Pneumatosis intestinalis with extensive intrahepatic portal venous gas secondary to intra-abdominal sepsis: a rare occurrence

Description

A 32-year-old man presented with a 3-day history of abdominal pain, vomiting and diarrhoea. He was afebrile and haemodynamically stable (saturating at 97% on air with a respiratory rate of 15, his blood pressure was 117/65 with a heart rate of 78 bpm). Clinical examination revealed right iliac fossa tenderness with localised guarding. His inflammatory markers were raised (white cell count 21 x10⁹/L , neutrophils 16 and C-reactive protein 26). He was diagnosed with acute appendicitis and had an emergency open appendectomy. The operative findings were a periappendicular mass with a necrotic tip of appendix and pus within the abdomen.

Unfortunately he had a complex postoperative course. He developed paralytic ileus by day 3 and was managed conservatively via insertion of a nasogastric tube, rehydration with intravenous fluid and correction of his electrolyte imbalance. By day 6 he became febrile (39°), increasingly short of breath with a grossly distended non-tender...

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