Ultrasound evaluation of portal venous gas and its mimics

Portal venous gas on abdominal ultrasound classically represents an indirect indicator of bowel ischemia, a critical condition which poses a high patient mortality and therefore warrants emergent corrective action. While the classic appearance of portal venous gas on ultrasound is well-described in the literature, the characteristic descriptors are nonspecific and may actually represent other less emergent mimics. Therefore, while radiologists should remain vigilant for the detection of findings corresponding to portal venous gas, they should also be aware of similar-appearing entities in order to provide the most accurate diagnosis. This pictorial essay will open with imaging examples of true portal venous gas attributable to bowel ischemia and describe the classic features which should alert radiologists to this specific diagnosis. Subsequently, this pictorial essay will provide imaging examples of other various other clinical entities which on ultrasound may share similar imaging characteristics. An important objective of this pictorial essay is to highlight distinguishing imaging features along with specific clinical circumstances for each pathological entity which can direct radiologists into identifying the correct diagnosis.

Clinical Correlates of Cholestasis in Preterm Infants with Surgical Necrotizing Enterocolitis

Background

We sought to investigate the clinical determinants and outcomes of cholestasis in preterm infants with surgical necrotizing enterocolitis (sNEC).

Methods

Retrospective comparison of clinical information in preterm infants who developed cholestasis vs those who did not.

Results

Sixty-two (62/91, 68.1%) infants with NEC developed cholestasis at any time following the onset of illness. Cholestasis was seen more frequently in those who had received ionotropic support at 24 hours following sNEC diagnosis (87.1% vs 58.6%; p = 0.002), had higher mean C-reactive protein levels 2 weeks after NEC diagnosis (p = 0.009), had blood culture-positive sepsis [25 (40.3%) vs 4 (13.8%); p = 0.011], received parenteral nutrition (PN) for longer durations (108.4 ± 56.63 days vs 97.56 ± 56.05 days; p = 0.007), had higher weight-for-length z scores at 36 weeks' postmenstrual age [-1.0 (-1.73, -0.12) vs -1.32 (-1.76, -0.76); p = 0.025], had a longer length of hospital stay (153.7 ± 77.57 days vs 112.51 ± 85.22 days; p = 0.024), had intestinal failure more often (61% vs 25.0%, p = 0.003), had more surgical complications (50% vs 27.6%; p = 0.044), and had >1 complication (21% vs 3.4%; p = 0.031). Using linear regression, the number of days after surgery when feeds could be started [OR 15.4; confidence interval (CI) 3.71, 27.13; p = 0.009] and the postoperative ileus duration (OR 11.9, CI 1.1, 22.8; p = 0.03) were independently associated with direct bilirubin between 2 and 5 mg/dL (mild-moderate cholestasis) at 2 months of age. The duration of PN was independently associated with direct bilirubin >5 mg/dL (severe cholestasis) at 2 months of age in these patients.

Conclusion

Cholestasis was seen in 68% of infants following surgical NEC. The most likely contributive factors are intestinal failure and subsequent PN dependence for longer periods. Our data suggest that identification and prevention of risk factors such as sepsis and surgical complications and early feeds following NEC surgery may improve outcomes.

The spectrum of pneumatosis intestinalis in the adult. A surgical dilemma

Pneumatosis intestinalis (PI) is a striking radiological diagnosis. Formerly a rare diagnostic finding, it is becoming more frequently diagnosed due to the wider availability and improvement of computed tomography scan imaging. Once associated only with poor outcome, its clinical and prognostic significance nowadays has to be cross-referenced to the nature of the underlying condition. Multiple mechanisms of pathogenesis have been debated and multiple causes have been detected during the years. All this contributes to creating a broad range of clinical and radiological presentations. The management of patients presenting PI is related to the determining cause if it is identified. Otherwise, in particular if an association with portal venous gas and/or pneumoperitoneum is present, the eventual decision between surgery and non-operative management is challenging, even for stable patients, since this clinical condition is traditionally associated to intestinal ischemia and consequently to pending clinical collapse if not treated. Considering the wide variety of origin and outcomes, PI still remains for surgeons a demanding clinical entity. The manuscript is an updated narrative review and gives some suggestions that may help make the decisional process easier, identifying patients who can benefit from surgical intervention and those who can benefit from non-operative management avoiding unnecessary procedures.

