Gas in the hepatic portal veins

Bezoar as a cause of portal vein pneumatosis: a case report

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.

Unraveling the Mystery of Hepatic Portal Vein Gas: Exploring Its Benign Nature and Surgical Implications

Hepatic portal venous gas (HPVG) is an infrequent yet potentially life-threatening condition that necessitates prompt diagnosis and effective management. This study presents the clinical scenario of an 88-year-old known diabetic patient, with chronic kidney disease (CKD), stroke, and hypertension, who was brought to the emergency department with symptoms of vomiting, constipation, and abdominal pain. Upon conducting a computed tomography (CT) scan of the abdomen, dilatation of the small bowel and pneumatosis intestinalis in the right abdomen, accompanied by the presence of air within the portal vein, were identified. Subsequently, an emergency laparotomy was performed, which revealed no evidence of ischemia, and the patient was treated with IV antibiotics. This case highlights the significance of adopting a multidisciplinary approach and timely interventions in the management of HPVG. The successful resolution of this complex case underscores the importance of prompt diagnosis, appropriate resuscitation, and surgical intervention, all of which play pivotal roles in enhancing patient outcomes.

Portal venous gas after a failed endoscopic retrograde cholangiopancreatography attempt in a patient with a large hepatocellular carcinoma: A case report

The cause of hepatic portal vein gas (HPVG) is variable. Good knowledge of the possible causes, combined with the clinical assessment of the patient and a good quality imaging, is required to correctly identify the underlying cause of HPVG and to best predict the prognosis.

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.

Benign versus life-threatening causes of pneumatosis intestinalis: differentiating CT features

OBJECTIVE

To assess the diagnostic performance of CT findings in differentiating causes of pneumatosis intestinalis (PI), including benign and life-threatening causes.

METHODS

All CT reports containing the word "pneumatosis" were queried from June 1st, 2006 to May 31st, 2015. A total of 42 patients with PI were enrolled (mean age, 63.4 years; 23 males and 19 females) and divided into two groups on based on electronic medical records: a benign group (n=24) and a life-threatening group (n=18). Two radiologists reviewed CT images and evaluated CT findings including bowel distension, the pattern of bowel wall enhancement, bowel wall defect, portal venous gas (PVG), mesenteric venous gas (MVG), extraluminal free air, and ascites.

RESULTS

CT findings including bowel distension, decreased bowel wall enhancement, PVG, and ascites were more commonly identified in the life-threatening group (all p<0.05). All cases with PVG were included in the life-threatening group (8/18 patients, 44.4%). Bowel wall defect, extraluminal free air, and mesenteric venous gas showed no statistical significance between both groups.

CONCLUSION

PI and concurrent PVG, bowel distension, decreased bowel wall enhancement, or ascites were significantly associated with life-threatening causes and unfavorable prognosis. Thus, evaluating ancillary CT features when we encountered PI would help us characterize the causes of PI and determine the appropriate treatment option.

Hepatic Portal Venous Gas

In a prospective investigation the sensitivity of conventional radiography, sonography, color Doppler flow imaging (CDFI) and CT in the detection of hepatic portal venous gas (HPVG) was compared in 7 patients with different diagnoses. For the identification of HPVG sonography, CDFI and CT have a higher sensitivity than conventional radiography. CT, however, was the most suitable method to identify the underlying cause of HPVG. Patients with iatrogenic HPVG as a result of diagnostic or therapeutic intervention had a good prognosis. In contrast, in all cases with a sudden appearance of HPVG and a noniatrogenic cause, exitus ensued within 1 week.

Ischemic colitis: spectrum of CT findings, sites of involvement and severity

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.

Case report: portal and systemic venous gas in a patient with perforated duodenal ulcer: CT findings

Gas within the portal circulation has been known to be associated with a number of conditions most commonly mesenteric ischemia and necrosis. Systemic venous gas is described with few conditions and is mostly iatrogenic in nature. We describe a case of combined portal and systemic venous gas detected by computed tomography in a patient with perforated duodenal ulcer.

A simple score for predicting mortality in patients with pneumatosis intestinalis

BACKGROUND AND AIM

This study was conducted to identify simple computerized tomography (CT) and clinical predictors of mortality in patients with pneumatosis intestinalis (PI). Thus, the clinical characteristics and outcomes of PI were assessed and the predictors of mortality were identified.

