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Liu A, Shen J, Long L, Shi X, Wen Q, Pan Z. Hepatic portal venous gas initially manifesting as severe shock: a case series. J Int Med Res 2024; 52:3000605241239469. [PMID: 38603615 PMCID: PMC11010767 DOI: 10.1177/03000605241239469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Accepted: 02/28/2024] [Indexed: 04/13/2024] Open
Abstract
Hepatic portal venous gas is often referred to as the "sign of death" because it signifies a very poor prognosis if appropriate treatments are not promptly administered. The etiologies of hepatic portal venous gas are diverse and include severe complex abdominal infections, mesenteric ischemia, diving, and complications of endoscopic surgery, and the clinical manifestations are inconsistent among individual patients. Thus, whether emergency surgery should be performed remains controversial. In this report, we present three cases of hepatic portal venous gas. The patients initially exhibited symptoms consistent with severe shock of unknown etiology and were treated in the intensive care unit upon admission. We rapidly identified the cause of each individual patient's condition and selected problem-directed intervention measures based on active organ support, antishock support, and anti-infection treatments. Two patients recovered and were discharged without sequelae, whereas one patient died of refractory infection and multiple organ failure. We hope that this report will serve as a valuable reference for decision-making when critical care physicians encounter similar patients.
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Affiliation(s)
- Anwei Liu
- Department of Intensive Care Unit, the General Hospital of Southern Theater Command, the Chinese People’s Liberation Army, Guangzhou, China
| | - Jiao Shen
- Department of Intensive Care Unit, the General Hospital of Southern Theater Command, the Chinese People’s Liberation Army, Guangzhou, China
| | - Liansheng Long
- Department of General Surgery, the General Hospital of Southern Theater Command, the Chinese People’s Liberation Army, Guangzhou, China
| | - Xuezhi Shi
- Department of Intensive Care Unit, the General Hospital of Southern Theater Command, the Chinese People’s Liberation Army, Guangzhou, China
| | - Qiang Wen
- Department of Intensive Care Unit, the General Hospital of Southern Theater Command, the Chinese People’s Liberation Army, Guangzhou, China
| | - Zhiguo Pan
- Emergency Department, the General Hospital of Southern Theater Command, the Chinese People’s Liberation Army, Guangzhou, China
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Chen L, Yan X, Yu X. Pneumatosis intestinalis and hepatic portal venous gas in patient with Amanita exitialis poisoning: A case report from Shenzhen, China. Toxicon 2023; 234:107276. [PMID: 37742873 DOI: 10.1016/j.toxicon.2023.107276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Revised: 08/09/2023] [Accepted: 08/29/2023] [Indexed: 09/26/2023]
Abstract
A 57-year-old male admitted as an emergency for mushroom poisoning with hypovolemic shock, acute renal injury (Cr 213 μmol/L) and metabolic acidosis (pH 7.1). Twenty-six hours ago, he consumed 4 caps of wild mushrooms and presented with acute gastroenteritis, generalized malaise and lower limbs jerk. On ICU admission, he developed ventricular defibrillation and was resuscitated with intubation and ventilation. In addition to plasma exchange and hemoperfusion therapy, the patient was managed with massive fluid and potassium replacement, vasopressors, activated charcoal, silymarin, penicillin G and piperacillin tazobactam. On ICU Day 2, the patient's general condition improved with vasopressor ceased, renal function normalized except large amount of diarrhea. On ICU Day 3, the patient deteriorated again with worsening abdominal distension leading to intra-abdominal hypertension (IAH). Toxic liver injury by mushroom became significant. Repeated acute renal injury, deranged clotting and compromised hemodynamics were also noted which indicated acute abdominal compartment syndrome. Emergent computed tomography (CT) of abdomen revealed Pneumatosis intestinalis (PI) in the small intestines and hepatic portal venous gas (HPVG) in the left liver lobe. Water assisted colonoscopy decompression was performed emergently for IAH relief. Thereafter, the patient improved rapidly with organ dysfunction recovered next day. Acute liver failure gradually subsided. On ICU Day 8, the patient was discharged to general ward. The mushroom was later morphologically identified as Amanita exitialis (A. exitialis) by at least two specialists from Chinese Centre for Disease Control and Prevention (CDC). A. exitialis is a lethal mushroom that mainly affect liver and gastrointestinal (GI) tract. The current case and literature review suggest that the severity of GI injury caused by lethal A. exitialis may be underestimated.