Severe small intestinal bacterial overgrowth syndrome after jejunal feeding requiring surgical intervention: a case report and review of the literature

BACKGROUND

Small intestinal bacterial overgrowth (SIBO) is a condition of unknown prevalence characterized by an excessive amount of bacteria in the small bowel, typically resulting in vague gastrointestinal symptoms with bloating being most commonly reported. Here we describe a severe case of SIBO leading to small bowel necrosis requiring surgical intervention.

CASE PRESENTATION

A 55-year-old Hispanic female with gastric outlet obstruction secondary to a newly diagnosed gastric adenocarcinoma, receiving neoadjuvant chemotherapy, developed bloody gastrostomy output and rapidly progressing nausea and abdominal distention 3 days after jejunostomy tube placement and initiation of jejunal enteral nutrition. Imaging revealed diffuse pneumatosis and portal venous gas. Surgical exploration confirmed segmental bowel necrosis requiring resection. Histologic findings were consistent with SIBO.

CONCLUSIONS

Presentation of severe SIBO in the setting of intestinal stasis secondary to gastric outlet after initiation of enteral feeds is a rare phenomenon. Early recognition and diagnosis of SIBO is critical in minimizing patient morbidity and mortality.

Pneumatosis intestinalis in children beyond the neonatal period: is it always benign?

PURPOSE

The significance and management of pediatric pneumatosis intestinalis (PI) remains poorly defined. We sought to add clarity in children beyond the neonatal period.

METHODS

Pediatric patients 3 months-18 years admitted to a quaternary children's hospital with a diagnosis of PI were included in this retrospective study. Pathologic PI was defined as irreversible, transmural intestinal ischemia.

RESULTS

167 children were identified with PI. Of these children, 155 (92.8%) had benign PI and 12 (7.2%) developed pathologic PI. The most common underlying diagnosis for pathologic PI was global developmental delay (75%), although we identified a spectrum of underlying diagnoses at risk for PI. Physical exam notable for abdominal distension (p = 0.023) or guarding (p = 0.028), and imaging with portal venous gas (p < 0.001) or bowel distension (p = 0.001) were significantly associated with pathologic PI. Only 6.6% of all children underwent an operation. For those undergoing non-surgical management of benign PI, 75% of children received antibiotics and average duration of bowel rest was 6.8 days.

CONCLUSIONS

PI in children is primarily a benign phenomenon and often does not warrant surgical intervention. Bowel rest and antibiotics are therapeutic strategies frequently used in the treatment of this finding.

A Case of Intratumoral and Hepatic Portal Venous Gas in Patient with Gastric Cancer Liver Metastases

BACKGROUND

Hepatic portal venous gas [HPVG] is not a common finding in daily practice. It is usually associated with mesenteric ischemia and bowel necrosis in adults. Combination of intratumoral gas in metastatic liver lesions with HPVG is quite rare and thought to be associated with chemotherapy-induced necrosis and infection of the necrotized metastasis.

OBJECTIVE

Here we present a case of gastric adenocarcinoma with portal venous and intratumoral gas in metastatic liver lesions due to the infected necrosis.

CASE PRESENTATION

The patient was presented to the emergency room with severe abdominal pain and septic condition after the second round of chemotherapy. Hepatic portal venous and intratumoral gas in metastatic liver lesions due to the infected necrosis of liver metastasis was detected in computed tomography images. There were no findings of mesenteric ischemia both clinically and radiologically. Massive intratumoral infected necrosis in metastatic liver lesions and fistulization to the right portal vein branches were detected on abdominopelvic CT. Secondary infection of the necrotic metastases and fistulization to portal vein branches was believed to cause the air in metastatic liver masses and portal venous gas.

