Ascending colon ischemic necrosis with hepatic portal venous gas: a case report

Abstract Background Hepatic portal venous gas (HPVG) is historically an ominous radiological sign. Although modern high-resolution computed tomography frequently detects benign HPVG, its presence in geriatric patients with extensive cardiovascular comorbidities remains a critical indicator of severe intestinal ischemia and impending necrosis. The diagnosis of non-occlusive mesenteric ischemia (NOMI) in this specific demographic is complicated by atypical clinical presentations and blunted neuro-inflammatory responses. Case presentation An 86-year-old female burdened with cardiovascular comorbidities presented with a three-day history of right lower quadrant pain. Despite severe leukocytosis and elevated inflammatory markers, she remained hemodynamically stable and lacked overt signs of rigid peritonitis. Initial contrast-enhanced CT revealed extensive HPVG, diminished mural enhancement of the ascending colon, and a proximal superior mesenteric artery (SMA) mural thrombus. Given the absence of peritonitis and the presence of preserved distal SMA flow, a trial of conservative management was initiated. A dynamic 24-hour follow-up CT demonstrated a reduction in HPVG. However, decisive indicators of progressive ischemic bowel-wall edema involving the ascending colon and emergent secondary paralytic ileus necessitated immediate operative intervention. An emergency diagnostic laparoscopy confirmed extensive ischemic necrosis of the right colon. A laparoscopic right hemicolectomy with an end ileostomy was performed, avoiding primary anastomosis. The patient experienced an uneventful recovery, was discharged within two weeks, and underwent a successful stoma reversal six months postoperatively, with a total follow-up period of 14 months. Conclusion Severe intestinal ischemia, particularly when driven by non-occlusive mechanisms (NOMI), exhibits a deceptive clinical nature in geriatric patients. Crucially, the transient resolution of HPVG on serial dynamic CT must never be misinterpreted as clinical improvement when accompanied by progressive bowel wall edema and secondary ileus. Early recognition of these specific radiological findings, paired with a minimally invasive surgical approach, yields favorable outcomes in vulnerable geriatric populations.