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Zhang Q, Meng H, Chen Y, Meng F. Bezoar as a cause of portal vein pneumatosis: a case report. J Int Med Res 2023; 51:3000605231180540. [PMID: 37377054 DOI: 10.1177/03000605231180540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/29/2023] Open
Abstract
Pneumatosis of the portal vein is considered a rare imaging sign rather than a disease. It usually occurs in patients with digestive tract diseases such as intestinal obstructive diseases, mesenteric vascular diseases, closed abdominal trauma, and liver transplantation. Because of its high mortality rate, it is also termed the "sign of death." Hawthorn contains tannic acid, and seafood is rich in calcium, iron, carbon, iodine, and other minerals and proteins. Thus, consuming both hawthorn and seafood together can result in the formation of an indigestible complex in the body, acting as the main pathogenic factor in patients with intestinal obstruction. We herein describe a patient with duodenal obstruction caused by hawthorn who developed the hepatic portal venous gas sign and was cured by nonsurgical treatment.
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Affiliation(s)
- Qing Zhang
- Department of Cardiology, China-Japan Union Hospital of Jilin University, Changchun, Jilin 130033, China
- Jilin Provincial Engineering Laboratory for Endothelial Function and Genetic Diagnosis of Cardiovascular Disease, Changchun, Jilin 130033, China
- Jilin Provincial Molecular Biology Research Center for Precision Medicine of Major Cardiovascular Disease, Jilin Provincial Cardiovascular Research Institute, Changchun, Jilin 130033, China
- Jilin Provincial Precision Medicine Key Laboratory for Cardiovascular Genetic Diagnosis, Changchun, Jilin 130033, China
| | - Heyu Meng
- Department of Cardiology, China-Japan Union Hospital of Jilin University, Changchun, Jilin 130033, China
- Jilin Provincial Engineering Laboratory for Endothelial Function and Genetic Diagnosis of Cardiovascular Disease, Changchun, Jilin 130033, China
- Jilin Provincial Molecular Biology Research Center for Precision Medicine of Major Cardiovascular Disease, Jilin Provincial Cardiovascular Research Institute, Changchun, Jilin 130033, China
- Jilin Provincial Precision Medicine Key Laboratory for Cardiovascular Genetic Diagnosis, Changchun, Jilin 130033, China
| | - Yanqiu Chen
- Department of Cardiology, China-Japan Union Hospital of Jilin University, Changchun, Jilin 130033, China
- Jilin Provincial Engineering Laboratory for Endothelial Function and Genetic Diagnosis of Cardiovascular Disease, Changchun, Jilin 130033, China
- Jilin Provincial Molecular Biology Research Center for Precision Medicine of Major Cardiovascular Disease, Jilin Provincial Cardiovascular Research Institute, Changchun, Jilin 130033, China
- Jilin Provincial Precision Medicine Key Laboratory for Cardiovascular Genetic Diagnosis, Changchun, Jilin 130033, China
| | - Fanbo Meng
- Department of Cardiology, China-Japan Union Hospital of Jilin University, Changchun, Jilin 130033, China
- Jilin Provincial Engineering Laboratory for Endothelial Function and Genetic Diagnosis of Cardiovascular Disease, Changchun, Jilin 130033, China
- Jilin Provincial Molecular Biology Research Center for Precision Medicine of Major Cardiovascular Disease, Jilin Provincial Cardiovascular Research Institute, Changchun, Jilin 130033, China
- Jilin Provincial Precision Medicine Key Laboratory for Cardiovascular Genetic Diagnosis, Changchun, Jilin 130033, China
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Reginelli A, Sangiovanni A, Vacca G, Belfiore MP, Pignatiello M, Viscardi G, Clemente A, Urraro F, Cappabianca S. Chemotherapy-induced bowel ischemia: diagnostic imaging overview. Abdom Radiol (NY) 2022; 47:1556-1564. [PMID: 33811514 PMCID: PMC9038829 DOI: 10.1007/s00261-021-03024-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 02/19/2021] [Accepted: 02/25/2021] [Indexed: 12/19/2022]
Abstract
Cancer patients need multimodal therapies to treat their disease increasingly. In particular, drug treatment, as chemotherapy, immunotherapy, or various associations between them are commonly used to increase efficacy. However, the use of drugs predisposes a percentage of patients to develop toxicity in multiple organs and systems. Principle chemotherapy drugs mechanism of action is cell replication inhibition, rapidly proliferating cells especially. Immunotherapy is another tumor therapy strategy based on antitumor immunity activation trough agents as CTLA4 inhibitors (ipilimumab) or PD-1/PD-L1 inhibitors as nivolumab. If, on the one hand, all these agents inhibit tumor growth, on the other, they can cause various degrees toxicity in several organs, due to their specific mechanism of action. Particularly interesting are bowel toxicity, which can be clinically heterogeneous (pain, nausea, diarrhea, enterocolitis, pneumocolitis), up to severe consequences, such as ischemia, a rare occurrence. However, this event can occur both in vessels that supply intestine and in submucosa microvessels. We report drug-related intestinal vascular damage main characteristics, showing the radiological aspect of these alterations. Interpretation of imaging in oncologic patients has become progressively more complicated in the context of “target therapy” and thanks to the increasing number and types of therapies provided. Radiologists should know this variety of antiangiogenic treatments and immunotherapy regimens first because they can determine atypical features of tumor response and then also because of their eventual bowel toxicity.