CONCLUSION

Infected necrosis of metastatic liver lesions and fistulizations to the portal venous structures is extremely rare. Clinicians and radiologists should be aware of such a rare complication because early detection is crucial for patient management.

Portal venous gas resulting from umbilical vein catheterization in a very-low-birth-weight infant with no interruption in early feeding

Introduction

Portal venous gas (PVG) is common in necrotizing enterocolitis and occasionally occurs in neonates after umbilical vein catheterization (UVC). Therefore, determining the cause of PVG requires further clinical evaluation in these cases.

Case presentation

We report the case of a very‐low‐birth‐weight infant who underwent UVC after birth. PVG was an unexpected finding on ultrasound following catheterization. The UVC was immediately removed and replaced with a peripherally inserted central catheter. The infant’s physical examination was unremarkable. Bedside X‐ray revealed neither PVG nor pneumatosis intestinalis, which would indicate the onset of necrotizing enterocolitis. After full evaluation, breastfeeding was started on the same day. The infant did not develop feeding intolerance, necrotizing enterocolitis, or other disorders.

Conclusion

PVG occasionally occurs in neonates who undergo UVC and is considered to be caused by exogenous gases. PVG is more easily detected with ultrasound than with X‐ray and does not affect early feeding in premature infants.

Incidence and importance of portal venous gas in children with hypertrophic pyloric stenosis

BACKGROUND

Hypertrophic pyloric stenosis (HPS) is a common cause of gastric outlet obstruction in young infants. Infants with HPS present with projectile vomiting, sometimes have electrolyte abnormalities and typically undergo pyloromyotomy to alleviate the obstruction. Abdominal US is the gold standard imaging study for diagnosis. Case reports of incidental hepatic portal venous gas have been reported in infants with HPS; however, no large studies have been conducted to determine the incidence or possible clinical implications of this finding.

OBJECTIVE

To assess the incidence of portal venous gas in infants with HPS and to determine whether the presence of this gas in infants with HPS indicates a more unstable patient, increased length of stay or worse outcome.

MATERIALS AND METHODS

We conducted a retrospective review of sonographic reports containing "pyloric stenosis," excluding negative descriptor, at a tertiary-care children's hospital from November 2010 to September 2017. Data collected included pyloric thickness/length, liver evaluation, portal venous gas, any additional imaging, demographics, symptomatology days, electrolyte abnormality, and length of hospital stay.

RESULTS

In a 7-year period, 545 US exams were positive for HPS. Of these, 334 exams included enough hepatic parenchyma to evaluate for portal venous gas. Infants in 6 of the 334 exams demonstrated portal venous gas (1.8%). Clinical presentation (length of symptoms and electrolyte abnormalities), demographics (male predominance and age at presentation) and imaging characteristics (pyloric thickness and length) were similar for the HPS groups with and without portal venous gas. There was no significant difference in outcome or length of hospital stay.

CONCLUSION

Visualization of portal venous gas in infants with HPS is not rare and appears benign, without need for further imaging. Portal venous gas in infants with HPS does not portend a more severe patient presentation or outcome.

Intramural gastric air in an acutely ill patient with endoscopic and surgical correlation

Intramural gastric air is a rare but potentially life-threatening imaging finding. We present the case of a 56-year-old female patient with a history of schizophrenia, who presented with multiple episodes of vomiting and altered mental status. CT scan revealed intramural gastric air and portal venous gas. The patient was treated conservatively with a favorable outcome. Gastric emphysema and emphysematous gastritis should be considered in the differential diagnosis of air in the gastric wall. It is critical to distinguish between these 2 entities as their clinical course and management differ significantly, although radiographic findings may mimic each other.

Portal venous gas as a radiological sign in a sigmoid diverticular abscess and its non-surgical management: a case report

A 62-year old man who presented unwell with no specific symptoms or signs was found to have portal venous circulation gas complicating a small diverticular abscess. He was successfully managed with a course of antibiotics and had full resolution of symptoms, therefore avoiding the need for surgical intervention. While most commonly associated with bowel ischaemia and therefore often warranting emergency laparotomy, portal venous gas within the context of other underlying pathology often presents opportunities for delayed surgery or more conservative management options.

