Dr. Leonardo Lidid A y cols. Revista Chilena de Radiología. Vol. 17 Nº 3, 2011; 120-125.

Air in periportal space: Beyond the classic triad

Drs. Leonardo Lidid A (1), Sebastián Yévenes A (2), Fabiola Vargas P (2).

1. Assistant Professor of Radiology. West Campus, School of Medicine, University of Chile. San Juan Dios Hospital.
Dipreca Hospital Staff.Santiago, Chile.
2. Radiology Resident. West Campus, School of Medicine, University of Chile. San Juan de Dios Hospital.Santiago, Chile.

Abstract: Intrahepatic gas, in particular when located in the bile duct and in the portal vein, has distinctive
morphological patterns especially evident on CT studies. This gas, however, may be found not only in these
places, but also in the periportal space, a little known extension of the subperitoneal space; it may exhibit intra-
hepatic distribution patterns similar to those already described, although with completely different pathological
and diagnostic implications. For these reasons we decided to characterize this sign and its CT findings, along
with its main differential diagnosis.
Keywords: Bile ducts, Cystoides intestinalis, Intestinal perforation, Pneumatosis, Pneumoperitoneum, Portal
system, Retroperitoneal space.

Resumen: El gas intrahepático, en particular el ubicado en relación con la vía biliar y la porta, tiene patrones
morfológicos característicos especialmente evidentes en los estudios por tomografía computada. El aire,sin
embargo, no solamente puede encontrarse en estos lugares, sino que también puede ubicarse en el espacio
periportal; una extensión poco conocida del espacio subperitoneal, con patrones de distribución intrahepáticos
similares a los ya descritos, pero con implicancias patológicas y diagnósticas completamente diferentes. Por
estas razones se decide caracterizar este signo y sus hallazgos en TAC, así como sus principales diagnósticos
diferenciales.
Palabras clave: Cystoides intestinalis, Ductos Biliares, Espacio Retroperitoneal, Perforación intestinal,
Pneumatosis, Pneumoperitoneo, Sistema portal.

Lidid L et al. Aire en el espacio periportal: más allá de la clásica tríada. Rev Chil Radiol 2011; 17 (3): 120-125.
Correspondence to: Dr. Leonardo Lidid A.
Mailing address: School of Medicine. West Campus. Universidad de Chile. Mail Box 33 052, 33. Santiago leolidid@gmail.com
Manuscript received June 3, 2011, Accepted for publication June 23, 2011.

Introduction of air at this level, its main differential diagnoses, and

Gas in the human body may exhibit many distribu-
tions, some normal, and some pathological. Concerning
the latter, the intrahepatic gas, mainly the one located
either in the bile duct or in the portal vein, presents
a typical distribution pattern, particularly evident on
CT studies. However, it may also have a very similar
distribution and yet not being directly linked to what is
commonly referred to as portal triad. Not only this gas
but also other pathological processes may affect the
periportal space, which implies an important range of
differential diagnoses, usually ignored when assessing
a CT study. In particular, lack of knowledge of this area
appears to have greater importance when working in
emergency care systems, especially in patients with
acute abdominal pathology. These reasons have led
us to fully describe this space, implications of presence
its morphological appearance on axial CT studies.
Periportal space
The Glisson capsule covers the liver surface
as an extension of the peritoneum, except for the
bare area. Glisson sheath corresponds to the por-
tion of the capsule surrounding the intrahepatic
portion of the hepatic portal system (Figure 1A).
The portal triad, nerves, and lymphatics (Figure 1b)
follow this path of connective tissue through the liver,
becoming an extension of the subperitoneal space
(subserosal) that comes from the gastrohepatic and
hepatoduodenal ligaments (Figure 2a-b)(1-3).
At hepatic level, the Glisson sheath also continues
to cephalic portion with the subperitoneal space of
ligamentum teres and falciform ligament (Figure 1a).

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1a 1b

Figure 1. a) Glisson capsule and Glisson sheath. The diagram depicts the continuity of the Glisson sheath, which extends
sorrouding the portal vein and its extension through the ligamentum teres and the falciform ligament (see Figure 3). b)
Periportal space. The diagram illustrates the portal vein (blue) and the structures of the periportal region which include the
hepatic artery (red), bile duct (green), lymphatics (white) and nerves (yellow). Interstitial connective tissue is not represented,
but it corresponds to the space between these structures.

