Portal vein gas in emergency surgery

[Clinical characteristics of 7 cases of hepatic portal venous gas]

OBJECTIVE

To summarize and analyze the clinical characteristics of patients diagnosed with hepatic portal venous gas (HPVG).

METHODS

This was a single center retrospective observational study. All of the patients were diagnosed with HPVG. The patients were admitted to Peking University Third Hospital from January 2017 to January 2021. Demographic characteristics, clinical manifestations, laboratory tests, abdominal imaging, treatment of the primary disease, and clinical outcomes of the patients were collected via electronic medical records. The study was approved by institutional review board and the information of all the patients was kept de-identified.

RESULTS

A total of seven cases were included in the study. The median age of the patients was 67 (63, 81) years. Six of the patients were male. The seven patients all presented with sudden onset of severe abdominal pain, which was the most common symptom. Six patients developed septic shock after admission. The signs of HPVG were detected by CT scans in all the patients, showing gas embolization. It might also be found as unique "aquarium sign" in abdominal ultrosonography. Four cases were caused by intestinal lesions, including acute volvulus, intestinal obstruction, and rectal abscess. Two were caused by ischemic bowel disease and the other one was caused by severe acute pancreatitis. The gas accumulation could disappear after effective anti-shock therapy and surgery (Cases 1, 2, and 6). Two patients had good postoperative outcomes, and one patient was discharged after non-surgical treatment. However, the prognosis was poor in the patients with intestinal ischemia necrosis accompanied by shock and multiple organ dysfunction (Cases 3, 4, 5, and 7 all died).

CONCLUSION

The HPVG patients generally have acute abdominal pain and show up at Emergency Department. The prognosis depends on the potential cause of HPVG. The mechanism and clinical management for the appearance of gas in the portal vein is not well understood. Patients complicated with shock, ascites, and peritonitis may have intestinal necrosis, which indicates surgical intervention and higher mortality. CT is the preferred diagnostic method in standard clinical practice. Physicians need to have a comprehensive understanding of the proactive diagnostic strategy, and active treatment for the primary disease.

Acute mesenteric ischemia diagnosed using the aquarium sign: A case report

RATIONALE

The diagnosis of mesenteric ischemia in critically ill patients remains challenging; however, the aquarium sign, comprising a large number of bubble images in the right cardiac chambers on echocardiography, may be used as a point-of-care ultrasound finding to diagnose acute mesenteric ischemia (AMI).

PATIENT CONCERNS

A 65-year-old woman diagnosed with lymphoma was urgently admitted to the intensive care unit with suspected tumor lysis syndrome. High-dose vasopressor and inotropic agents were required to manage the patient's shock with marked lactic acidosis and peripheral hypoperfusion with mottled skin, and multidisciplinary treatment was initiated. By day 6, the lactate levels normalized and there were no abnormal abdominal findings. An echocardiogram was performed to examine the mass lesion associated with lymphoma in the right atrium and evaluate the hemodynamics; it revealed an "aquarium sign." Similar findings were found in the inferior vena cava and portal vein.

DIAGNOSES

Contrast-enhanced computed tomography of the abdomen revealed hepatic portal vein gas, poor contrast of the colon wall, and intramural emphysema, and a diagnosis of AMI was made. Lower gastrointestinal endoscopy showed necrosis of the colon.

INTERVENTIONS

The patient underwent urgent subtotal colorectal resection.

OUTCOMES

Although a tracheostomy was required, the patient's general condition improved after surgery, and she was discharged to the ward without mechanical ventilatory support in the intensive care unit on Day 19.

LESSONS

In patients with risk factors for AMI, repeated evaluation for the presence of aquarium signs by echocardiography may be warranted, even if there are no abdominal findings or abnormalities in biomarkers, such as lactate levels and trends. When the aquarium sign is found, AMI should be aggressively suspected, and a definitive diagnosis should be made to initiate early therapeutic intervention.