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Affiliation(s)
- Lanchun Chen
- Department of Intensive Care Medicine, The Second Affiliated Hospital, School of Medicine, The Chinese University of Hong Kong, Shenzhen, China
| | - Xianrang Yan
- Department of Intensive Care Medicine, The Second Affiliated Hospital, School of Medicine, The Chinese University of Hong Kong, Shenzhen, China
| | - Xuetao Yu
- Department of Intensive Care Medicine, The Second Affiliated Hospital, School of Medicine, The Chinese University of Hong Kong, Shenzhen, China.
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Mehl L, Schmidt C, Weidner U, Lock G. Sonographically Detected Hepatic Portal Venous Gas - Prevalence, Causes, and Clinical Implications. ULTRASCHALL IN DER MEDIZIN (STUTTGART, GERMANY : 1980) 2023; 44:408-413. [PMID: 35483869 DOI: 10.1055/a-1797-9986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
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.
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Affiliation(s)
- Lisa Mehl
- Internal Medicine, Albertinen Hospital, Hamburg, Germany
| | | | - Ulrike Weidner
- Institute for Radiology, Albertinen Hospital, Hamburg, Germany
| | - Guntram Lock
- Internal Medicine, Albertinen Hospital, Hamburg, Germany
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Tohma T, Kobe Y, Yoshida M, Ushio M. Portal venous gas accompanied by gallbladder torsion: a case report. J Surg Case Rep 2022; 2022:rjac491. [PMID: 36329779 PMCID: PMC9624199 DOI: 10.1093/jscr/rjac491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 10/05/2022] [Indexed: 11/06/2022] Open
Abstract
Portal venous gas (PVG) generally suggests critically ill conditions such as severe bowel ischemia. We herein report a rare case of gallbladder torsion with PVG. An 88-year-old woman complained of right hypogastric pain. Ultrasonography (US) showed diffuse wall thickening of her gallbladder and mobile echogenic foci moving inside the portal venous branches. Computed tomography showed a thickened wall of the gallbladder with poor enhancement and tiny pockets of air in the portal venous branches (segments 4 and 5). There was no evidence of other visceral ischemia. She was diagnosed with necrotic cholecystitis and immediately underwent an emergency operation. We found a gangrenous gallbladder with 180° clockwise rotation along the longitudinal axis and performed cholecystectomy. We confirmed the disappearance of PVG with US after the operation. Her postoperative course was uneventful. Gallbladder diseases can produce PVG, and US might be a useful diagnostic modality to evaluate changes in PVG.
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Affiliation(s)
| | - Yoshiro Kobe
- Department of Acute Care Surgery, Chiba Emergency Medical Center, Chiba, Japan
| | - Mitsuhiko Yoshida
- Department of Acute Care Surgery, Chiba Emergency Medical Center, Chiba, Japan
| | - Masaya Ushio
- Department of Acute Care Surgery, Chiba Emergency Medical Center, Chiba, Japan
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Zhang Y, Liu HL, Tang M, Wang H, Jiang HH, Lin MB. Clinical features and management of 20 patients with hepatic portal venous gas. Exp Ther Med 2022; 24:525. [PMID: 35837035 PMCID: PMC9257953 DOI: 10.3892/etm.2022.11452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 06/08/2022] [Indexed: 11/06/2022] Open
Abstract
The present study investigated the characteristics, diagnosis, treatment and prognosis of hepatic portal venous gas (HPVG) using the data of 20 patients from the Tongji University School of Medicine Affiliated with Yangpu Hospital (Shanghai, China). The aim of the present study was to optimize the management method and improve the prognosis of patients with HPVG. A total of 20 patients were selected using a CT scan to confirm HPVG. All patients were enrolled and identified via a search engine, which examined all CT radiology reports containing the words pneumatosis and/or portal venous gas/air. Data were collected and analyzed, including sex, age, laboratory evidence, etiologies at admission, therapeutic method and in-hospital mortality. The patients consisted of 14 women (mean age, 79.1 years) and six men (mean age, 67.8 years). The results demonstrated that HPVG indicated a higher inflammatory index. The etiologies of HPVG included abdominal infection, pulmonary infection and hemorrhage, whereas the comorbidities included hypertension, diabetes, coronary disease, cerebrovascular disease and renal insufficiency. The present study determined that intestinal obstruction, acute enteritis and pulmonary infection were the main causes of HPVG. Of the 20 patients enrolled in the present study, four patients received surgery and 16 patients received conservative treatment. The overall in-hospital mortality was 25%. The present study indicated that the causes of HPVG may be closely related to inflammation and blood vessel injury. It was also determined that hemodynamic disorders of the intestinal tract and the combination of different types of infection were important contributors towards patient mortality.