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Affiliation(s)
- Alfonso Reginelli
- Department of Precision Medicine, University of Campania "L. Vanvitelli,", 80138, Naples, Italy.
| | - Angelo Sangiovanni
- Department of Precision Medicine, University of Campania "L. Vanvitelli,", 80138, Naples, Italy
| | - Giovanna Vacca
- Department of Precision Medicine, University of Campania "L. Vanvitelli,", 80138, Naples, Italy
| | - Maria Paola Belfiore
- Department of Precision Medicine, University of Campania "L. Vanvitelli,", 80138, Naples, Italy
| | - Maria Pignatiello
- Department of Precision Medicine, University of Campania "L. Vanvitelli,", 80138, Naples, Italy
| | - Giuseppe Viscardi
- Department of Precision Medicine, University of Campania "L. Vanvitelli,", 80138, Naples, Italy
| | - Alfredo Clemente
- Department of Precision Medicine, University of Campania "L. Vanvitelli,", 80138, Naples, Italy
| | - Fabrizio Urraro
- Department of Precision Medicine, University of Campania "L. Vanvitelli,", 80138, Naples, Italy
| | - Salvatore Cappabianca
- Department of Precision Medicine, University of Campania "L. Vanvitelli,", 80138, Naples, Italy
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Mehmood A, Essrani R, Parvataneni S, Iqbal U. Unique Case of Gastroenteritis Presenting as Pneumatosis Intestinalis With Emphysematous Gastritis and Portal Vein Gas: Do Not Take Gastroenteritis Lightly. Cureus 2020; 12:e8765. [PMID: 32676256 PMCID: PMC7362622 DOI: 10.7759/cureus.8765] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Accepted: 06/22/2020] [Indexed: 11/29/2022] Open
Abstract
Pneumatosis intestinalis (PI) consists of multiple, thin, gas-filled cysts in the wall of the gastrointestinal (GI) tract. It is an uncommon entity that can involve any gastrointestinal site from the stomach to the rectum. Isolated stomach involvement is rare. PI can represent a broad spectrum of diseases with variable prognoses. We present the case of a patient who was admitted with gastroenteritis-like symptoms. He remained hemodynamically stable, and on further imaging with contrast-enhanced computed tomography of the abdomen and pelvis, air was found in the portal vein and gastric wall, with minimal thickening of the proximal small bowel concerning for emphysematous gastroenteritis. Further workup results were negative, including blood cultures, stool studies, Clostridium difficile toxins, and lactic acid levels. The patient was managed nonoperatively and recovered without serious complications. Our case is unique in terms of the presence of air in the portal vein, which would otherwise suggest the possible spread of infection across the bowel wall.
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Affiliation(s)
- Asif Mehmood
- Internal Medicine, Geisinger Medical Center, Danville, USA
- Internal Medicine, Abington Hospital - Jefferson Health, Abington, USA
| | - Rajesh Essrani
- Internal Medicine, Geisinger Medical Center, Danville, USA
- Internal Medicine, Lehigh Valley Health Network, Allentown, USA
| | | | - Umair Iqbal
- Internal Medicine, Geisinger Commonwealth School of Medicine, Danville, USA
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4
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Chou DW, Wey KC. Emphysematous liver abscess with hepatic portal venous gas. Intern Emerg Med 2019; 14:1335-1336. [PMID: 31485818 DOI: 10.1007/s11739-019-02184-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2019] [Accepted: 08/22/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Deng-Wei Chou
- Department of Critical Care Medicine, Tainan Municipal Hospital (Managed by Show Chwan Medical Care Corporation), Tainan, Taiwan.
- Department of Nursing, Chung Hwa University of Medical Technology, Tainan, Taiwan.
