The prognostic factors of adult patients with hepatic portal venous gas in the ED

Impact of Hepatic Portal Venous Gas on the Prognosis of Traumatic Out-of-Hospital Cardiac Arrest: A Reason to Consider Terminating Cardiopulmonary Resuscitation

Background

We evaluated the prognosis of traumatic out-of-hospital cardiac arrest (OHCA) by assessing the presence of hepatic portal vein gas (HPVG) observed in ultrasound (US) or point-of-care ultrasonography (POCUS) performed during CPR. Furthermore, we aimed to understand the role of HPVG in decision-making regarding CPR discontinuation or withholding in traumatic OHCA.

Methods

The retrospective study was conducted at the level 1 trauma center of urban academic medical centers in South Korea. We included adult trauma OHCA patients who underwent CPR between January 1, 2020, and June 30, 2022. Data on traumatic OHCA patients who presented to the level I trauma center during this period were extracted from the hospital's electronic medical record system. The arrest data were separately managed through the hospital's electronic medical record system for quality control, specifically the arrest registry. US images or clips of the hepatic portal vasculature (HPV) during CPR were used to assess the presence of HPVG. These images were independently reviewed by two emergency medicine physicians with several years of US examination experience who were blinded to all clinical details and outcomes. We evaluated the prognosis of traumatic OHCA by assessing the presence of HPVG using the US. In addition, we analyzed the general characteristics and assessed the impact on the ROSC in traumatic OHCA.

Results

Among the 383 cardiac arrest patients, 318 traumatic OHCA patients were included. The mean age was 54.9 ± 19.4 years, and most patients were male. The initial rhythm was mainly asystole, and falls were the most frequent cause of injury. The overall ROSC rate was 18.8%, with a survival rate of 7.2% at hospital discharge. Among the 50 patients who underwent a US examination of HPV, 40 showed HPVG. The HPVG group had a significantly lower ROSC rate and survival rate at ED discharge and hospital discharge compared to the group without HPVG.

Conclusion

Traumatic OHCA with HPVG presents a significantly worse prognosis. This suggests that early consideration of termination or withholding of CPR may be appropriate in such cases.

Sonographically Detected Hepatic Portal Venous Gas - Prevalence, Causes, and Clinical Implications

PURPOSE

 Hepatic portal venous gas (HPVG) is a rare clinical finding, often caused by a severe underlying disease. In the literature as well as in clinical practice, HPVG is considered "signum malum" with a poor prognosis and bowel ischemia as the most common cause. Most studies are based on the results of computed tomography (CT) examinations. The aim of this retrospective study is to report on the prevalence, causes, and clinical course of HPVG in a monocentric cohort of abdominal ultrasound (US) investigations.

MATERIALS AND METHODS

 The US database of an academic teaching hospital was searched with specific keywords (timespan 01/2000 to 12/2020). Reports, pictures, and clinical data of all cases with HPVG were re-evaluated.

RESULTS

 Out of 134 804 US examinations, 8 HPVG cases were identified. There was a wide variety of underlying diseases, with mesenteric ischemia being seen in only 2 cases. 5 patients were discharged in stable condition, with 4 of them having undergone surgical treatment. 2 patients who had rejected further measures died, and one was lost to follow-up.

DISCUSSION

 HPVG is a rare phenomenon in clinical US. However, ultrasonographic prevalence is comparable to the prevalence in CT studies. Underlying diseases are mostly severe, and in nearly all cases an underlying cause can be found by thorough investigation. In some cases, US may even be superior to CT scans for the detection of HPVG. Despite its rarity, every sonographer should know the typical sonographic presentation of HPVG, and appropriate images should be included in US teaching modules.