A case of portal venous gas after obstructive transverse colon cancer surgery

BACKGROUND

Portal venous gas has traditionally been considered an inevitable harbinger of death due to its association with bowel necrosis. Recently, an increasing number of cases of portal venous gas have been reported in patients with various clinical conditions and without bowel necrosis. We herein report the case of a patient in whom portal venous gas developed after transverse colon cancer surgery.

CASE PRESENTATION

A 69-year-old man who had transverse colon cancer underwent insertion of a transanal ileus tube for decompression. Transverse colon resection was performed on the 11th day after the insertion of the transanal ileus tube. The patient had a high fever on the 6th day after the operation. Computed tomography showed portal venous gas over the entire area of the liver and pneumatosis intestinalis in the wall of the ascending colon. There were no signs of anastomotic leakage or bowel necrosis, so we decided to use conservative therapy with fasting and antibiotics. The portal venous gas disappeared on the 19th day after the operation. The patient was discharged in good condition on the 29th day after the operation.

CONCLUSIONS

Conservative treatment for portal venous gas is reasonable for patients without signs of anastomotic leakage or bowel necrosis. However, it is important to carefully observe patients with portal venous gas during conservative treatment because portal venous gas may be life-threatening.

Portal venous gas in intestinal malrotation with mild midgut volvulus

Background

Portal venous gas has been considered as a radiological sign requiring urgent operative intervention; however, the reports concerning portal venous gas associated with favorable outcome are recently increasing.

Case presentation

We describe a 9-month-old boy with acute onset high fever and vomiting. The ultrasonography demonstrated micro-gas bubbles continuously floating in the intrahepatic portal vein. Contrast-enhanced CT, performed 1 h later from echography, revealed a whirlpool sign suggesting an intestinal malrotation with midgut volvulus, but with no signs of residual intrahepatic gas. Operative findings showed a mild volvulus with neither congestion nor ischemic change of the twisted bowel. Detorsion and Ladd’s procedure were completed laparoscopically.

Conclusions

Transient portal venous gas bubbles may be generated even in the mild intestinal volvulus with no bowel ischemia. Ultrasonography can be a sensitive detector to visualize such small amounts of gas.

Electronic supplementary material

The online version of this article (10.1186/s40792-019-0700-z) contains supplementary material, which is available to authorized users.

Pneumoperitoneum, pneumatosis intestinalis and portal venous gas: Rare gastrostomy complications case report

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Open gastrostomy lethal complications include intestinal pneumatosis and portal venous gas.

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Intestinal necrosis, disruption of mucosa, increased permeability of mucosa, and pulmonary disease, can cause complications.

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There are several theories describing pathophysiology of intestinal pneumatosis. one of them, secondary to surgery or trauma.

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Medical versus surgical management of the complications depend on the patient’s comorbidities and physician’s consideration.

Introduction

The gastrostomy is one of the most common procedures performed in general surgery. Although a simple procedure, it is not exempted from potential complications, specifically portal venous gas and intestinal pneumatosis being some of the ones with higher rates of mortality. The following case report presents a pneumoperitoneum due to extensive pneumatosis from esophageal, gastric, intestinal and portal gas. These rare complications were managed medically without undergoing emergency surgical intervention.

Presentation of Case

A 19-year-old male patient, with previous history of cerebral palsy, chronic malnutrition and severe physical deconditioning, required a nutritional access. Due to co-existing pathologies, an open gastrostomy was chosen as the best intervention, which was performed without complications. On the tenth postoperative day, patient presents abdominal pain and diarrhea; laboratory results were within normal limits, and the abdominal computed tomography scan reported extensive pneumatosis compromising esophagus, stomach, small intestine, part of the colon, pneumoperitoneum and gas in the portal venous system. Medical management was carried out with an adequate recovery.

