British Journal of Radiology 74 (2001),393-394 © 2001 The British Institute of Radiology
Pyrexia of unknown origin in an elderly lady
C Brenner, FRCR and
S Hamilton, FRCR
Department of Radiology, The Adelaide & Meath Hospital, Tallaght, Dublin 24, Ireland
Correspondence: Dr S Hamilton
A 76-year-old lady was admitted to hospital for investigation of pyrexia of unknown origin. CT of the abdomen was performed as part of her assessment (Figures 1–3
). What are the findings and what is the likely diagnosis?
CT following oral and intravenous contrast medium showed extensive intrahepatic portal venous gas as well as gas almost completely filling the splenic vein (Figure 1
). Gas was also visible in mesenteric veins (Figure 2). A small mass of soft tissue density was identified adjacent to a segment of sigmoid diverticular disease. This mass indented the bladder and was thought to represent an abscess (Figure 3). Subsequent laparotomy confirmed a diverticular abscess and a Hartmann's procedure was performed. Pathological examination of the resected specimen showed a perforated diverticulum with an associated abscess. Repeat CT 5 days later showed complete resolution of the intravenous gas.
Since it was first described on plain radiographs in 1955, portal venous gas has usually been associated with a poor prognosis [1]. Newer modalities can identify smaller amounts of portal venous gas than plain radiographs and its presence is not always as serious as previously thought [2, 3]. The development of mesenteric and portal venous gas is related to a combination of mucosal damage, raised intraluminal pressure and sepsis. It may be iatrogenic or due to underlying disease as in this case [2, 4].
In this patient, large amounts of portal venous gas were present and the aetiology was suggested by gas tracking through mesenteric vessels from a small mass related to adjacent diverticular disease. It is rare to see gas in mesenteric veins, even on CT, and it is seldom visible on plain radiographs [5]. Identification of the source of sepsis allowed prompt intervention, with recovery of the patient and resolution of the intravenous gas.
In summary, when visualized on CT, portal venous gas does not always suggest a poor outcome. It should prompt a thorough scrutiny of the images for a possible source, which may be amenable to successful treatment.
Received for publication May 15, 2000.
Revision received August 29, 2000.
Accepted for publication September 25, 2000.
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