2a 2b

Figure 2. a) Anatomical relationship between the portal triad, gastric antrum and duodenal bulb. The gastric antrum
and the duodenal bulb are attached to the lesser omentum. b) The liver and the various gastrointestinal tract segments
are interconnected by ligaments and mesenteries. Between the liver and the stomach, gastrohepatic ligaments and the
hepatoduodenal ligament are found. Subperitoneal space is the basis for the potential interconnection between retroperitoneum
and peritoneal cavity. This complex interconnecting space is mainly composed of fatty tissue that contains nerve structures,
vessels, and lymphatic tissue surrounded by serous layers which constitute the ligaments and mesenteries associated
with the major abdominal organs and viscera. Therefore, it represents an important pathway for disease spread within
the peritoneal cavity. The thick arrow in 2a) depicts the possible routes of air spread among the lesser omentum folds,
dissecting the periportal space.

Thus, the anatomical continuity of subperito-
neal space allows for disease dissemination,
both among intraperitoneal structures and bet-
ween extra- and intraperitoneal regions (1,4,5) .
Among the pathological phenomena that may use
the periportal route of spread, fluid (edema), blood,
inflammatory processes (pancreatic exudates), tu-
mor infiltrations (Figure 3), and air are included (1-3).
The latter is often associated, but not limited, to per-
forated viscus, mainly of the upper gastrointestinal
segment (especially if recent); intrahepatic gas may
be observed in periportal location as well as in the liver
fissure (by extension)surrounding the round ligament
(Figure 4), and continuing through this pathway even
to its umbilical insertion (1,3,6).
The gas, in this case, is located in the interstitial
tissue that surrounds the portal vein, showing intra
and extrahepatic distribution (Figure 5). However, both
the bile duct and the portal vein by themselves may,
under certain conditions, contain air and mimick the
distribution of above-described findings, especially
when there is little air.

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3a 3b 3c

Figure 3. Patient with peritoneal carcinomatosis of unknown primary site with invasion of periportal space and ligamentum
teres. More progressively cephalic slices. b) There is a carcinomatous mass compromising the interior of the lesser sac
(arrowheads), ventral to the pancreas (wide arrows), and in c) it invades the hepatic hilum, involving the periportal space
(black arrows); it communicates through this with the ligamentum teres (white arrows), which is better seen in b). Liver
metastases (*).

4a 4b 4c

4d

Figure 4. Abdominal CT images of a patient aged 73, admitted

with epigastric pain and vomiting of two weeks’ duration, secondary
to perforated antral ulcer. a-b) Axial and sagittal reconstruction of
perforated ulcer (white arrow), which determines communication
of gastric lumen (*) to an extraluminal air collection (a) visualized
regionally due to omentum with inflammatory phlegmon-like
mass(e). A fluid collection (c) in the subserosal space of the
lesser omentum (greater curvature) secondary to the above-
4e described perforation is also seen. c-d) Axial reconstructions
showing subperitoneal extension of the gas, seen both in the round
ligament (white arrowhead) and in thickened periportal interstitial
space [periportal edema] (black arrowheads). Initially, periportal
free air was viewed as biliary air; however, the intraoperative
cholangiogram (not shown) ruled it out. e) Detail of the left hepatic
lobe showing a branch of the left portal vein (P), flanked by two
hypodensities; the edematized periportal interstitium, partially
dissected by air, can be observed(arrowhead).

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5a 5b

5c

Figure 5. Male patient aged 48 with mesenteric ischemia,

portal venous air, and subsequent perforated viscus, with
subperitoneal air, and severe secondary pneumoperitoneu
m. a-b) Axial CT sections showing gas extension through
subperitoneal via, adjacent to the pancreas, to the splenic
vein (white arrowheads) and through the gastrosplenic
ligament (double barrel arrow). There is also cephalad spread
of air through the hepatoduodenal ligament, adjacent to the
common hepatic artery (black arrow head) and its own artery
(thick arrow). There is also intraportal gas (arrow) secondary
to ischemia. c) Coronal reconstruction that clearly illustrates
the extension of gas via hepatoduodenal ligament (thick
arrow) (compare with Figure 2a). Gas failed to dissect the
intrahepatic fissure; portal air is observed here(arrows).
There is also omental and retroperitoneal gas (arrowheads).
Pancreatic head (P). Free fluid and pneumoperitoneum (*).
Duodenum (D). Stomach (E). Lesser sac (T).