Conservative treatment of hepatic portal venous gas resulting from non-occlusive mesenteric ischemia: a case report

A 73-year-old man with severe intellectual disability, malnutrition, and hypoalbuminemia presented to our hospital after experiencing vomiting following dinner. Electrocardiography revealed a sinus rhythm. Plain abdominal radiography showed branching radiolucency in the liver. Abdominal computed tomography (CT) revealed branching gaseous foci of low density in the portal vein and its tributaries, suggesting the presence of hepatic portal venous gas (HPVG). Abdominal contrast-enhanced CT showed a segmental lack of contrast enhancement in the intestinal wall despite the absence of vascular occlusion in the main trunk and branches of the mesenteric artery. The patient was diagnosed with non-occlusive mesenteric ischemia (NOMI) accompanied by HPVG. Peripheral parenteral nutrition, antibiotic treatment, and human serum albumin were administered. The HPVG disappeared approximately 20 h after hospitalization. Intravascular dehydration associated with hypoalbuminemia was considered to be the cause of NOMI; the latter improved through the early correction of dehydration and hypoalbuminemia. The presence of HPVG is usually considered a diagnostic clue in patients with abdominal catastrophe and is associated with high mortality. However, the current case demonstrates the pitfalls of assessing the severity of the underlying condition based solely on the presence of HPVG.

Contrast-enhanced ultrasound of intrahepatic portal vein gas: Case report and review of literature

Portal vein gas is a rare imaging finding and a concomitant sign of abdominal disease. Here, we report a 64-year-old man with an emphasis on contrast-enhanced ultrasound for describing the findings for portal vein gas and evaluating liver blood perfusion. Ultrasonography is a favorable imaging modality for the rapid bedside evaluation and monitoring of portal vein gas in the emergency room.

Mortality in patients with hepatic gas on point-of-care ultrasound in cardiac arrest: Does location matter?

PURPOSE

Prior research has suggested an association of hepatic venous gas with mortality in cardiac arrest. As point of care ultrasound (POCUS) is frequently used in the context of resuscitation, we sought to evaluate if the presence of hepatic gas on POCUS had a similar mortality association.

METHODS

A retrospective review was conducted of patients who experienced nontraumatic cardiac arrest. Archived ultrasound images were independently reviewed to determine the presence of gas in the hepatic parenchyma and vasculature. Electronic medical records were then reviewed to collect remaining clinical data.

RESULTS

From 1 January 2017 through 16 June 2019, 87 patients met inclusion criteria. Among them, 68 (78.2%) patients died. Among those who died, 40 (58.8%) had hepatic gas, while 28 (41.2%) had none. Only a single survivor demonstrated hepatic venous gas (11%). While the difference in mortality with respect to presence of undifferentiated hepatic gas was not significant (P = .37), there was a significant difference with respect to the presence of venous gas (P = .004).

CONCLUSION

Our study demonstrated that the incidence of postarrest hepatic gas on POCUS was common, and that the presence of hepatic venous gas during cardiac resuscitation was associated with increased mortality, while hepatic parenchymal gas alone was not.

Optimal treatment strategies for hepatic portal venous gas: A retrospective assessment

BACKGROUND

Hepatic portal venous gas (HPVG) generally indicates poor prognoses in patients with serious intestinal damage. Although surgical removal of the damaged portion is effective, some patients can recover with conservative treatments.

AIM

To establish an optimal treatment strategy for HPVG, we attempted to generate computed tomography (CT)-based criteria for determining surgical indication, and explored reliable prognostic factors in non-surgical cases.

METHODS

Thirty-four cases of HPVG (patients aged 34-99 years) were included. Necessity for surgery had been determined mainly by CT findings (i.e. free-air, embolism, lack of contrast enhancement of the intestinal wall, and intestinal pneumatosis). The clinical data, including treatment outcomes, were analyzed separately for the surgical cases and non-surgical cases.

RESULTS

Laparotomy was performed in eight cases (surgical cases). Seven patients (87.5%) survived but one (12.5%) died. In each case, severe intestinal damage was confirmed during surgery, and the necrotic portion, if present, was removed. Non-occlusive mesenteric ischemia was the most common cause (n = 4). Twenty-six cases were treated conservatively (non-surgical cases). Surgical treatments had been required for twelve but were abandoned because of the patients' poor general conditions. Surprisingly, however, three (25%) of the twelve inoperable patients survived. The remaining 14 of the 26 cases were diagnosed originally as being sufficiently cured by conservative treatments, and only one patient (7%) died. Comparative analyses of the fatal (n = 10) and recovery (n = 16) cases revealed that ascites, peritoneal irritation signs, and shock were significantly more frequent in the fatal cases. The mortality was 90% if two or all of these three clinical findings were detected.