Discussion

Intestinal pneumatosis and portal venous gas are rare and potentially lethal complications. Surgical intervention as well as severe malnutrition impairs carbohydrate digestion and promotes bacterial fermentation forming large volumes of gas and dissection of the intestinal mucosal wall, causing the intestinal pneumatosis evidenced in this case report.

Conclusions

This case report presents a rare open gastrostomy complication, as well as a differential diagnosis to pneumoperitoneum. Additionally, the medical management poses a successful alternative to an emergency surgical intervention.

Extreme dilatation of the interposed jejunal pouch after proximal gastrectomy associated with portal venous gas: A case report

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Dilatation of the interposed jejunal pouch developed after proximal gastrectomy.

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Shock state with portal venous gas was restored after conservative therapy.

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The pouch dilatation recurred soon after resuming oral ingestion.

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Resection of the pouch with R-Y esophagojejunostomy relieved the patient.

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Surgical intervention should be considered for refractory pouch dilatation.

Introduction

The jejunal pouch interposition (JPI) after proximal gastrectomy (PG) was proposed as a reconstructive procedure to provide a gastric reservoir substitute and prevent postgastrectomy syndrome. However, food residue remaining in some of the pouches resulted in the adverse effect of abdominal bloating, thereby body weight loss. Here, we report a rare case with an extreme dilation of the interposed jejunal pouch (JP) 8 years after PG, requiring pouch resection.

Presentation of case

A 65-year-old-man who had undergone PG with an inverted U-shaped JPI for early gastric cancer 8 years previously, suffered from shock after right hip joint implantation. Abdominal enhanced CT scan revealed an extremely dilated JP accompanied by portal venous gas. After 5 months of conservative therapy, he underwent resection of the JP and gastric remnant with Roux-en-Y esophagojejunostomy reconstruction. After the operation, the patient has remained in good health for over 3 years.

Discussion and conclusion

Long-term operative outcome following pouch operation for gastric cancer still remains controversial. Surgical intervention should be considered when we encounter patients who have refractory pouch dilatation after surgery for gastric cancer.

Transient portal venous gas associated with reversible non-occlusive mesenteric ischemia: A case report

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Ultrasonography is a useful tool for portal venous gas identification in critically ill patients.

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Portal venous gas can be observed at the early phase of acute mesenteric ischemia.

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Transient portal venous gas with rapid disappearance is indicative of the resolution of the ischemia.

Objectives

To report the utility of abdominal ultrasonography (US) to identify the presence of portal venous gas (PVG) during non-occlusive mesenteric ischemia (NOMI), and to follow the disappearance of portal venous gas after resolution of the NOMI.

Data sources

This was a clinical observation of a patient, with images of abdominal computed tomography (CT), and a video of portal venous gas identified by ultrasonography.

Data synthesis

We describe the case of an adult patient admitted to our ICU for NOMI developing 48 h after cardiac surgery. Medical intensive care associated with jejunal resection and vacuum-assisted closure led to rapid recovery. Three weeks later, the patient presented acute pulmonary edema, and developed a new episode of NOMI that was suspected by identification of PVG on US, and then confirmed on abdominal CT. The patient rapidly improved after orotracheal intubation and treatment of pulmonary edema. A second US performed 9 h later showed disappearance of PVG. The laparotomy performed 10 h after the first US did not find evidence of small bowel or colon ischemia. The postoperative period was uneventful.

Conclusions

US is a useful tool for the detection of PVG in critically ill patients, prompting suspicion of AMI. PVG can be observed at the early phase of AMI, even before irreversible transmural gut ischemia; transient PVG that disappears rapidly (within several hours) may suggest resolution of the NOMI.

Disappearing portal venous gas in acute pancreatitis and small bowel ischemia

We report an usual case of hepatic portal venous gas (HPVG) in the setting of acute pancreatitis and small bowel ischemia. Interestingly, the HPVG disappeared within 2 hours of the original computed tomography scan, despite the patient having small bowel ischemia. The patient had a complicated clinical course, dying 62 days postadmission. This case highlights that HPVG in setting of acute pancreatitis and small bowel ischemia has a very high morbidity and mortality, requiring early detection and aggressive surgical management.

