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From question on page 768

The computed tomography (CT) scan shows intrahepatic gas with linear branching at the periphery, suggestive of gas in the portal venous system (fig 1). In addition, the sigmoid colon appears thick walled and abnormal (fig 2). This is different from air in the biliary tree (pneumobilia) where the low attenuation is central due to centripetal flow of bile.

On the basis of the CT findings, the patient underwent emergency laparotomy. An inflammatory mass involving the sigmoid colon was found. The liver appeared congested and mottled but the gall bladder was normal. The sigmoid colon was resected with end transverse colostomy formation. Postoperative recovery was unremarkable.

The presence of portal venous gas is not in itself a predictor of mortality; the clinical context is a more relevant prognosticator. Numerous conditions have been associated with its development, with no cause found in 15% of cases. Most can be managed non-operatively. However, surgical intervention is recommended in mesenteric ischaemia.

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