Incidence and Diagnostic Challenges of Bowel Ischemia after Continuous-flow Left Ventricular Assist Device Therapy

Long-term continuous-flow left ventricular assist device (CFLVAD) therapy is limited by complications. Compared with stroke and renal dysfunction, post-CFLVAD bowel ischemia is poorly characterized. Adult patients who underwent first-time durable CFLVAD implantation at our institution between 2008 and 2018 were identified and screened for bowel ischemia using Current Procedural Terminology codes for abdominal surgical exploration and International Classification of Disease codes for intestinal vascular insufficiency. Patients who developed biopsy-proven bowel ischemia (cases) were matched to controls (1:1, nearest neighbor, caliper = 0.29) based on preoperative characteristics. Incidences of postoperative right heart failure and renal replacement therapy were compared using McNemar's test. One year survival was estimated using the Kaplan-Meier method. Overall, 711 patients underwent CFLVAD implantation. Nineteen (2.7%) developed bowel ischemia (cases) median 17 days postimplantation (IQR 8-71). The majority of cases were male (78.9%), Black (63.2%), received HeartMate II (57.9%), treated as destination therapy (78.9%), and had a history of hypertension (89.5%), chronic kidney disease (84.2%), hyperlipidemia (84.2%), smoking (78.9%), and atrial fibrillation (57.9%). Post-LVAD, case patients were more likely to develop moderate-severe right heart failure (89.5% vs. 68.4%, p = 0.005), require renal replacement therapy (21.1% vs. 0%, p < 0.001), and less likely to survive to discharge (52.6% vs. 89.5%, p = 0.02) compared with controls. Case subjects demonstrated worse 1 year survival. While less common than stroke and renal dysfunction, post-CFLVAD bowel ischemia is associated with high 1 year mortality. Multi-institutional registries should consider reporting abdominal complications such as bowel ischemia as an adverse event to further investigate these trends and identify predictors of this complication to reduce patient mortality.

Hepatic portal venous gas without definite clinical manifestations of necrotizing enterocolitis in a 3-day-old full-term neonate: A case report

BACKGROUND

Neonatal hepatic portal venous gas (HPVG) is associated with a high risk of necrotizing enterocolitis (NEC) and was previously believed to be associated with an increased risk of surgery.

CASE SUMMARY

A 3-day-old full-term male infant was admitted to the pediatrics department after presenting with “low blood glucose for 10 min”. Hypoglycemia was corrected by intravenous glucose administration and oral breast milk. On the 3^rd d after admission, an ultrasound examination showed gas accumulation in the hepatic portal vein; this increased on the next day. Abdominal vertical radiograph showed intestinal pneumatosis. Routine blood examination showed that the total number of white blood cells was normal, but neutrophilia was related to age. There was a significant increase in C-reactive protein (CRP). The child was diagnosed with neonatal NEC (early-stage). With nil per os, rehydration, parenteral nutritional support, and anti-infection treatment with no sodium, his hepatic portal vein pneumatosis resolved. In addition, routine blood examination and CRP examination showed significant improvement and his symptoms resolved. The patient was given timely refeeding and gradually transitioned to full milk feeding and was subsequently discharged. Follow-up examination after discharge showed that the general condition of the patient was stable.

CONCLUSION

The presence of HPVG in neonates indicates early NEC. Early active anti-infective treatment is effective in treating NEC, minimizes the risk of severe NEC, and reduces the need for surgery. The findings of this study imply that early examination of the liver by ultrasound in a sick neonate can help with the early diagnosis of conditions such as NEC.

Pneumatosis intestinalis and porto-mesenteric venous gas: a multicenter study

BACKGROUND

Estimating the prognosis of patients with pneumatosis intestinalis (PI) and porto-mesenteric venous gas (PMVG) can be challenging. The purpose of this study was to refine prognostication to improve decision making in daily clinical routine.

METHODS

A total of 290 patients with confirmed PI were included in the final analysis. The presence of PMVG and mortality (90d follow-up) were evaluated with regard to the influence of possible risk factors. Furthermore, a linear estimation model was devised combining significant parameters to calculate accuracies for predicting death in patients undergoing surgery by means of a defined operation point (ROC-analysis).

