy. According to the surgeon’s preferences, preoperative bowel preparation, opioid analgesia and prolonged fasting were avoided. Nevertheless, we did not strictly adhere to Enhanced Recovery After Surgery (ERAS) protocol. The patient underwent open radical cystectomy with cutaneous ureterostomy as planned, received antibiotics on induction, venous thromboembolism prophylaxis, meticulous fluid management and no epidural anaesthesia was administered. No intraoperative complications were encountered, with minimal blood loss and no concerns of mesentery/bowel injury. Postoperative intensive care unit admission was not deemed necessary by the operating team. Early nutrition and opioid analgesia were avoided with introduction of parenteral nutrition for the first 72 hours. Minimal surgical drainage was reported. Twelve-hour post procedural clinical review revealed abdominal distention while the patient complained of nausea, suggestive of possible postoperative bowel obstruction, and a nasogastric tube was inserted. Although his symptoms seemed controlled, they persisted until 72 hours postoperative when he became tachypnoic and mildly acidotic (pH 7.3, lactate 2.3 mmol/L). His biochemistry results showed white cell count of 14.200 ×10⁹/L, C-reactive protein (CRP) of 46 mg/L, estimated glomerular filtration rate (eGFR) of 38 mL/min and creatine of 2.2 mg/dL with a baseline of 87 and 1.15, respectively.

Urgent high dependency unit transfer and non-contrast CT scan were arranged. Imaging demonstrated not only a massively air-filled colon but also air in the colonic wall (pneumatosis coli) and PVG extending peripherally to the hepatic branches (figures 1–3). On exploratory laparotomy, the ascending colon and approximately 120 cm of terminal ileum appeared necrotic and were removed. Although the typical ‘skip lesions’ of intestinal ischaemia were missing and the mesenteric vessels were patent, the condition was consistent with necrotising enterocolitis. During dissection, the respective mesentery appeared thickened with tense adhesions, but tissue sampling was avoided to minimise iatrogenic damage. Acute sclerosing mesenteritis was suspected as possible cause, nonetheless no histological evidence exists. Pathology report confirmed full thickness intestinal ischaemia scattered through the specimen. The initial operation was straightforward and to our knowledge, no surgical mishap took place which may have caused the above complication. The only compounding factor recognised was the prolonged paralytic ileus which is a common occurrence after major abdominal surgery. Hirobe et al showed that paralytic ileus was one of the most common complications that occurred in 22.2% of the patients post radical cystectomy.³ Case demonstrating PVG in X-ray was successfully managed conservatively.⁴ Nevertheless, ultrasonography and CT scan are considered more sensitive in detection of PVG than conventional radiography.⁵

Figure 1.

Abdominal X-ray showing distended bowel loops (arrows) and bilateral single-J ureteric stents appropriately sited through cutaneous ureterostomy.

Figure 2.

Axial plane of non-contrast CT scan. On the left, acute mesentery ischaemia is evidenced by distended bowel loops with gas in the bowel wall (arrows), superior mesenteric vein and mesenteric veins (arrowheads) indicating bowel gangrene. On the right, the arrowhead depicts air in transhepatic portal branches mainly in left lobe.

Figure 3.

Coronal plane of non-contrast CT scan depicting gas in the wall of descending colon near the splenic flexure (arrows) and extensive air presence in superior mesenteric vein (arrowheads).

Learning points.

• Urologists should have a high level of suspicion to timely distinguish such a covert condition from paralytic ileus on the postoperative setting of radical cystectomy.

• Early imaging with CT scan or ultrasonography following bowel obstruction symptoms can prompt timely intervention and reduce postoperative complication-related mortality.

• Portal venous gas associated with pneumatosis intestinalis is associated with poor prognosis post radical cystectomy.

Ethics statements

Patient consent for publication

Consent obtained from next of kin.