Portomesenteric vein gas: pathologic mechanisms, CT findings, and prognosis

Portomesenteric vein gas is a rare condition whose pathogenesis is not fully understood. Portomesenteric vein gas is most commonly caused by mesenteric ischemia but may have a variety of other causes. The primary factors that favor the development of this pathologic entity are intestinal wall alterations, bowel distention, and sepsis. Portomesenteric vein gas is idiopathic in approximately 15% of cases. Advanced imaging techniques such as computed tomography (CT) have increased the sensitivity for detection of portomesenteric vein gas. At CT, portal vein gas appears as tubular areas of decreased attenuation in the liver, predominantly in the left lobe. Gas in the great mesenteric veins can easily be demonstrated with contrast material-enhanced CT, whereas gas in the small mesenteric veins appears as tubular or branched areas of decreased attenuation in the mesenteric border of the bowel. Findings of portomesenteric vein gas at CT should be carefully evaluated in the context of clinical findings. In the majority of cases, the prognosis is favorable and surgery is not required. However, when CT demonstrates portomesenteric vein gas and clinical findings suggest the presence of mesenteric ischemia, surgery is mandatory.