RESULTS

Overall, 90d mortality was 55.2% (160/290). In patients with PI only, mortality was 46.5% (78/168) and increased significantly to 67.2% (82/122) in combination with PMVG (median survival: PI: 58d vs. PI and PMVG: 41d; p < 0.001). In the entire patient group, 53.5% (155/290) were treated surgically with a 90d mortality of 58.8% (91/155) in this latter group, while 90d mortality was 51.1% (69/135) in patients treated conservatively. In the patients who survived > 90d treated conservatively (24.9% of the entire collective; 72/290) PMVG/PI was defined as "benign"/reversible. PMVG, COPD, sepsis and a low platelet count were found to correlate with a worse prognosis helping to identify patients who might not profit from surgery, in this context our calculation model reaches accuracies of 97% specificity, 20% sensitivity, 90% PPV and 45% NPV.

CONCLUSION

Although PI is associated with high morbidity and mortality, "benign causes" are common. However, in concomitant PMVG, mortality rates increase significantly. Our mathematical model could serve as a decision support tool to identify patients who are least likely to benefit from surgery, and to potentially reduce overtreatment in this subset of patients.

An unexpected cause of persistent bacteraemia and portomesenteric venous gas

We report the case of a 59-year old man with portomesenteric venous gas (PMVG) due to inferior mesenteric vein fistulization caused by sigmoid diverticulitis with an unusual evolution. The patient initially presented with classic symptoms of lower abdominal pain and fever. Diagnosis of uncomplicated sigmoid diverticulitis was confirmed on computed tomography (CT) for which intravenous antibiotics were initiated. Hemocultures were positive for omnisensitive Escherichia Coli, but despite adequate intravenous antibiotic therapy, episodes of bacteraemia persisted and hemocultures remained positive. Repeat CT scan demonstrated regression of inflammation without signs of abcedation or perforation consistent with clinical findings. Endocarditis was excluded with a normal transoesophageal echocardiography. Finally, positron emission tomography-computed tomography (PET-CT) suspected a colovenous fistula and the presence of PMVG. The patient was successfully treated with laparoscopic sigmoidectomy. This case report summarises the diagnostic pathway and aims for higher awareness of non-ischemic PMVG causes.

Idiopathic Hepatic Portal Venous Gas in a Healthy Young Man

Background

Hepatic portal venous gas (HPVG) is a pathological condition characterized by gas in the portal venous system and its branches. The clinical manifestations of HPVG range from benign to life-threatening conditions. Here, we present a rare case of HPVG accompanied by free air in a healthy young patient without any suspicious etiology.

Case Presentation

A 28-year-old man without any specific medical history complained of sudden-onset dyspnea. On admission, his vital signs were stable, and the laboratory tests and physical examinations were within normal range. A plain chest and abdominal film revealed subphrenic free air and HPVG. Contrast-enhanced computed tomography (CT) showed extensive portal venous gas throughout the liver; however, there were no abnormal findings indicative of the etiology. Considering the stable vital signs and the lack of physical findings suggesting a surgical acute abdomen, the patient was managed conservatively. On admission day 3, the subphrenic free air and HPVG shown in the initial study had almost resolved, with no new symptoms. He was discharged on the fourth day after admission without any complications. Esophagogastroduodenoscopy, colonoscopy, and colonography protocol CT scan showed no significant abnormalities.

Conclusion

This case suggests that idiopathic HPVG could appear in healthy patients complaining only of vague symptoms. Initial conservative management could be considered if HPVG does not result from a life-threatening condition that needs immediate management, and if the patient is stable.

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.

Unexplained Portal Gas in a Patient with an Esophageal Ulcer

Emphysematous gastritis is the infection of gastric mucosa by gas producing microorganisms. It is a rare infection with less than 100 cases reported in the literature. The association of portal venous gas along with emphysematous gastritis is a rare entity. The concomitant portal venous gas worsens the outcome and warrant for surgical treatment. Our case has portal venous gas on CT scan along with suspicion of emphysematous gastritis and an esophageal ulcer on upper GI endoscopy. Medical treatment was given in our case of portal venous gas with the esophageal ulcer. Our case is unique because our patient responded to the conservative management. The patient presented with past history of polysubstance abuse and chronic kidney disease presented with symptoms of acute abdomen. CT scan revealed portal venous gas and suspicion of gastric emphysema. In addition, few foci of gas are seen along the vessels traversing between the stomach and liver. Endoscopy with gastric mucosa biopsy showed Candida albicans. Subsequently, antifungals were started. There was improvement in clinical condition of the patient. We, hereby, also summarize all the reported cases of emphysematous gastritis with treatment and outcome in each case. There has been change in trend from surgical to medical treatment.