| | - Keh-Cherng Wey
- Department of Internal Medicine, Tainan Municipal Hospital (Managed by Show Chwan Medical Care Corporation), Tainan, Taiwan
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Torres US, Fortes CD, Salvadori PS, Tiferes DA, D′Ippolito G. Pneumatosis From Esophagus to Rectum: A Comprehensive Review Focusing on Clinico-Radiological Differentiation Between Benign and Life-Threatening Causes. Semin Ultrasound CT MR 2018; 39:167-182. [DOI: 10.1053/j.sult.2017.09.002] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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Cruz C, Abujudeh HH, Nazarian RM, Thrall JH. Ischemic colitis: spectrum of CT findings, sites of involvement and severity. Emerg Radiol 2015; 22:357-65. [PMID: 25732355 DOI: 10.1007/s10140-015-1304-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2015] [Accepted: 02/13/2015] [Indexed: 02/06/2023]
Abstract
To summarize the frequency of findings on IV contrast, enhanced computer tomography (CT) in 335 patients with pathologically proven ischemic colitis (IC) determine the most frequent locations and patterns of involvement and establish the correlation of these findings with the severity of IC. 231 patients were excluded for not having a concomitant CT or for having underlying comorbidities. 104 cases were analyzed. Scans were evaluated for abnormal wall enhancement (AE), bowel wall thickening (BWT), bowel dilatation (DIL), mesenteric fat stranding (FS), venous engorgement (VE), pericolonic free fluid (FF), and pneumatosis (PN) and portomesenteric venous gas. Segmental versus pancolonic involvement was noted. Severity was determined by histopathology criteria. Data obtained are as follows: female to male incidence, 69 % (70) vs. 31 % (34); average age, 64.5; and positive CT, 102/104 (98.1 %). The most frequent findings include FS (88 %), BWT (88 %), and AE (82 %) regardless of severity of involvement. Statistically significant increased risk ratio and likelihood of severe ischemia for PN, DIL, and FF individually. BWT, DIL, FS, FF, VE, and PN together have a probability for severe IC of 91.8 %. A correlation between fewer findings and milder IC was found (R (2) = 0.6771). The most frequently involved segments: descending (64 %) and sigmoid colon (54 %). Splenic flexure (SF) was infrequently involved (n = 8, 7.84 %). Females had two times higher incidence of IC. The most frequent CT findings in IC are FS, BWT, and AE regardless of the severity. PN is suggestive of severe IC. Segmental involvement is the predominant pattern. The distal colon is more frequently involved. SF contrary to the conventional literature is not disproportionately involved in IC.
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Affiliation(s)
- Cinthia Cruz
- , 25 New Chardon Street 449A, Boston, MA, 02114, USA,
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7
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Wong MF, Lien WC. Hepatic Portal Venous Gas in a COPD Patient. J Med Ultrasound 2014. [DOI: 10.1016/j.jmu.2013.10.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
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Tseng CY, Chiu YH, Chuang JL, Chen JD, Huang HH, How CK, Yen DHT, Huang MS. How to differentiate spontaneous intramural intestinal hemorrhage from acute mesenteric ischemia. Am J Emerg Med 2013; 31:1586-90. [PMID: 24051008 DOI: 10.1016/j.ajem.2013.08.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Revised: 08/08/2013] [Accepted: 08/09/2013] [Indexed: 01/20/2023] Open
Abstract
OBJECTS The purpose of our study was to assess the diagnostic values of laboratory tests to differentiate spontaneous intramural intestinal hemorrhage (SIIH) from acute mesenteric ischemia (AMI) after abdominal computed tomography (CT) survey in the emergency department (ED). METHOD We retrospectively included 76 patients diagnosed SIIH or AMI after abdominal CT. RESULTS The mean ages of 28 SIIH patients and 48 AMI patients were 75.9 ± 13.7 years and 75.8 ± 11.6 years, respectively. Patients with SIIH had significantly higher rate of Coumadin use (P < .001) and localized tenderness (P < .05). In laboratory findings, SIIH patients had prolonged prothrombin time (PT) (83.6 ± 30.0 vs. 13.4 ± 3.2, P < .001), lower blood urea nitrogen (P < .05), lower creatinine (P < .05), and lower creatine kinase (P < .05). Prolonged PT showed good discriminative value to differentiate acute abdomen patients with SIIH from AMI after abdominal CT, with an area under the receiver operating characteristic curve of 0.980 (95% confidence interval, 0.918-0.998; P < .0001). Prolonged PT cut-off value of ≧22.5 seconds had a sensitivity of 92.9% and a specificity of 100%. Logistic regression analysis identified prolonged PT as an independent predictor of SIIH (odds ratio, OR, 22.2; P = .007). CONCLUSION Abdominal pain patients with either SIIH or AMI are rare in the ED, but abdominal CT sometimes cannot help to differentiate them due to similar CT findings. Prolonged PT might help emergency physicians and surgeons differentiate SIIH from AMI in such cases.
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Affiliation(s)
- Chia-Ying Tseng
- Department of Emergency Medicine, Taichung Veterans General Hospital, Taichung 407, Taiwan; Emergency Medicine, College of Medicine, National Yang-Ming University, Taipei 112, Taiwan
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Lee JY, Han HS, Lim SN, Shim YK, Choi YH, Lee OJ, Lee KH, Kim ST. Pneumatosis intestinalis and portal venous gas secondary to Gefitinib therapy for lung adenocarcinoma. BMC Cancer 2012; 12:87. [PMID: 22405425 PMCID: PMC3314573 DOI: 10.1186/1471-2407-12-87] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2011] [Accepted: 03/10/2012] [Indexed: 12/13/2022] Open
Abstract
Background Pneumatosis intestinalis (PI), defined as the presence of gas in the bowel wall, and portal venous gas (PVG) are relatively rare radiological findings. Although several chemotherapeutic agents and anti-vascular endothelial growth factor agents are reported to be associated with PI and PVG, an association with anti-epidermal growth factor receptor (EGFR) agents has not been described previously. Case presentation The present report describes a case of PI and PVG secondary to treatment with an EGFR tyrosine kinase inhibitor. A 66-year-old woman who had been diagnosed with metastatic lung adenocarcinoma presented with nausea, vomiting and abdominal distension after commencing gefitinib. A computed tomography (CT) scan of the abdomen revealed PI extending from the ascending colon to the rectum, hepatic PVG, and infarction of the liver. Gefitinib therapy was discontinued immediately and the patient was managed conservatively. A follow-up CT scan 2 weeks later revealed that the PI and hepatic PVG had completely resolved. Conclusion This is the first report of PI and PVG caused by EGFR tyrosine kinase inhibitor. Although these complications are extremely rare, clinicians should be aware of the risk of PI and PVG in patients undergoing targeted molecular therapy.
