Differential Diagnosis for Portal Venous Gas in the Liver on CT

The patient's presentation of sharp chest pain radiating to the right jaw, along with the finding of portal venous gas (PVG) on CT, requires a thoughtful approach to differential diagnosis. PVG can be associated with a range of conditions, some of which are life-threatening. Here's a categorized differential diagnosis:

• Single Most Likely Diagnosis

  • Pulmonary Embolism (PE) with PVG: The initial presentation of sharp chest pain radiating to the jaw could suggest a pulmonary embolism. While PVG is not a common direct consequence of PE, the embolism could potentially lead to hypoxia or other complications that indirectly result in PVG. However, this would be an unusual presentation and might not directly explain the PVG without other complicating factors.

• Other Likely Diagnoses

  • Mesenteric Venous Thrombosis: This condition could lead to PVG and might not initially present with abdominal pain or tenderness, especially in early stages. The chest pain could be unrelated or a referred pain.
  • Hepatic Artery Thrombosis or Embolism: Although less common, this could lead to liver ischemia and potentially PVG. The initial chest pain might be unrelated or due to a complication.

• Do Not Miss Diagnoses

  • Necrotizing Hepatitis or Liver Infarct: Conditions that lead to liver necrosis can produce PVG. These are serious and potentially life-threatening conditions that require immediate attention.
  • Budd-Chiari Syndrome: Thrombosis of the hepatic veins can lead to PVG and might present with abdominal pain, but early stages could be asymptomatic or present with atypical symptoms.
  • Septic Emboli: In the context of bacteremia or sepsis, septic emboli could lodge in the liver, causing abscesses and PVG. This diagnosis is critical to identify due to its high mortality if untreated.

• Rare Diagnoses

  • Intrahepatic Shunting: Certain conditions that cause abnormal shunting within the liver could potentially lead to PVG, though this would be an unusual cause.
  • Idiopathic Portal Venous Gas: In some cases, PVG can occur without an identifiable cause, though this is exceedingly rare and would require extensive investigation to rule out other causes.

Each of these diagnoses requires careful consideration of the patient's clinical presentation, laboratory findings, and imaging results. The presence of PVG is a significant finding that necessitates a thorough evaluation to determine the underlying cause and appropriate management.