In-Hospital Mortality for Hepatic Portal Venous Gas: Analysis of 1590 Patients Using a Japanese National Inpatient Database

BACKGROUND

Hepatic portal venous gas (HPVG) is rare but potentially serious condition. Main cause of HPVG is bowel ischemia, while detection of HPVG without bowel ischemia may have been increasing possibly due to widespread use of computed tomography. However, little is known about variation in etiologies of HPVG and mortality of HPVG with each etiology. We examined patient backgrounds, underlying diseases, and in-hospital mortality of HPVG patients using a national inpatient database.

METHODS

Using the Diagnosis Procedure Combination database in Japan, we identified inpatients diagnosed with HPVG from July 1, 2010 to March 31, 2015. Patients' data included age, sex, comorbidities at admission, complications after admission, body mass index, surgical procedures, medications, and discharge status. In-hospital mortality was compared between the subgroups divided by the patient backgrounds and underlying diseases.

RESULTS

A total of 1590 patients were identified during the study period. The mean age was 79.3 years old and the proportion of bowel ischemia was 53%. The overall in-hospital mortality was 27.3%. In-hospital mortality of HPVG with bowel ischemia, gastrointestinal tract (GIT) obstruction or dilation, GIT perforation, GIT infection, or sepsis was 26.8, 31.1, 33.3, 13.6, or 56.4%, respectively. Among patients with bowel ischemia, 32.2% patients received operation and their in-hospital mortality was 16.5%.

CONCLUSIONS

HPVG patients in the present study were relatively older but less likely to die than those in previous studies. Attention should be paid to the fact that mortality of HPVG without bowel ischemia was not always lower compared to that with bowel ischemia.

Clinical significance of pneumatosis intestinalis - correlation of MDCT-findings with treatment and outcome

Objectives

To evaluate the clinical significance of pneumatosis intestinalis (PI) including the influence on treatment and outcome.

Method and Materials

Two radiologists jointly reviewed MDCT-examinations of 149 consecutive emergency patients (53 women, mean age 64, range 21-95) with PI of the stomach (n = 4), small (n = 68) and/or large bowel (n = 96). PI extension, distribution and possibly associated porto-mesenteric venous gas (PMVG) were correlated with other MDCT-findings, risk factors, clinical management, laboratory, histopathology, final diagnosis and outcome.

Results

The most frequent cause of PI was intestinal ischemia (n = 80,53.7 %), followed by infection (n = 18,12.1 %), obstructive (n = 12,8.1 %) and non-obstructive (n = 10,6.7 %) bowel dilatation, unknown aetiologies (n = 8,5.4 %), drugs (n = 8,5.4 %), inflammation (n = 7,4.7 %), and others (n = 6,4 %). Neither PI distribution nor extension significantly correlated with underlying ischemia. Overall mortality was 41.6 % (n = 62), mostly related to intestinal ischemia (p = 0.003). Associated PMVG significantly correlated with underlying ischemia (p = 0.009), as did the anatomical distribution of PMVG (p = 0.015). Decreased mural contrast-enhancement was the only other MDCT-feature significantly associated with ischemia (p p < 0.001). Elevated white blood count significantly correlated with ischemia (p = 0.03).

Conclusion

In emergency patients, ischemia remains the most common aetiology of PI, showing the highest mortality. PI with associated PMVG is an alerting sign. PI together with decreased mural contrast-enhancement indicates underlying ischemia.

Key Points

• In emergency patients, PI may be caused by various disorders.

• Intestinal ischemia remains the most common cause of PI in acute situations.

• PI associated with decreased mural contrast-enhancement indicates acute intestinal ischemia.

• PI associated with PMVG should alert the radiologist to possible underlying ischemia.