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Affiliation(s)
- Joo Young Lee
- Department of Internal Medicine College of Medicine, Chungbuk National University, 410 Seongbong-ro, Heungduk-Gu, Cheongju 361-711, South Korea
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Shah PA, Cunningham SC, Morgan TA, Daly BD. Hepatic gas: widening spectrum of causes detected at CT and US in the interventional era. Radiographics 2012; 31:1403-13. [PMID: 21918051 DOI: 10.1148/rg.315095108] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The spectrum of causes of hepatic gas detected at computed tomography (CT) and ultrasonography (US) is widening. There are many iatrogenic and noniatrogenic causes of hepatic parenchymal, biliary, hepatic venous, and portal venous gas. Hepatic gas may be an indicator of serious acute disease (infarct, infection, abscess, bowel inflammation, or trauma). In other clinical scenarios, it may be an expected finding related to therapeutic interventions (such as surgery; hepatic artery embolization for a tumor or for active bleeding in acute trauma cases; percutaneous tumor ablation performed with radiofrequency, cryotherapy, laser photocoagulation, or ethanol). In some cases, hepatic gas is an incidental finding of no clinical significance. Familiarity with the expanding list of newer intervention-related causes of hepatic gas detected at CT and US, knowledge of the patient's clinical history, and a careful search for associated clues on images are all factors that may allow the radiologist to better determine the clinical relevance of this finding.
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Affiliation(s)
- Priti A Shah
- Department of Diagnostic Radiology and Surgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA
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Idris M, Khan N, Memon WA, Kashif N, Humayun S, Zubairi T. Portal Venous Gas Secondary to Gangrenous Gallbladder and Mirizzi Syndrome Diagnosed by Gray-Scale Sonography but Not on 64-Slice MDCT: A Case Report and Literature Review. JOURNAL OF DIAGNOSTIC MEDICAL SONOGRAPHY 2011; 27:81-84. [DOI: 10.1177/8756479311401915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
Portal venous gas is a rare entity that is associated with many fatal and nonfatal conditions. Its exact etiology remains unclear. Computed tomography (CT) has been described as a sensitive and primary imaging tool for detecting this condition, but there are only a few case reports in the literature where portal venous gas was not detected on CT scan but was found by sonography. This case reports portal venous gas developing secondary to gangrenous gallbladder with Mirizzi syndrome which was diagnosed by sonography but remained undetected on 64-slice MDCT.
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Affiliation(s)
- Muhammad Idris
- Department of Radiology, Aga Khan University Hospital, Karachi, Pakistan,
| | - Nadir Khan
- Department of Radiology, Aga Khan University Hospital, Karachi, Pakistan
| | - Wasim A. Memon
- Department of Radiology, Aga Khan University Hospital, Karachi, Pakistan
| | - Nazia Kashif
- Department of Radiology, Aga Khan University Hospital, Karachi, Pakistan
| | - Sidra Humayun
- Department of Radiology, Aga Khan University Hospital, Karachi, Pakistan
| | - Talha Zubairi
- Department of Radiology, Aga Khan University Hospital, Karachi, Pakistan
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12
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Chou CT, Su WW, Chen RC. Successful conservative treatment of pneumatosis intestinalis and portomesenteric venous gas in a patient with septic shock. Kaohsiung J Med Sci 2010; 26:105-8. [PMID: 20123600 DOI: 10.1016/s1607-551x(10)70016-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
Pneumatosis intestinalis (PI) and portomesenteric venous gas (PMVG) are alarming radiological findings that signify bowel ischemia. The management of PI and PMVG remain a challenging task because clinicians must balance the potential morbidity associated with unnecessary surgery with inevitable mortality if the necrotic bowel is not resected. The combination of PI, portal venous gas, and acidosis typically indicates bowel ischemia and, inevitably, necrosis. We report a patient with PI and PMVG caused by septic shock who completely recovered after conservative treatment.