6a

Portal venous gas

Portomesenteric venous gas and its associated
finding, i.e., intestinal pneumatosis, represent signs
traditionally associated with a poor prognosis since
they generally indicate an acute intestinal injury, usually
either ischemic or infectious. Nevertheless, anything
altering the intestinal wall integrity and causing disrup-
tion of the mucosal surface may cause these findings,
which include pathological dilatation of bowel loops, 6b
intestinal ulcers, trauma, inflammatory bowel disease,
and surgical procedures, among others. Likewise,
there are a number of benign diagnoses that may be
associated with this signology, so it is higly relevant to
consider the clinical context of each individual patient(7,8).
On CT scans, images of air-filled tubular structu-
res may be observed; they ramify from the center
toward the periphery of the liver, even to reach the
capsule of this organ (Figure 6 ab) (8,9,10). Then,
depending on its volume, the air tends to have an
antigravitational distribution, predominantly in the left
liver lobe. Associated findings such as pneumatosis
intestinalis may also be observed (Figure 6 c-d)(7).

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6c 6d

Figure 6. Portal venous air. Same patient as in Figure 5. a) Scout view depicting pneumoperitoneum and portal venous
air. It is hard to define if gas is actually located in the portal vein (white arrows). Usually, the radiographic image appears to
be relatively nonspecific for this diagnosis, since it is often confused with aerobilia. Gas location is easier to be determined
on axial slices. b). Axial computed tomography image showing the portal vein (P) with air (white arrows) reaching the
capsule of the left hepatic lobe, pneumoperitoneum, and free fluid (*). c) Axial CT slices at a still more caudal level, showing
pathological loop dilatation with parietal thickening, and pneumatosis. Note how intramural gas (arrows) is separated from
the bowel lumen (L), which becomes more evident in d) due to its antigravitational position (arrow). Free subphrenic and
interloop fluid and interloops are also observed.

Gas in the biliary tract (aerobilia)

It refers to the accumulation of air in the biliary
tree secondary to multiple causes, being the most
frequent ones surgical biliary-enteric anastomosis,
spontaneous biliary-enteric fistulas, and incompe-
tence of the sphincter of Oddi (commonly iatroge- 7b
nic, secondary to post ERCP sphincterotomy, and
rarely due to non-iatrogenic causes, e.g., secondary
to recent passage of stones, among others). Less
common causes include infections (cholangitis), and
bronchopleural fistula (9).
On CT studies, gas has a typical distribution on
the Scout view (Figure 7 a) that correlates perfectly
with its morphology in the axial slices, where it is dis-
played as branches with air density that tend to have
a more central location, converging in the common
hepatic duct (due to centripetal flow of bile) (Figure
7 b-c), preferably occupying the left hepatic lobe, as
described concerning air in the portal vein. Due to bile
flow distribution, air in the periphery rarely extends
to within 2 cm of the liver capsule (Figure 7d)(9,11,12).

7a 7c

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7d
Figure 7. A 45-year-old female patient with biliary-digestive
bypass for recurrent pancreatitis secondary to anatomical
variation of the choledochopancreatic duct junction. a) Scout
View. Classical radiological image (simulating a “Y”) in the
right upper quadrant of the abdomen, corresponding to the
common right and left bile ducts. Intrahepatic bile duct with
air (black arrows) and common hepatic duct with air (white
arrow) just before its distal anastomosis. b) Contrast CT
scan axial cut showing biliary tract gas within 2 cm of the
liver capsule (black arrows). The bile duct of the posterior
aspect (white arrow) is dilated but with no air in its lumen
(antigravitational distribution). Portal vein (arrowhead). c)
Axial CT slice showing loop (top arrow) anastomosed to
the common hepatic duct(thin arrow). Also, biliary duct air
(black arrows), and drainage at the surgical site (broad
arrow)may be observed. d) Axial section from another
patient in which location of the air in biliary tract is more
clearly seen (black arrows), separated from the portal
vein (arrowhead). Incidentally, chronic liver damage and
sequelar focal dilatation of the posterior region of the bile
duct (without air) is seen (*).
Conclusions
Periportal space is rather unknown as a region of
abdominal pathology. It is best understood if considered
as an intrahepatic extension of the subperitoneal space
(mesenteric and retroperitoneal spaces). Although
periportal space may be affected by any process
of subperitoneal spread, the presence of air at this
level is highly suggestive of hollow viscus perforation,
mainly of its upper gastrointestinal segment; it must
be differentiated from its main differential diagnoses,
GASTROINTESTINAL
i.e., portal and biliary air, since its etiology and clinical
outcome are completely different.
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