An unusual triad of pneumatosis intestinalis, portal venous gas and pneumoperitoneum in an asymptomatic patient

Pneumatosis intestinalis (PI) is defined as the presence of gas within the serosal or mucosal layer bowel wall. This sign is usually found upon radiographic imaging and is most commonly secondary to acute gastro-intestinal ischaemia. Fifteen per cent of cases can present with a primary condition called pneumatosis cystoides intestinalis (PCI). PCI is usually a benign condition and patients are usually asymptomatic. Portal venous gas (PVG) or the presence/accumulation of free gas within the hepatic portal vein. It is most commonly associated with acute bowel ischaemia, and when seen in the presence of ischaemia the mortality rate is between 75 and 90%. Other associations include mechanical causes (e.g. obstruction), chemotherapy, liver transplant and diverticulitis. Benign PI has previously been described with PVG, but usually in the presence of other associated conditions such as AIDS, malignancy or chemotherapy. Some examples have been described without these associations, but not with free intra-peritoneal air. We describe a case of PCI and PVG with pneumoperitoneum, investigations and ongoing management.

Vomiting-induced gastric emphysema and hepatoportal venous gas: a case report and review of the literature

Gastric pneumatosis is the presence of air within the wall of the stomach. It represents a spectrum of conditions ranging from benign disease to septic shock and death. Etiopathologically, it can be classified into emphysematous gastritis or gastric emphysema (GE). Along with hepatoportal venous gas (HPVG), it was considered as an ominous radiological sign and warranted an emergent surgical exploration; however, with widespread use of computerized tomographic (CT) scan, an increasing number of benign causes of GE and HPVG have been reported in the literature, where patients can be managed by noninvasive and conservative measures. We hereby describe a case where recurrent episodes of vomiting led to development of GE and HPVG and the patient was managed successfully by conservative measures.

Extensive gas embolism of portacaval system in a patient with blunt abdominal trauma

Extensive portal vein and inferior vena cava gas embolism is the late presentation of hepatic portal venous gas (HPVG), and it is a rare clinical condition. This paper reports a case of extensive gas embolism of the portocaval system due to closed abdominal injury. A literature review was also performed to better understand the epidemiology, etiology, pathogenesis, diagnosis and treatment of HPVG.

Anaphylactoid Reaction from IV Contrast Dye Causing Ischemic Colitis with Portal Venous Gas

Portal venous gas is a radiographic finding with numerous causes. The most common etiologies include bowel ischemia or other intra-abdominal catastrophes. The finding of portal venous gas carries a high mortality rate. We report the first case of portal venous gas associated with anaphylactoid reaction to intravenous contrast dye in a middle-aged woman. This was likely secondary to anaphylactoid-induced ischemic colitis. This patient was managed conservatively and had a good outcome.

"STOP, LOOK, and LISTEN." Hepatic Portal Venous Gas: Time for Clinical Assessment!

Pneumatosis intestinalis and portal venous gas are findings usually associated with intra-abdominal surgical catastrophes that frequently require emergent surgical intervention. Herein we present a case of a patient who presented in septic shock, with extensive portal vein gas, diffuse intestinal wall thickening, and atherosclerotic vascular insufficiency in the absence of pneumatosis intestinalis. Given his advanced age, multiple comorbidities, magnitude of the initial findings, and his dramatic clinical response to aggressive fluid resuscitation, a cognitive decision was made to continue with nonoperative management. The patient recovered uneventfully and was discharged home in a stable condition.

Hepatic portal venous gas: comparison of two cases

Context. Hepatic portal venous gas (HPVG) is a rare and sinister finding. Its mortality is associated with the underlying causative condition. When secondary to bowel ischaemia, mortality rates exceed 50%. Case Report. Two cases of HPVG are described. One case describes HPVG in association with gastric ischaemia, with complete resolution following conservative management. The second case describes HPVG in association with widespread intra-abdominal ischaemia, with resultant mortality. Conclusion. A "watch and wait" management of HPVG associated with gastric ischaemia is suggested in certain patients, with a low threshold for surgical intervention. HPVG associated with bowel ischaemia is an absolute indication for surgical intervention, where intervention may change the clinical course.

Portomesenteric venous gas in a 2-week-old Holstein calf

A 2-week-old Holstein Friesian female calf was presented with profuse diarrhea and abdominal distension. Clinicopathological findings included marked hypoproteinemia, hypoglycemia and leucopenia, mild hyperlactatemia, and hyperfibrinogenemia. On abdominal ultrasonography, features were consistent with portomesenteric venous gas (PVG), a rare condition reported in the medical literature. The PVG in this calf was associated with severe gastrointestinal illness and sepsis.

