An uncommon cause of coffee ground emesis : necrotizing enteritis with pneumatosis intestinalis

Hepatic Portal Venous Gas (HPVG) is a rare imaging finding and it used to be associated with a very high mortality rate of up to 75%, even after urgent laparotomy. In more recent decades abdominal CT and utrasound have resulted in the detection of HPVG in more non-fatal conditions such as diverticulitis, enteritis, colovenous fistulae, gastric dilatation and after endoscopic mucosal dissection (1). A 42-year old deaf-mute Caucasian man presented at the emergency department with coffee ground emesis. He complained that he had been suffering from anorexia for 4 consecutive days and also experienced postprandial abdominal pain. The patient was a non-smoker and had undergone a left colectomy 7 years ago for a volvulus. On presentation he was hypotensive and tachycardic. An ultrasound of the abdomen was performed and showed a dilated stomach in addition to dilated small intestinal loops. An urgent abdominal CT scan showed distinct pneumatosis intestinalis, mainly in the proximal jejunum and mesenterial free air with presence of air bubbles in the superior mesenteric vein and concurrent intrahepatic portal air without arguments for obstruction. No biliary or pancreatic abnormality was identified.