Series Editor: Herbert L. Fred, MD

Prepared by Bret J. Spier, MD, Internal Medicine Resident, and Gregory K. Nelligan, MD, Associate Professor, Division of Gastroenterology, Department of Medicine, University of Wisconsin Medical School, Madison

A 73-year-old man underwent esophagogastroduodenoscopy (EGD) with dilatation for an esophageal stricture. Shortly after the procedure, he developed neck pain, pleuritic chest pain, and dyspnea. Review of his history revealed no biliary tract manipulation. On physical examination, the patient was hemodynamically stable, with palpable crepitus in his neck anteriorly and mild epigastric tenderness without rebound or guarding. Computed tomography (CT) demonstrated extensive pneumomediastinum, pneumatosis of the gastric fundus, and hepatic venous air (Figure). Emergent esophagram revealed no extravasation of Gastrografin, suggesting no large perforation or tear. The patient received prophylactic antibiotics intravenously and was managed conservatively. Repeat CT revealed improvement, with no further extravasated air or abscess formation.

Figure—CT demonstrating hepatic venous air (arrows).

Points to remember: Complications of EGD can include bleeding, perforation, or esophageal tear. The finding of hepatic venous air in this patient can be explained by extravasation of air into the gastric veins, which return blood to the heart via the portal/hepatic venous system.

Diagnosis: Hepatic venous air from gastroesophageal perforation.