Hepatic portal venous gas from perforated sigmoid diverticulitis.

A 68-year-old man was seen in the emergency department with fever, rigors and left lower quadrant pain 2 days after being discharged from hospital for treatment of sigmoid diverticulitis. He was febrile (body temperature 40°C) and hypotensive (blood pressure 90/60 mm Hg). There was a firm, tender mass in the left lower quadrant. His leukocyte count was 19.7 × 109/L. Urgent CT revealed the unusual finding of gas scattered throughout the portal venous branches in the liver (Fig. 1). There was air in an abscess in the left retroperitoneum, and gas was seen in the inferior mesenteric vein (Fig. 2). A diagnosis of a retroperitoneal abscess and portal pyelophlebitis was made, secondary to perforated sigmoid diverticulitis. Emergency laparotomy revealed a large diverticular mass in the left lower quadrant and an abscess extending from the sigmoid mesentery into the left retroperitoneum. The abscess was evacuated and a Hartmann’s resection was performed. Blood cultures grew Enterococcus and Pseudomonas spp. The patient had an uncomplicated postoperative course, and the colostomy was closed 6 months later. Discussion