Portomesenteric venous gas: is gas distribution linked to etiology and outcome?

PURPOSE

To investigate various anatomical locations of portomesenteric venous gas detected by computed tomography (CT) and their relationship with the underlying etiology and the outcome.

METHODS

The study group consisted of 47 cases with evidence of portomesenteric venous gas detected on abdominal CT examinations, 12 cases were identified through a retrospective PACS search, 35 were prospectively included. The presence of gas at specific anatomical locations in the portomesenteric venous vasculature was assessed according to a pre-defined classification: the arcade vessels close to the bowel segments followed by segmental vessels, the superior mesenteric vein, the extra- and intrahepatic portal vein. The etiology of portomesenteric venous gas and its prognosis were assessed by review of surgical reports, histopathology and medical records. Surgery was performed on 30 patients.

RESULTS

Overall 68.1% of cases were of ischemic etiology. Gas present in the arcade vessels was the best indicator for ischemia (sensitivity 93.8%; specificity 70.0%, positive predictive value 90.9%, negative predictive value 77.8%) compared to other locations and the mere presence of portomesenteric gas independent from the location. The overall mortality rate was 53.2%. Only gas in the arcade and segmental vessels were associated with considerably higher mortality rates (65.8% and 75.0%, respectively) and acceptable frequency (occurrence in 80.9% and 59.6%, respectively).

CONCLUSIONS

The study results indicate that the presence of gas at specific anatomical locations in the portomesenteric venous system, namely the arcade and segmental vessels, may serve as strong indicator for ischemic etiology and poor prognosis in the assessment of individual cases.

A rare case of portal vein gas: accidental hydrogen peroxide ingestion

Hydrogen peroxide (H(2)O(2)) is a colourless and odourless liquid with oxidant characteristics used for various purposes. Whereas in lower concentrations (3%), H(2)O(2) is used as a disinfectant in home cleaning products and wound care, in higher concentrations (35%) it is used in textile and paper industry as a bleaching agent and is diluted for use in lightening hair dyes. Like other caustic substances, direct injuries may develop if H(2)O(2) is swallowed and systemic air embolisms may occur due to the resultant gaseous oxygen. This study discusses a patient who was detected with the presence of gas in the portal venous system due to H(2)O(2) intoxication and was treated conservatively.

Hepatic portal venous gas--three non-fatal cases and review of the literature

BACKGROUND

Hepatic portal venous gas is a rare imaging finding most commonly associated with intestinal ischaemia and high mortality. Increased use of advanced imaging techniques has resulted in increased reporting and recognition of hepatic portal venous gas. Advanced imaging can also recognise the many associated pathologies which have variable management strategies and prognoses.

METHODS

We report 3 non-fatal cases and review the pathogenesis, aetiology, diagnosis, management and prognosis of hepatic portal venous gas.

CONCLUSION

Once considered an indication for urgent surgery, hepatic portal venous gas is a rare imaging finding. More recently, HPVG has been recognised to be associated with various benign causes many of which may be treated non-operatively. However, intestinal ischaemia remains the most common cause and the most important to exclude. CT is the diagnostic modality of choice. The underlying cause determines the treatment strategy and outcome.

Portal venous gas and pneumatosis intestinalis; radiologic signs with wide range of significance in surgery

BACKGROUND

Portal vein gas (PVG) was described as an uncommon ominous radiologic sign usually harboring an intra-abdominal catastrophe. When accompanied by pneumatosis intestinalis (PI), it is more predictive of bowel ischemia. Since the wide use of computed tomography (CT), both signs could also be viewed as incidental findings during routine radiologic investigations.

METHODS

We present a series of 12 cases that showed either or both signs, collected in a district general hospital between 1991 and 2011.

RESULTS

The diagnoses in these cases varied between fatal bowel ischemia and the mere presence of radiologic signs in the absence of significant pathology.

CONCLUSION

PVG and PI are radiologic signs that can represent a wide range of pathology.