Conservative approach to Hepatic Portal Venous Gas: A case report

INTRODUCTION

Hepatic Portal Venous Gas (HPVG), a rare condition in which gas accumulates in the portal venous circulation, is often associated with a significant underlying pathology, such as Crohn's disease, ulcerative colitis, diverticulitis, pancreatitis, sepsis, intra-abdominal abscess, endoscopic procedures, mesenteric ischemia, abdominal trauma.

PRESENTATION OF CASE

Here we report a case of HPVG in an 82-year-old patient who underwent a left colectomy for stenosing tumor of the descending colon. The patient was treated conservatively, and his symptoms resolved. Follow-up computed tomography (CT) scan showed complete resolution of HPVG.

DISCUSSION

The mechanism underlying the passage of the gas from the intestine into the mesenteric, then portal, venous system is not fully understood. Historically, this condition has been related to acute intestinal ischemia, as a consequence of a bacterial translocation through a wall defect.

CONCLUSION

This case underscores the role of conservative management, highlighting how the severity of the prognosis of HPVG should be related to the underlying pathology, and not influenced by the presence of HPVG itself.

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

Backgrounds/Aims

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

Methods

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

Results

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

Conclusions

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

Hepatic portal venous gas after endoscopy in a patient with anastomotic obstruction

A 72-year-old male underwent a laparoscopic low anterior resection for advanced rectal cancer. A diverting loop ileostomy was constructed due to an anastomotic leak five days postoperatively. Nine months later, colonoscopy performed through the stoma showed complete anastomotic obstruction. The mucosa of the proximal sigmoid colon was atrophic and whitish. Ten days after the colonoscopy, the patient presented in shock with abdominal pain. Abdominal computed tomography scan showed hepatic portal venous gas (HPVG) and a dilated left colon. HPVG induced by obstructive colitis was diagnosed and a transverse colostomy performed emergently. His subsequent hospital course was unremarkable. Rectal anastomosis with diverting ileostomy is often performed in patients with low rectal cancers. In patients with anastomotic obstruction or severe stenosis, colonoscopy through diverting stoma should be avoided. Emergent operation to decompress the obstructed proximal colon is necessary in patients with a blind intestinal loop accompanied by HPVG.

Symptomatic pneumatosis intestinalis (including portal venous gas) after laparoscopic total colectomy

The development of intramural intestinal gas may indicate a serious postoperative complication and therefore any radiological indication of such “pneumatosis intestinalis” (PI) in an unwell patient after surgery should put the clinical team on high-alert. However immediate recourse to relook laparotomy may not be always necessary and, further, in some cases may possibly accelerate the deterioration especially if it proves to be non-therapeutic. Careful and close clinical monitoring, as is described in this clinical report, may allow discriminative identification of those in whom this finding is in fact transient and therefore benign and who therefore can be successfully treated without operative re-intervention. We describe the presenting features and background scenario of PI early after laparoscopic total colectomy for medically refractory, severe ulcerative colitis and detail the critical postoperative decision pivots.

[Hepatic portal venous gas: surgery or not surgery?]

Finding hepatic portal venous gas with pneumatosis intestinalis on computed tomography (CT) represents diagnostic and therapeutic challenge. The intestinal necrosis, particularly associated with acute mesenteric ischemia, is the very first hypothesis to assess, with the underlying question of an urgent surgery. However, knowing the non-surgical causes that have been identified in the last decade seems necessary to better assess the risk-benefit ratio of emergency surgery. Among these causes, we report the case of the acute colonic pseudo-obstruction, also known as Ogilvie's syndrome, whose first line treatment is medical.

Pneumatosis and portal venous gas: do CT findings reassure?

BACKGROUND

Small, single-institution studies have suggested risk factors for bowel ischemia/necrosis (I/N) in patients with computed tomography (CT) findings of pneumatosis (PN) and portal venous gas (PVG). Here, analysis has been expanded in a large, multicenter study.