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Affiliation(s)
- Chen-Te Chou
- Department of Radiology, Changhua Christian Hospital, Er-Lin branch, Taipei, Taiwan
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13
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Lamparter S, Goecke W, Koehler HH. Hepatic portal venous gas after upper endoscopy in a patient with a gastrointestinal stromal tumor. JOURNAL OF CLINICAL ULTRASOUND : JCU 2009; 37:401-402. [PMID: 19475552 DOI: 10.1002/jcu.20598] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
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Sakurai Y, Hikichi M, Isogaki J, Furuta S, Sunagawa R, Inaba K, Komori Y, Uyama I. Pneumatosis cystoides intestinalis associated with massive free air mimicking perforated diffuse peritonitis. World J Gastroenterol 2008; 14:6753-6. [PMID: 19034985 PMCID: PMC2773324 DOI: 10.3748/wjg.14.6753] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2008] [Revised: 10/21/2008] [Accepted: 10/28/2008] [Indexed: 02/06/2023] Open
Abstract
While pneumatosis cystoides intestinalis (PCI) is a rare disease entity associated with a wide variety of gastrointestinal and non-gastrointestinal disorders, PCI associated with massive intra- and retroperitoneal free air is extremely uncommon, and is difficult to diagnose differentially from perforated peritonitis. We present two cases of PCI associated with massive peritoneal free air and/or retroperitoneal air that mimicked perforated peritonitis. These cases highlight the clinical importance of PCI that mimics perforated peritonitis, which requires emergency surgery. Preoperative imaging modalities and diagnostic laparoscopy are useful to make an accurate diagnosis.
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Ijuin H, Tokitoku D, Atsuchi Y, Kosaihira T, Nagamine M, Nozaki K, Arima T, Takahama T, Ishida H. Flaming portal vein as a new color Doppler sign of portal gas: report of two cases. J Med Ultrason (2001) 2008; 35:119-23. [PMID: 27278834 DOI: 10.1007/s10396-008-0184-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2007] [Accepted: 02/04/2008] [Indexed: 11/24/2022]
Abstract
Portal gas is relatively rare, and the majority of reported cases have shown it to have a close relation to bowel diseases. At present, portal exploration usually begins with color Doppler sonography, and clinicians now possess a good understanding of color Doppler findings of a wide spectrum of portal abnormalities. However, the color Doppler sign we present in this article has not been reported before. We report two cases of ischemic bowel disease in which B-mode ultrasound showed multiple hyperechoic spots moving in the portal vein; the color Doppler appearance was as if the portal vein was on fire (flaming portal vein sign). Knowledge of this simple color Doppler sign helps to improve the diagnostic strategies in patients with portal gas.
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Affiliation(s)
- Hiroyasu Ijuin
- Department of Internal Medicine, Tenyokai Chuo Hospital, 6-7 Izumi, Kagoshima, 892-0822, Japan.
| | - Daigo Tokitoku
- Department of Internal Medicine, Tenyokai Chuo Hospital, 6-7 Izumi, Kagoshima, 892-0822, Japan
| | - Yoshihiko Atsuchi
- Department of Internal Medicine, Tenyokai Chuo Hospital, 6-7 Izumi, Kagoshima, 892-0822, Japan
| | - Tomohisa Kosaihira
- Department of Internal Medicine, Tenyokai Chuo Hospital, 6-7 Izumi, Kagoshima, 892-0822, Japan
| | - Mio Nagamine
- Department of Clinical Laboratory, Tenyokai Chuo Hospital, Kagoshima, Japan
| | - Kayoko Nozaki
- Department of Clinical Laboratory, Tenyokai Chuo Hospital, Kagoshima, Japan
| | - Takeshi Arima
- Department of Surgery, Tenyokai Chuo Hospital, Kagoshima, Japan
| | | | - Hideaki Ishida
- Center of Diagnostic Ultrasound and Department of Radiology, Red Cross Hospital, Akita, Japan
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Kung D, Ruan DT, Chan RK, Ericsson ML, Saund MS. Pneumatosis intestinalis and portal venous gas without bowel ischemia in a patient treated with irinotecan and cisplatin. Dig Dis Sci 2008; 53:217-9. [PMID: 17530401 DOI: 10.1007/s10620-007-9846-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2006] [Accepted: 04/05/2007] [Indexed: 02/06/2023]
Abstract
Pneumatosis intestinalis and gas within the portal venous system are findings predictive of bowel ischemia. The etiologies of these alarming radiographic signs are diverse and not all causes require emergent surgical intervention. The combination of pneumatosis intestinalis, portal venous gas, and acidosis typically portends bowel ischemia and inevitable necrosis. This case report is the first description of benign pneumatosis and portal venous gas secondary to irinotecan and cisplatin.
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Affiliation(s)
- David Kung
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA
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Pan HB, Huang JS, Yang TL, Liang HL. Hepatic portal venous gas in ultrasonogram--benign or noxious. ULTRASOUND IN MEDICINE & BIOLOGY 2007; 33:1179-83. [PMID: 17467157 DOI: 10.1016/j.ultrasmedbio.2007.01.014] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/12/2006] [Revised: 01/05/2007] [Accepted: 01/12/2007] [Indexed: 05/15/2023]
Abstract
The purpose of this study was to investigate and differentiate the characteristics of benign hepatic portal venous gas (HPVG) and noxious HPVG on sonographic images. This study included seven patients (age 65 to 89 y; mean 75 y) with sonograms and computed tomography (CT) images performed within 4-h interval. The sonographic findings of HPVG could be categorized into three patterns: (1) dot-like pattern in two patients; (2) streak-like pattern in three patients; and (3) fruit-pulp-like pattern in two. In the cases of dot-like pattern, it is of a benign transient situation; this phenomenon may be only demonstrated on sonograms but not necessarily on CT. The prognosis is more favorable and any subsequent CT may not be required. In the cases of streak-like or fruit-pulp-like patterns without localized liver lesions (e.g., abscess), it usually indicates a noxious scenario with worse clinical sequelae. We concluded that the identification of sonographic patterns of HPVG might be important to predict patient's outcome.