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Affiliation(s)
- Yuan Zhang
- Department of General Surgery, Yangpu Hospital, School of Medicine, Tongji University, Shanghai 200090, P.R. China
| | - Hai-Long Liu
- Department of General Surgery, Yangpu Hospital, School of Medicine, Tongji University, Shanghai 200090, P.R. China
| | - Min Tang
- Department of General Surgery, Yangpu Hospital, School of Medicine, Tongji University, Shanghai 200090, P.R. China
| | - Hui Wang
- Department of General Surgery, Yangpu Hospital, School of Medicine, Tongji University, Shanghai 200090, P.R. China
| | - Hui-Hong Jiang
- Department of General Surgery, Yangpu Hospital, School of Medicine, Tongji University, Shanghai 200090, P.R. China
| | - Mou-Bin Lin
- Department of General Surgery, Yangpu Hospital, School of Medicine, Tongji University, Shanghai 200090, P.R. China
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Zorzetti N, Lauro A, Ruffato A, D'Andrea V, Ferruzzi L, Antonacci N, Tranchino RM. Gas in the Portal Vein: An Emergency or Just Hot Air? Dig Dis Sci 2021; 66:3290-3295. [PMID: 34189669 DOI: 10.1007/s10620-021-07126-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/16/2021] [Indexed: 12/17/2022]
Abstract
We report the case of a 87-year-old woman admitted to our Emergency Department for mild abdominal pain associated with vomiting. An abdominal X-ray showed gas present in the portal venules of the left hepatic lobe, a finding associated with numerous surgical and medical conditions. The patient was successfully managed with conservative treatment. Isolated intrahepatic gas is a rare radiologic finding; emergency surgery should be performed only when there are signs of associated acute intestinal infarction.
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Affiliation(s)
- N Zorzetti
- Department of General Surgery, "Ospedale Civile Umberto I", Lugo, Ravenna, Italy.
| | - A Lauro
- Department of Surgical Sciences, Sapienza University, Rome, Italy
| | - A Ruffato
- Department of General Surgery, "Ospedale Civile Umberto I", Lugo, Ravenna, Italy
| | - V D'Andrea
- Department of Surgical Sciences, Sapienza University, Rome, Italy
| | - L Ferruzzi
- Department of General Surgery, "Ospedale Civile Umberto I", Lugo, Ravenna, Italy
| | - N Antonacci
- Department of General Surgery, "Ospedale Civile Umberto I", Lugo, Ravenna, Italy
| | - R M Tranchino
- Department of General Surgery, "Ospedale Civile Umberto I", Lugo, Ravenna, Italy
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Cordella A, Bertolini G. Multiphase multidetector-row CT reveals different patterns of hepatic portal venous gas and pneumobilia. Vet Radiol Ultrasound 2020; 62:68-75. [PMID: 33245597 DOI: 10.1111/vru.12928] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 08/06/2020] [Accepted: 09/04/2020] [Indexed: 02/06/2023] Open
Abstract
Hepatic portal venous gas and pneumobilia (PB) are uncommon findings, indicating the accumulation of gas in the portal vein and its branches and in the biliary tree, respectively. Aims of this retrospective, descriptive study were to describe the computed tomographic (CT) features and visualization techniques of hepatic portal venous gas (HPVG) and PB in a group of small animal veterinary patients. The CT data of patients with HPVG and PB were retrospectively reviewed. Thin-section multiplanar reformatting and minimum intensity projection (MinIP) views were used to assess the acquired volume dataset. The CT features recorded were as follows: amount, aspect, distribution, and localization of the gas in the liver. Five patients were included (four dogs and one cat), two presenting HPVG and three with PB. Gas in HPVG presented a peripheral location, whereas in PB was characterized by a central location. The aspect of the gas was tubular in case of HPVG and mixed tubular and rounded in PB. An analogous number of animals between the two groups showed comparable amount (mild, moderate, and severe) and distribution (diffuse and focal). Thin-section CT can detect the presence of gas in the liver, and a combination of two-dimensional and thin-slab MinIP can differentiate between HPVG and PB in dogs and cats. The distinctive features are peripheral versus central location and tubular versus rounded aspect of the gas.