MATERIALS & METHODS

Logistic regression models and receiver operating characteristic curves were used to construct a scoring system for I/N in cases of PN/PVG.

RESULTS

Of 265 patients with PN/PVG identified, 209 had adequate data. In unadjusted analyses the following variables were significantly associated with I/N: age, peritoneal signs, ascites, the presence of both PVG and PN, blood urea nitrogen (BUN), CO2, albumin, and a history of hypertension, myocardial infarction, or stroke. In contrast, the CT findings of mesenteric stranding, bowel-wall thickening, and type of PN were not associated with I/N. In adjusted analyses, three variables were significantly associated with I/N: age ≥60 y (odds ratio = 2.51, 95% confidence interval: 1.26-4.97), peritoneal signs (10.58, 4.23-26.4), and BUN >25 mg/dL (3.08, 1.54-6.17), whereas presence of both PN and PVG (versus only one) was associated with an increase (but not statistically significant increase) in odds (2.01, 0.94-4.36). Although several ad hoc models were used to maximize diagnostic ability, with maximal odds ratio = 174, the areas of receiver operating characteristic curves were all below 0.80, revealing suboptimal accuracy to diagnose I/N.

CONCLUSIONS

Older age, peritoneal signs, and high BUN are associated with I/N, suggesting an ability to predict which patients need operation. CT findings traditionally suggestive of ischemic PN/PVG, however, do not diagnose I/N accurately enough to reliably identify patients needing operation.

Enterovenous fistulization: A rare complication of Crohn’s disease

The presence of hepatic portal venous gas (HPVG) is associated with numerous diseases, and has been regarded as a serious, even catastrophic condition. However, anecdotal reports mention that some patients with inflammatory bowel disease (IBD), who developed HPVG after diagnostic examinations of the colon, were successfully managed with antibiotic therapy and have followed benign courses. In contrast, among IBD patients, the development of HPVG is rarely caused by enterovenous fistula. We describe a 32-year-old man with Crohn’s ileocolitis who presented with hypotension and fever associated with HPVG, as well as superior mesenteric vein thrombosis, possibly caused by enterovenous fistula, who was successfully managed by surgery. We also review the literature concerning portal venous gas associated with Crohn’s disease.

Portal venous gas and thrombosis in a Chinese patient with fulminant Crohn’s colitis: A case report with literature review

Ever since its earliest reports, portal venous gas (PVG) has been associated with numerous intraabdominal catastrophes and has served as an indication for urgent surgical exploration. It is traditionally regarded to be an ominous finding of impending death, with highest mortality reported in patients with underlying bowel ischemia. Today, computed tomography has demonstrated a wider range of clinical conditions associated with PVG, some of which are ‘benign’ and do not necessarily require surgery, unless when there are signs of intraabdominal catastrophe or systemic toxicity. One of these ‘benign’ conditions is Crohn’s disease. The present report describes a 19-year-old Chinese boy with Crohn’s pancolitis who presented with septic shock associated with PVG and portal vein thrombosis, and was successfully managed surgically. To our knowledge, this is the first report of PVG and portal vein thrombosis associated with Crohn’s disease in a Chinese patient. In addition, we have also reviewed the reports of another 18 Crohn’s patients with PVG previously described in the English literature. Specific predisposing factors for PVG were identified in 8 patients, including barium enema, colonoscopy, blunt abdominal trauma, and enterovenous fistula. The patients who developed PVG following barium enema and blunt trauma were all asymptomatic and no specific treatment was necessary. Eleven patients (58%) who presented with signs of intraabdominal catastrophe or systemic toxicity required either immediate or eventual surgery. The overall mortality rate among the 19 patients was only 11%. The present literature review has shown that the finding of PVG associated with Crohn’s disease does not always mandate surgical intervention. It is the clinical features and the related complications that ultimately determine the treatment approaches. The overall outcome of PVG associated with Crohn’s disease has been favourable.