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Affiliation(s)
- Huay-Ben Pan
- Department of Radiology, Kaohsiung Veterans General Hospital, Kaohsiung, Taiwan
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18
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Monneuse O, Pilleul F, Barth X, Gruner L, Allaouchiche B, Valette PJ, Tissot E. Portal Venous Gas Detected on Computed Tomography in Emergency Situations: Surgery Is Still Necessary. World J Surg 2007; 31:1065-71. [PMID: 17429565 DOI: 10.1007/s00268-006-0589-0] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
BACKGROUND Portal venous gas (PVG) has been reported to be associated with lethal surgical diagnosis. Recent studies tend to confirm the clinical significance of gas in the portal vein; however, some patients are managed without surgical treatment. The aim of this study was to assess both the diagnoses and the treatment of patients with PVG in an emergency surgical setting. MATERIALS AND METHODS We performed a retrospective chart review of 15 patients with PVG in the emergency setting detected by computed tomography (CT) between July 1999 and July 2004. Characteristics assessed included age, sex, clinical presentation, first CT diagnosis of both PVG and the underlying pathology, American Society of Anesthesiologists (ASA) score, surgical findings, final clinical diagnosis, duration of hospitalization, and evolution of the illness/mortality. All patients were examined one month after operation. RESULTS This series of 5 women and 10 men ranged in age from 38 to 90 years at the time they underwent emergency surgical treatment. The mean preoperative ASA score was 4.20. Computed tomography diagnosed the underlying pathology in all cases: bowel obstruction (4 cases), bowel necrosis (9 cases), and diffuse peritonitis (2 cases). The mean length of hospital stay was 12.4 days. The mortality rate was 46.6%; (7 patients). CONCLUSIONS A wide range of pathologies can generate PVG. Computed tomography can detect both the presence of gas and the underlying pathology. In emergency situations, all the diagnosed causal pathologies required a surgical procedure without delay. We report that the prognosis was related to the pathology itself and was not influenced by the presence of PVG.
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Affiliation(s)
- Olivier Monneuse
- Digestive and Emergency Surgery Department, Hôpital Edouard Herriot, Pavillon G visceral, 5 Place d'Arsonval, 69437, Lyon Cedex 03, France.
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Magrach LA, Martín E, Sancha A, García M, Cendoya I, Olabarria I, Gómez-Portilla A, Tejada I, Carrero C, López de Torre J, García-Urra JA, Echavarri J. [Hepatic portal venous gas. Clinical significance and review of the literature]. Cir Esp 2006; 79:78-82. [PMID: 16539944 DOI: 10.1016/s0009-739x(06)70824-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Hepatic portal venous gas in adults is a rare entity. The most frequent cause is intestinal ischemia. However, an increasing number of cases associated with benign conditions suitable for conservative treatment are being reported. We review the literature to define the clinical significance of portal venous gas, the role of computed tomography, and the need to perform emergency exploratory laparotomy.
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Affiliation(s)
- Luis Alberto Magrach
- Servicio de Cirugía General y Aparato Digestivo, Hospital Santiago Apóstol, Vitoria, Alava, Spain.
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20
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Schindera ST, Triller J, Vock P, Hoppe H. Detection of hepatic portal venous gas: its clinical impact and outcome. Emerg Radiol 2006; 12:164-70. [PMID: 16547739 DOI: 10.1007/s10140-006-0467-y] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2005] [Accepted: 12/16/2005] [Indexed: 12/18/2022]
Abstract
The clinical impact and outcome of a rare radiographic finding of hepatic portal venous gas (HPVG) as well as the effectiveness of computed tomography (CT), CT scanogram, and conventional radiography in the detection of HPVG were retrospectively analyzed. CT scans, CT scanogram, and plain film radiographs of 11 patients with HPVG were reviewed and compared with their medical records and surgical and pathology reports. Eight of the 11 patients underwent plain film radiographs 1 day before or after the CT scan. HPVG was detected at CT in all 11 patients, on CT scanogram in three (3 of 11, 27.3%), and on plain films in one (one of eight, 12.5%). In nine of 11 patients (81.8%), CT revealed an associated pneumatosis intestinalis. In six of the 11 patients (54.6%), acute mesenteric ischemia was the underlying disease for HPVG. Seven patients (63.6%) underwent emergency exploratory laparotomy. The mortality rate for HPVG alone was 27.3% (3 of 11) and for HPVG related to mesenteric bowel disease 50% (three of six). Acute mesenteric ischemia is the most common cause of HPVG, which continues to have a predictably higher mortality. CT is superior to CT scanograms and radiographs in the detection of HPVG and its underlying diseases and, therefore, should be used as the primary diagnostic tool.