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Affiliation(s)
- Alessia Cordella
- Diagnostic and Interventional Radiology Division, San Marco Veterinary Clinic and Laboratory, Padua, Italy
| | - Giovanna Bertolini
- Diagnostic and Interventional Radiology Division, San Marco Veterinary Clinic and Laboratory, Padua, Italy
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Hong S. Reply on "Successful Conservative Management of Hepatic Portal Venous Gas due to Anastomosis Leakage After a Sigmoidectomy". Ann Coloproctol 2020; 36:212. [PMID: 32919436 PMCID: PMC7508479 DOI: 10.3393/ac.2019.08.12] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 08/12/2019] [Indexed: 11/24/2022] Open
Affiliation(s)
- Seongwoo Hong
- Department of Surgery, Inje University Seoul Paik Hospital, Seoul, Korea
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Carannante F, Capolupo GT, Mascianà G, Caricato M. Hepatic Portal Venous Gas and Anastomotic Leakage. Ann Coloproctol 2020; 36:211. [PMID: 32919435 PMCID: PMC7508481 DOI: 10.3393/ac.2019.06.13] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Accepted: 06/13/2020] [Indexed: 12/18/2022] Open
Affiliation(s)
| | | | - Gianluca Mascianà
- Colorectal Surgery Unit, Campus Bio-Medico University of Rome, Italy
| | - Marco Caricato
- Colorectal Surgery Unit, Campus Bio-Medico University of Rome, Italy
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Türkel Küçükmetin N, Çiçek B, Baba F. An unusual colonoscopic complication of inflammatory bowel disease. TURKISH JOURNAL OF GASTROENTEROLOGY 2020; 31:272-273. [PMID: 32343240 DOI: 10.5152/tjg.2020.19127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- Nurten Türkel Küçükmetin
- Department of Gastroenterology, Acıbadem Mehmet Ali Aydınlar University School of Medicine, İstanbul, Turkey
| | - Bahattin Çiçek
- Department of Gastroenterology, Acıbadem Mehmet Ali Aydınlar University School of Medicine, İstanbul, Turkey
| | - Füsun Baba
- Department of Pathology, Acıbadem International Hospital, İstanbul, Turkey
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Mehta S, Desai GS, Shah S, Mehta H, Phadke A. Hepatic Portal Venous Gas: An Ill Omen or a Misleading Sign. Surg J (N Y) 2020; 6:e37-e41. [PMID: 32133413 PMCID: PMC7054055 DOI: 10.1055/s-0040-1702919] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 01/14/2020] [Indexed: 12/25/2022] Open
Abstract
Hepatic portal venous gas (HPVG), a rare radiological finding, is historically considered an ominous sign with 100% mortality rates. The dictum that HPVG warrants surgical intervention is challenged in the recent literature. This is because of the identification of various causes of HVPG other than bowel gangrene. Most of these newly identified causes can be managed conservatively. However, bowel gangrene, if missed, is fatal. Hence, sound clinical judgment and accurate diagnosis based on specific clinical parameters and imaging findings are important. We present a case of a young male with tumor lysis syndrome and neutropenic sepsis. He underwent treatment for a relapse of T-cell acute lymphocytic leukemia and presented with abdominal pain and distension. Computed tomography (CT) scan showed HPVG, and the differential diagnosis was neutropenic colitis or pseudomembranous colitis, with steroid use as the probable cause. The patient was managed conservatively. The case emphasizes that the evaluation for a specific cause of HPVG is important to reduce unnecessary surgery. A succinct literature review provides the reasons for the changing mortality rates.
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Affiliation(s)
- Shruti Mehta
- Department of Internal Medicine, Lilavati Hospital and Research Centre, Mumbai, Maharashtra, India
| | - Gunjan S Desai
- Department of Surgical Gastroenterology, Lilavati Hospital and Research Centre, Mumbai, Maharashtra, India
| | - Saumil Shah
- Department of Internal Medicine and Medical Gastroenterology, Lilavati Hospital and Research Centre, Mumbai, Maharashtra, India
| | - Hitesh Mehta
- Department of Surgical Gastroenterology, Lilavati Hospital and Research Centre, Mumbai, Maharashtra, India
| | - Aniruddha Phadke
- Department of Internal Medicine and Medical Gastroenterology, Lilavati Hospital and Research Centre, Mumbai, Maharashtra, India
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