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Computed tomography scan of abdomen revealed a large collection of intrahepatic gas peripherally (fig 1) and dilated loops of intestine with pneumatosis (fig 2). Hypotension persisted despite aggressive volume resuscitation. Exploratory laparotomy revealed necrotic intestine from the proximal jejunum to the hepatic flexure. The necrotic intestine was resected, and jejunotransversostomy was performed.

Figure 2

Computed tomography scan demonstrating gas collections in the intestinal wall (black arrows), and a thickened oedematous intestinal wall (arrowhead). White arrow represents luminal air.

Intrahepatic gas may represent either an incidental finding or a life threatening condition. Intrahepatic gas may be present in either the biliary or portal venous systems. Computed tomography scan may help differentiate gas in the biliary system from that of the portal venous vasculature. Biliary gas tends to be located centrally in the hilar region in the larger bile ducts. In contrast, gas in the portal system extends to the smaller portal venous branches, resulting in a less localised peripheral distribution. Mucosal and submucosal bowel wall damage may allow some intraluminal air to enter the damaged or dissected bowel wall, leading to pneumatosis, and also to enter some intramural veins, leading to portal venous gas. Therefore, portal venous gas may be observed in any patient with severe inflammation of the intestinal walls—for example, necrotising enterocolitis, ulcerative colitis, Crohn’s disease, large ulcerating gastric carcinoma, appendicitis, and diverticulitis.

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