This document describes a case scenario of a 59-year-old woman who presented with nausea, epigastric pain, and hypotension. Blood tests showed abnormal liver function and imaging found gas in her liver parenchyma and portal veins. She was diagnosed with emphysematous hepatitis, a rare condition where gas forms in the liver due to infection, usually with fatal consequences. Risk factors in this case included diabetes, possible thrombus or embolism, and Klebsiella pneumoniae bacteria. The pathogenesis of emphysematous hepatitis remains unclear but involves gas-forming infection and alterations of the bowel wall or portal system allowing gas into the liver.

1. Gastroenterology Case Scenario
An Uncommon Cause for a Common Scenario
Waleed Mahrous

2. Case Scenario
 A 59-year-old woman presented to the
emergency department with nausea and
epigastric pain for 2 days preceded by 2 weeks
of anorexia. Several years ago, she was
diagnosed as glucose intolerant, but did not
receive regular follow-up. On examination, her
temperature was 34.8°C and her blood pressure
was 81/53 mm Hg. She had icteric
sclera, palpated tenderness in the upper right
quadrant of the abdomen, and hepatomegaly
(liver span of 14 cm at the midclavicular line).

3. Case Scenario
 Blood tests showed a leukocyte count of
5700/mm3, (55% neutrophils; 19% lymphocytes), a
glucose level of 347 mg/100 mL, an aspartate
aminotransferase level of 10,920 U/L, an alanine
aminotransferase level of 3,651 U/L, a total bilirubin of
4.8 mg/dL, and a creatinine level of 3.4 mg/100 mL.
Plain film of the chest was normal, but plain film of the
abdomen revealed a mottled appearance (Figure
A, arrowheads) with branching radiolucencies (Figure
A, arrows) in the liver. Hypotension persisted despite
maximum inotropic support and the use of broadspectrum antibiotics. She was hemodynamically
unstable and died within 20 hours. A blood culture
grew Klebsiella pneumoniae.

4. Case Scenario
Dr Waleed Kh. Mahrous
Dr Waleed Kh. Mahrous

5. Case Scenario

6. Case Scenario

7. Case Scenario
 Noncontrast computed tomography showed
extensive replacement of the liver parenchyma with
interstitial (Figure B, arrowheads) and bilateral
peripheral portal venous gas (Figure B, arrows).
 The patient was diagnosed with emphysematous
hepatitis (EH), which is equivalent to a severe
gas-forming liver infection and septic shock.
 In contrast with other affected organs, such as
emphysematous pyelonephritis or
cholecystitis, emphysematous changes in the liver
are extremely rare.

8. Case Scenario
 EH is fundamentally different from gas-forming pyogenic
liver abscesses, which are usually characterized by cluster
signs, septal breakage, or collections of pus.
 Computed tomography would show hepatic portal venous gas
and "alveolarization" of the hepatic parenchyma if the hepatic
structure adjacent to the portal system were also destroyed.
 To our knowledge, the previously reported cases of EH were
all fatal in a fulminant course within 8-72 hours after
arriving at the hospital.
 The potential etiologies in these reported cases were
bacteremia caused by suppuration from neighboring organs
or following a hepaticojejunostomy owing to orthotopic liver
transplantation or lobectomy.

9. Case Scenario
 The pathogenesis of EH remains unclear;
however, some factors have been implicated in our
case, including gas-forming bacteria (K.
pneumoniae) associated with an intra-abdominal
infection, a high serum glucose level, a thrombus or
gas embolus (during tissue necrosis and
disseminated intravascular coagulation) that in turn
alters the bowel wall, permitting intraluminal gas to
pass through the portal venous system into the liver
parenchyma in a vicious cycle.
 There is no definite treatment guideline for EH.

10. Portal venous gas
 Portal venous gas is merely the accumulation of
gas in the portal vein and its branches. It needs to be
distinguished from pneumobilia, pattern of gas
(i.e. peripheral in portal venous gas, central in
pneumobilia).
 Although traditionally considered a harbinger of
death, portal venous gas is increasingly recognized
in a variety of conditions, many of which do not carry
as high mortality or morbidity risks.

11. Portal venous gas
 Adult
 Alterations
of bowel wall
Ischaemic bowel (usually mural gas as well
as mesenteric gas : mortality of 75 - 90% :
but gas is not an independent predictor)
Necrotic / ulcerated colorectal carcinoma
(CRC)
Inflammatory bowel disease (IBD)
Perforated peptic ulcer

12. Portal venous gas
 bowel
luminal distention
Iatrogenic gastric and bowel dilatation (e.g
upper and lower endoscopic
procedures, enemas)
Paralytic ileus / mechanical obstruction
Acute gastric dilatation
Barotrauma.

13. Portal venous gas

Intra-abdominal sepsis
Diverticulitis
 Pelvic abscess
 Cholecystitis and Cholangitis
 Appendicitis


unknown mechanism
Pneumatosis intestinalis
 Chronic obstructive pulmonary disease (COPD)
 Corticosteroid usage