Hepatic portal venous gas associated with severe graft-versus-host disease of the gastrointestinal tract

We report a 67-year-old woman who was diagnosed with hepatic portal venous gas associated with severe graft-versus-host disease (GVHD) of the gastrointestinal tract. The patient received allogenic peripheral blood stem cell transplantation from a haploidentical son against Philadelphia chromosome-positive acute lymphocytic leukemia. The patient developed grade 3 intestinal GVHD on day 90 from the transplantation. On day 149, she presented septic shock and computed tomography (CT) scan revealed hepatic portal venous gas (HPVG); an ileocecal resection was performed immediately. The damage of gastrointestinal mucosa by GVHD resulted in the invasion of gas-producing bacteria. Although HPVG-associated gastrointestinal GVHD is extremely rare, we should pay special attention to this pathogenesis.

Intrahepatic portal-vein gas associated with rotavirus infection

Rotavirus enteritis is an infectious disease of the small bowel caused by an RNA reovirus. It is manifested by cytotoxic diarrhea [1]. Rotavirus is the most common viral cause of enteritis (incidence 15-35%) [2]. In infants and children with abdominal pain and diarrhea, ultrasonography is the diagnostic study of choice, and its use has increased significantly in young patients. We describe two cases in which portal-vein gas was detected on abdominal ultrasound scans in children with severe dehydration secondary to rotavirus gastroenteritis, which resolved rapidly after treatment.

Small bowel necrosis in association with jejunal tube feeding

Early recognition and appropriate treatment of bowel ischemia is imperative to reduce morbidity and mortality in any situation, including in conjunction with enteral tube feeding. GI intolerance can manifest as increased nasogastric tube output, unexplained abdominal pain/distension, and pneumatosis intestinalis in critically ill patients who are on tube feedings and may be experiencing periods of splanchnic hypotension. Recommendations are to immediately cease tube feedings when these signs and symptoms are recognized, and total parenteral nutrition should be considered. Surgical exploration during the early stages should be considered to prevent the usual and fatal catastrophic cascade of widespread bowl infarction.

Hepatic portal venous gas due to cryptosporidiosis in a patient with acquired immunodeficiency syndrome

Although the presence of hepatic portal venous gas (HPVG) on computed tomography (CT) is typically an ominous finding, HPVG may sometimes be less catastrophic. The clinical significance of HPVG is variable, and it depends primarily on the underlying pathology. We report a case of a patient with acquired immunodeficiency syndrome (AIDS) who was found to have HPVG on CT as a presumed result of gastrointestinal cryptosporidiosis, an association that, to our knowledge, has not been reported. This case illustrates another cause of HPVG that should be considered in patients with AIDS.

Unusual radiological finding of lethal pneumatosis intestinalis and portomesenteric vein gas

Pneumatosis intestinalis and portomesenteric vein gas are rare and potentially severe radiological findings that occur both in pediatric and adult populations. They actually are radiographic signs of underlying intra-abdominal pathology, abnormality or diagnostic medical interference. If combined with other radiological or clinical signs of intestinal ischemia or sepsis, the prognosis is dismal and urgent laparotomy is mandatory. We report two cases of surgical treatment with ominous outcome in an effort to characterize this finding correctly as an absolute surgical indication or as an additional diagnostic criterion that simply marks a further breakdown of the systems in patients with a long list of severe medical conditions.

Hepatic portal venous gas: Physiopathology, etiology, prognosis and treatment

Hepatic portal venous gas (HPVG), an ominous radiologic sign, is associated in some cases with a severe underlying abdominal disease requiring urgent operative intervention. HPVG has been reported with increasing frequency in medical literature and usually accompanies severe or lethal conditions. The diagnosis of HPVG is usually made by plain abdominal radiography, sonography, color Doppler flow imaging or computed tomography (CT) scan. Currently, the increased use of CT scan and ultrasound in the inpatient setting allows early and highly sensitive detection of such severe illnesses and also the recognition of an increasing number of benign and non-life threatening causes of HPVG. HPVG is not by itself a surgical indication and the treatment depends mainly on the underlying disease. The prognosis is related to the pathology itself and is not influenced by the presence of HPVG. Based on a review of the literature, we discuss in this paper the pathophysiology, risk factors, radiographic findings, management, and prognosis of pathologies associated with HPVG.