CONCLUSION

HPVG related to intestinal necrosis requires surgery, and our CT-based criteria are probably useful to determine the surgical indication. In non-surgical cases, ascites, peritoneal irritation signs and shock were closely associated with poor prognoses, and are applicable as predictors of patients' prognoses.

Portal Venous Gas in Adults: Clinical Significance, Management, and Outcomes of 25 Consecutive Patients

BACKGROUND

Portal venous gas (PVG) is a rare finding and has a grave prognosis. The most common and critical underlying pathology of PVG is bowel necrosis. However, bowel necrosis is sometimes difficult to accurately diagnose. We retrospectively analyzed data from patients that contributed to the decision to perform emergency surgery and bowel resection.

METHODS

Between 2009 and 2019, 25 consecutive adult patients with PVG were identified retrospectively and divided into the Operation and Non-operation groups. The Operation group was further subdivided into the Bowel resection and Non-resection groups. Clinical, laboratory, and radiographic variables were analyzed.

RESULTS

Conservative management was successful for 32% (8/25) of patients (Non-operation group: mortality 0%); 68% (17/25) were treated surgically (Operation group: mortality 35.3%). In the Operation group, 52.9% (9/17) underwent bowel resection (Bowel resection group: mortality 55.6%); however, bowel resection was unnecessary in 47.1% (8/17) of cases (Non-resection group: mortality 12.5%). Univariate analysis revealed significant differences between the Operation and Non-operation groups in GCS, APACHE II, abdominal distention, CRP, lactate, and CT findings of bowel dilatation, pneumatosis intestinalis, and attenuation of contrast effects of the bowel wall. However, with the exception of GCS, there was no significant difference between the Bowel resection and Non-resection groups.

CONCLUSIONS

Analysis of clinical, laboratory, and radiographic variables can inform decisions on conservative management. However, 47.1% of the present patients who underwent surgery for suspected bowel necrosis did not require bowel resection, suggesting that this approach alone may not be sufficient to avoid non-therapeutic laparotomy. A new approach should be developed to improve this situation.

Hepatic portal venous gas associated with transcathete cardiac defibrillator implantation: A case report

INTRODUCTION

Hepatic Portal Venous Gas (HPVG) is a rare pathological condition that may be caused by iatrogenic factors.

CASE REPORT

A 66-year-old Chinese male patient with HPVG underwent laparotomy for chronic bowel ischemia. Transcathete cardiac defibrillator was implanted via left subclavian vein for ventricular tachycardia.

DISCUSSION

There are many hypotheses about how gas runs through the intestine into the mesenteric portal venous system. HPVG patients can be improved through comprehensive management. Patients with mesenteric ischemia should be observed in hospital and after discharge, and need surgical intervention if chronic bowel ischemia recurs.

CONCLUSION

This case proves the usefulness of comprehensive management in treating HPVG. Prognosis of HPVG should consider the pathological changes contributing to HPVG.

Rapid Emergency Medicine Score: A novel prognostic tool for predicting the outcomes of adult patients with hepatic portal venous gas in the emergency department

Objective

This study aims to evaluate the performance of Rapid Emergency Medicine Score (REMS), Rapid Acute Physiology Score (RAPS), and Modified Early Warning Score (MEWS) in ascertaining the severity of illness and predicting the mortality of adult hepatic portal venous gas (HPVG) patients presenting to the emergency department (ED). This will assist emergency physicians (EPs) in risk stratification.

Methods

Data for 66 adult HPVG patients who visited the EDs of 2 research hospitals between October 1999 and April 2016 were analyzed. REMS, RAPS, and MEWS were calculated based on data in the ED, and probability of death was calculated for each patient based on these scores. The ability of REMS, RAPS, and MEWS to predict group mortality was assessed by using receiver operating characteristic (ROC) curve analysis and calibration analysis.

