COTW April 24: The Case of the...What on Earth is Going On with that RUQ?

A 65 year old F with a history of ESRD on HD came in with severe abdominal pain and hypotension that began during her dialysis session.

On exam she was tender, hypotensive 70/40, but not particularly ill appearing. A bedside ultrasound of the RUQ showed the following:

COTW Portal System Pneumatosis.gif

A CT scan demonstrated “gas throughout the portal vein and the portal venous system in the liver” as well as “areas of pneumatosis involving the small bowel some of which  demonstrate thickened wall” which were “findings concerning for small bowel ischemia.”

CTA of the abdomen showed no vascular explanation for small bowel ischemia. The patient went to the OR but was found not to have ischemic bowel.

The patient was admitted to the ICU and placed on pressor support, pain control and IVF hydration and was discharged a few days later.

The working theory is that she developed transient mesenteric ischemia secondary to hypovolemia due to fluid shifts related to her dialysis.