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Affiliation(s)
- Sebastian T Schindera
- Department of Diagnostic Radiology, University Hospital of Bern, Inselspital, 3010 Bern, Switzerland
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21
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Ruíz DSM, de Perrot T, Majno PE. A case of portal venous gas secondary to acute appendicitis detected on gray scale sonography but not computed tomography. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2005; 24:383-386. [PMID: 15723852 DOI: 10.7863/jum.2005.24.3.383] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/24/2023]
Affiliation(s)
- Diego San Millán Ruíz
- Department of Radiology, Geneva University Hospital, 24 rue Micheli-du-Crest, 1211 Geneva 14, Switzerland.
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23
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Hou SK, Chern CH, How CK, Chen JD, Wang LM, Lee CH. Hepatic portal venous gas: clinical significance of computed tomography findings. Am J Emerg Med 2004; 22:214-8. [PMID: 15138961 DOI: 10.1016/j.ajem.2004.02.017] [Citation(s) in RCA: 93] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Hepatic portal venous gas (HPVG) is a rare radiographic finding of significance. Most cases with HPVG are related to mesenteric ischemia that have been associated with extended bowel necrosis and fatal outcome. With the help of computed tomography (CT) in early diagnosis of HPVG, the clinical outcome of patients with mesenteric ischemia has improved. There has been also an increasing rate of detection of HPVG with certain nonischemic conditions. In this report, we present two cases demonstrating HPVG unrelated to mesenteric ischemia. One patient with cholangitis presented abdominal pain with local peritonitis and survived after appropriate antibiotic treatment. Laparotomy was avoided as a result of lack of CT evidence of ischemic bowel disease besides the presence of HPVG. The other case had severe enteritis. Although his CT finding preluded ischemic bowel disease, conservative treatment was implemented because of the absence of peritoneal signs or clinical toxic symptoms. Therefore, whenever HPVG is detected on CT, urgent exploratory laparotomy is only mandatory in a patient with whom intestinal ischemia or infarction is suspected on the basis of radiologic and clinical findings. On the other hand, unnecessary exploratory laparotomy should be avoided in nonischemic conditions that are usually associated with a better clinical outcome if appropriate therapy is prompted for the underlying diseases. Patients with radiographic diagnosis of HPVG should receive a detailed history review and physical examination. The patient's underlying condition should be determined to provide a solid ground for exploratory laparotomy. A flow chart is presented for facilitating the management of patients with HPVG in the ED.
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Affiliation(s)
- Sen-Kuang Hou
- Emergency Department, Veterans General Hospital-Taipei, National Yang-Ming University Taipei, Taiwan
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24
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Saksena M, Harisinghani MG, Wittenberg J, Mueller PR. Case report. Hepatic portal venous gas: transient radiographic finding associated with colchicine toxicity. Br J Radiol 2004; 76:835-7. [PMID: 14623787 DOI: 10.1259/bjr/13712140] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Hepatic portal venous gas has traditionally been associated with a grave prognosis and high mortality. However, with the advent of ultrasound and CT, numerous less serious causes have been associated with this dramatic radiological finding. We present a previously unreported association with colchicine toxicity. The patient ingested a large dose of colchicine and was subsequently found to have portal venous gas on CT. The source of gas was felt to be intestinal gas penetrating through the demonstrated bowel injury. No surgical intervention was deemed necessary and the finding resolved spontaneously.
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Affiliation(s)
- M Saksena
- Department of Abdominal Imaging and Intervention, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, White 270, Boston, MA 02135, USA
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25
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Wiesner W, Mortelé KJ, Glickman JN, Ji H, Ros PR. Pneumatosis intestinalis and portomesenteric venous gas in intestinal ischemia: correlation of CT findings with severity of ischemia and clinical outcome. AJR Am J Roentgenol 2001; 177:1319-23. [PMID: 11717075 DOI: 10.2214/ajr.177.6.1771319] [Citation(s) in RCA: 257] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
OBJECTIVE The purpose of this study was to analyze the correlation between pneumatosis or portomesenteric venous gas, or both, the severity of mural involvement, and the clinical outcome in patients with small- or large-bowel ischemia. MATERIALS AND METHODS CT scans of 23 consecutive patients presenting with pneumatosis or portomesenteric venous gas caused by bowel ischemia were reviewed. The presence and extent of both CT findings were compared with the clinical outcome in all patients and with the severity and extent of ischemic bowel wall damage as determined by surgery (15 patients), autopsy (three patients), or follow-up (five patients). RESULTS Seven patients showed isolated pneumatosis, and 16 patients showed portomesenteric venous gas with or without pneumatosis (11 and five patients, respectively). Pneumatosis and portomesenteric venous gas were associated with transmural bowel infarction in 14 (78%) of 18 patients and 13 (81%) of 16 patients, respectively. Nine patients (56%) with portomesenteric venous gas died. Of seven patients with infarction limited to one bowel segment (jejunum, ileum, or colon), only one patient (14%) died, whereas of the 10 patients with infarction of two or three bowel segments, eight patients (80%) died. CONCLUSION CT findings of pneumatosis intestinalis and portomesenteric venous gas due to bowel ischemia do not generally allow prediction of transmural bowel infarction, because they may be observed in patients with only partial ischemic bowel wall damage. The clinical outcome of patients with bowel ischemia with these CT findings seems to depend mainly on the severity and extent of their underlying disease.