Results

The sensitivity, specificity, and accuracy for each scoring system were 92.1%, 89.3%, and 90.9% for REMS, 86.8%, 82.1%, and 84.8% for RAPS, and 78.9%, 89.3%, and 83.3% for MEWS respectively. In the ROC curve analysis, the areas under the curve for REMS, RAPS, and MEWS were 0.929, 0.877, and 0.856 respectively.

Conclusion

Our study is the largest series performed in a population of adult HPVG patients in the ED. The results from this study demonstrate that REMS is superior in predicting the mortality of these patients compared to RAPS and MEWS. We therefore recommend that REMS be used for outcome prediction and risk stratification of adult HPVG in the ED.

Role of Computed tomography in predicting prognosis of Hepatic portal venous gas

•

When hepatic portal venous gas is diagnosed on computed tomography, the first etiology that radiologist should look for is the intestinal necrosis.

•

The association of hepatic portal venous gas and pneumatosis intestinalis is highly suggestive of acute mesenteric ischemia.

•

Abundance of hepatic portal venous gas on CT is not correlated with prognosis.

Background

The aim of this study was to report through 13 cases the particularities of abdominal computed tomography (CT) aspects of hepatic portal venous gas (HPVG) and its correlation with patient prognosis.

Methods

We analyzed abundance of HPVG and its association with pneumatosis intestinalis (PI) in correlation with fatal outcome using chi-square tests.

Results

Etiologies were mesenteric infarction (n = 5), sigmoid diverticulitis (n =  1), septic shock (n = 1), postoperative peritonitis (n = 1), acute pancreatitis (n = 1), iatrogenic cause (n = 3) and idiopathic after a laparotomy (n = 1). The outcome was fatal in for 6 patients. Abundance of HPV was expressed in total number of hepatic segments involved. The involvement of 3 or more segments was a sensitive sign for lethal outcome with high sensitivity (100%) but it was not specific (50%). Negative predictive value of this sign was 100% (p ≤ 0.005). Positive predictive value of PI for death was 100% (p ≤ 0.001).

Discussion

Abundance of HPVG is correlated with prognosis. The presence of PI announces poor outcome Negative predictive value of presence of HPVG in 3 or more segments is interesting. Predicting prognosis with CT can help surgeons to assess the most adequate treatment. Iatrogenic causes are increasingly described after interventional radiology procedures with favorable course.

Conclusion

The first etiology radiologists should look for in front of HPVG involving more than 3 hepatic segments and associated with PI is intestinal necrosis which announces a poor prognosis. This study shows that outside of shock situations, HPVG involving 2 or less hepatic segments without PI predicts a good outcome.

Asymptomatic hepatic portal venous gas with gastric emphysema as a chronic complication of gastrostomy tube placement: a case report

Background

Percutaneous endoscopic gastrostomy feeding is widely used as a route for enteral feeding for patients with impaired swallowing ability, particularly in older patients. Hepatic portal venous gas is a condition that may arise from several causes. Hepatic portal venous gas that develops after an endoscopic procedure is generally reported to be nonfatal, yet there is little information available concerning the characteristics of hepatic portal venous gas as a chronic complication of percutaneous endoscopic gastrostomy feeding.

Case presentation

We experienced a case of hepatic portal venous gas that happened to be detected in an 81-year-old Japanese man with long-term percutaneous endoscopic gastrostomy use who was admitted to our hospital with aspiration pneumonia. While aspiration pneumonia was treated with antibiotics and suspension of tube feedings, he recovered from hepatic portal venous gas without any treatment.

Conclusions

The presence of a percutaneous endoscopic gastrostomy tube may have induced hepatic portal venous gas through a mechanism in which vomiting led to increased abdominal pressure and eventually gastric emphysema. This case suggests that hepatic portal venous gas without any signs of bowel ischemia or emphysematous gastritis can resolve without treatment, which is a finding that could be helpful for clinicians who deal with those supported by percutaneous endoscopic gastrostomy feeding.

Clinical outcomes in surgical and non-surgical management of hepatic portal venous gas

Backgrounds/Aims

Hepatic portal venous gas (HPVG) is a rare condition, with poor prognosis and a mortality rate of up to 75%. Indications for surgical and non-surgical management of HPVG including associated complications and mortality remain to be clarified.

Methods

From January 2008 to December 2014, 18 patients with HPVG diagnosed through abdominal computed tomography (CT) imaging were retrospectively identified. Clinical symptoms, laboratory data, underlying diseases, treatment, and mortality rate were analyzed. Patients were classified into 2 groups: surgical management recommended (SR, n=10) and conservative management (CM, n=8). The SR group was further subdivided into patients who underwent surgical management (SM-SR, n=5) and those who were managed conservatively (NS-SR, n=5).

Results

Conditions underlying HPVG included mesenteric ischemia (38.9%), intestinal obstruction (22.2%), enteritis (22.2%), duodenal ulcer perforation (5.6%), necrotizing pancreatitis (5.6%), and diverticulitis (5.6%). In terms of mortality, 2 patients (40%) died in the SM-SR group, 1 (12.5%) in the CM group, and 100% in the NS-SR group. Higher scores from Acute Physiology and Chronic Health Evaluation (APACHE) II predicted the mortality rates of the NS-SR and CM groups.

Conclusions

Identification of HPVG requires careful consideration for surgical management. If surgical management is indicated, prompt laparotomy should be performed. However, even in the non-surgical management condition, aggressive laparotomy can improve survival rates for patients with high APACHE II scores.

Chronic tubo-ovarian abscess complicated by hepatic portal venous gas

44-year-old female with massive chronic tubo-ovarian abscess complicated by hepatic portal venous gas (HPVG). She presented to the emergency department of our hospital with a diffusely tender abdomen and 2 weeks history of frequent non-bloody loose stools. She had a relevant past medical history of poorly controlled type 1 diabetes mellitus and hypertension. Abdominal computerized tomography revealed massive right abdomino-pelvic mass measuring 17.6 × 12.1 × 20 cm and diffuse HPVG. Patient underwent exploratory laparotomy, salpingo-oophorectomy, peritoneal lavage with antibiotics and treatment for septic shock. No similar case known to us has been reported in the literature previously.

Performance assessment of the Simplified Acute Physiology Score II, the Acute Physiology and Chronic Health Evaluation II score, and the Sequential Organ Failure Assessment score in predicting the outcomes of adult patients with hepatic portal venous gas in the ED

OBJECTIVE

This study aims to evaluate the performance of Simplified Acute Physiology Score II (SAPS II), the Acute Physiology and Chronic Health Evaluation II (APACHE II) score, and the Sequential Organ Failure Assessment (SOFA) score for predicting illness severity and the mortality of adult hepatic portal venous gas (HPVG) patients presenting to the emergency department (ED). This will assist emergency physicians in risk stratification.

METHODS

Data for 48 adult HPVG patients who visited our ED between December 2009 and December 2013 were analyzed. The SAPS II, APACHE II score, and SOFA score were calculated based on the worst laboratory values in the ED. The probability of death was calculated for each patient based on these scores. The ability of the SAPS II, APACHE II score, and SOFA score to predict group mortality was assessed by using receiver operating characteristic curve analysis and calibration analysis.

RESULTS

The sensitivity, specificity, and accuracy were 92.6%,71.4%, and 83.3%, respectively, for the SAPS II method; 77.8%, 81%, and 79.2%, respectively, for the APACHE II scoring system, and 77.8%, 76.2%, and 79.2%, respectively, for the SOFA score. In the receiver operating characteristic curve analysis, the areas under the curve for the SAPS II, APACHE II scoring system, and SOFA score were 0.910, 0.878, and 0.809, respectively.

CONCLUSION

This is one of the largest series performed in a population of adult HPVG patients in the ED. The results from the present study showed that SAPS II is easier and more quickly calculated than the APACHE II and more superior in predicting the mortality of ED adult HPVG patients than the SOFA. We recommend that the SAPS II be used for outcome prediction and risk stratification in adult HPVG patients in the ED.