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Affiliation(s)
- W Wiesner
- Department of Radiology, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115, USA
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26
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Abstract
Hepatic portal venous gas is easily diagnosed radiographically by the appearance of tubular lucencies branching horizontally from the porta hepatis and extending to within 2cm of the liver capsule. Associated conditions vary from benign to potentially lethal diseases which require emergency operations. A case of hepatic portal venous gas secondary to small bowel obstruction is presented and a review of the literature is also provided.
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Affiliation(s)
- M Yamamuro
- Department of General Surgery, The Cleveland Clinic Foundation, OH 44195, USA
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Monneuse O, Gruner L, Henry L, Barth X, Olagne E, Beatrix O, Tissot E. [Hepatic portal venous gas]. ANNALES DE CHIRURGIE 2000; 125:435-8. [PMID: 10925484 DOI: 10.1016/s0003-3944(00)00217-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
STUDY OBJECTIVE Hepatic portal venous gas is a radiological symptom associated with a poor prognosis (75% to 90% mortality). The aim of this retrospective study was to report 7 cases observed over a 2-year period. PATIENTS AND METHOD From June 1997 to November 1999, hepatic portal venous gas was diagnosed in 6 patients by CT scan and in one patient by echosonography. It was not detected in any case by plain abdominal X-rays. Three patients had small bowel obstruction with necrosis, three had extensive superior mesenteric infarction and one had preperforative necrosis of the colon. RESULTS One patient with extensive intestinal infarction and a metastatic head and neck cancer was not operated. Two patients were operated, but the extensive mesenteric infarction was not amenable to surgical management. Three of the 7 patients died, while the other four patients survived after resection of the necrotic small intestine (n = 3) and left colectomy extended to the transverse colon (n = 1). CONCLUSION Hepatic portal venous gas was associated with intestinal necrosis in the seven cases of this series. The severity of portal venous gas is only correlated with the severity of the disease causing portal venous gas.
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Affiliation(s)
- O Monneuse
- Service d'urgence chirurgie viscérale, hôpital Edouard-Herriot, Lyon, France
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Chang YS, Wang HP, Huang GT, Wu MS, Lin JT. Sonographic "gastric corona sign": diagnosis of gastric pneumatosis caused by a penetrating gastric ulcer. JOURNAL OF CLINICAL ULTRASOUND : JCU 1999; 27:409-412. [PMID: 10440791 DOI: 10.1002/(sici)1097-0096(199909)27:7<409::aid-jcu9>3.0.co;2-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
We present a case of gastric pneumatosis associated with splenoportal venous gas caused by a giant penetrating gastric ulcer. On sonography, the gastric pneumatosis appeared as a circular hyperechoic band with distal reverberations due to gas collection in the gastric wall; we termed this appearance the "gastric corona sign. "Awareness of this sonographic sign may aid in the early diagnosis of gastric pneumatosis.
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Affiliation(s)
- Y S Chang
- Department of Internal Medicine, Taipei Municipal Ho-Ping Hospital, No. 33, Section 2, Chung-Hwa Road, Taipei 108, Taiwan
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Muscari F, Suc B, Lagarrigue J. [Hepatic portal venous gas: is it always a sign of severity and surgical emergency?]. CHIRURGIE; MEMOIRES DE L'ACADEMIE DE CHIRURGIE 1999; 124:69-72. [PMID: 10193035 DOI: 10.1016/s0001-4001(99)80045-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Hepatic portal venous gas is a radiological finding due to the presence of gas in the portal vein. It was associated with a mortality rate ranging from 75% to 90% and with an indication for exploratory laparotomy. We report one case following an abdominal trauma. The portal vein gas was detected on CT Scan. The patient who was asymptomatic was not operated on and survived. The severity of this radiological symptom requiring a laparotomy has to be reassessed. CT Scan is the most efficient method to recognize portal vein gas and its larger use has allowed to diagnose more cases not detected by simple abdominal X-rays. In conclusion, surgical exploration should not be done systematically but has to be decided in relation with the clinical status of the patient.
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Affiliation(s)
- F Muscari
- Service de chirurgie digestive, hôpital de Rangueil, Toulouse, France
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Abstract
A case of hepatic portal venous gas following intestinal ileus in a critically ill patient in the intensive care unit, who went on to have a successful outcome, is described. Although hepatic portal venous gas (HPVG) is usually associated with an abdominal catastrophe and portends a poor clinical outcome, there are a number of benign causes of HPVG. The pathophysiological processes such as gut bacterial translocation and altered intestinal permeability that may occur as a paraphenomenon in the setting of HPVG are discussed.
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32
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Macari M, Panicek DM, Morris E. CT demonstration of infected SVC thrombus. Clin Imaging 1998; 22:122-3. [PMID: 9543590 DOI: 10.1016/s0899-7071(97)00077-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
We report a case in which computed tomography (CT) demonstrated gas within a thrombus in the superior vena cava in a patient with fever of unknown origin (FUO), indicating that the thrombus was infected. This CT finding is important to recognize, as it affects subsequent therapy.
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Affiliation(s)
- M Macari
- Department of Radiology, Memorial Sloan-Kettering Cancer Center, New York, New York 10021, USA
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