METHODS

The medical records of 123 patients with PI were reviewed retrospectively. Multivariate logistic regression models were constructed to determine independent predictors of mortality. These data were used to develop a simple score that would predict mortality on the first and seventh day after diagnosis.

RESULTS

The median age at diagnosis was 62 (range, 20-91) years. The most common cause of PI was mesenteric vascular ischemia (n=43, 35.0%). Twenty-nine (23.6%) disease-related deaths occurred during the index admission. Both signs of peritoneal irritation on physical examination and decreased or absent enhancement of the bowel wall were associated with increased mortality. If both factors were absent, the in-hospital mortalities on both the first and seventh days after the diagnosis of PI were less than 5%. However, if both factors were present, the in-hospital mortality was 57% on the first day and 59% on the seventh day.

CONCLUSIONS

A simple and novel risk score that predicts mortality in patients with PI was proposed. Patients with both peritoneal irritation and decreased or absent enhancement of bowel wall on CT should be observed vigilantly and early intervention should be instituted.

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.

Gas in portal circulation and pneumatosis cystoides intestinalis during chemotherapy for advanced rectal cancer

OBJECTIVES

Acute abdominal symptoms with CT scan evidence of intramural gas in bowel walls (pneumatosis cystoides intestinalis, PCI) and of gas in the portal venous blood (PBG) in patients undergoing chemotherapy may represent a worrisome picture, suggestive of bowel necrosis. This picture remains a major clinical clue and the reporting of new cases may help to share awareness and experience on management. We describe a patient with acute abdominal symptoms and evidence of PCI with PBG under cetuximab, oxaliplatin, tegafur-uracil and folinic acid chemotherapy for metastatic adenocarcinoma of the rectosigmoid junction.

METHODS

After admission for mucositis with diarrhea and profound dehydration, and subsequent emergency laparotomy for derotation of an intestinal volvulus, on the tenth postoperative day the patient developed fever and abdominal pain, with CT scan evidence of PCI with PBG. The exam of the abdomen did not suggest major problems requiring emergency surgery, and antibiotic treatment with close monitoring were performed, followed by rapid improvement.

RESULTS

Twelve days later, after resumption of oral diet, the patient unexpectedly suffered a spontaneous jejunal microperforation, requiring emergency laparotomy and bowel resection. Pathology showed that the perforation was within an area of ulceration involving the inner superficial layer of the bowel. Subsequently recovery was normal and at present, after 15 months, the patient is well and continuing chemotherapy.

CONCLUSIONS

This is probably the first report of PCI with PBG related to intestinal toxicity during cetuximab, oxaliplatin, tegafur-uracil and folinic acid chemotherapy in a patient with advanced rectal carcinoma, followed by delayed small bowel perforation. It provides an example of the challenges involved in the management of this type of patient.

Successful conservative treatment of pneumatosis intestinalis and portomesenteric venous gas in a patient with septic shock

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.

Natural history, clinical pattern, and surgical considerations of pneumatosis intestinalis

Objective

Pneumatosis intestinalis has been increasingly detected in recent years with the more frequent use of computed tomography for abdominal imaging of the intestine. The underlying causes of the gas found during radiographic studies of the bowel wall can vary widely and different hypotheses regarding its pathophysiology have been postulated. Pneumatosis intestinalis often represents a benign condition and should not be considered an argument for surgery. However, it can also require life-threatening surgery in some cases, and this can be a difficult decision in some patients.

Methods

The spectrum of pneumatosis intestinalis is discussed here based on various computed tomographic and surgical findings in patients who presented at our University Medical Centre in 2003-2008. We have also systematically reviewed the literature to establish the current understanding of its aetiology and pathophysiology, and the possible clinical conditions associated with pneumatosis intestinalis and their management.

Results

Pneumatosis intestinalis is a primary radiographic finding. After its diagnosis, its specific pathogenesis should be ascertained because the appropriate therapy is related to the underlying cause of pneumatosis intestinalis, and this is sometimes difficult to define. Surgical treatment should be considered urgent in symptomatic patients presenting with an acute abdomen, signs of ischemia, or bowel obstruction. In asymptomatic patients with otherwise inconspicuous findings, the underlying disease should be treated first, rather than urgent exploratory surgery considered. Extensive and comprehensive information on the pathophysiology and clinical findings of pneumatosis intestinalis is provided here and is incorporated into a treatment algorithm.

Conclusions

The information presented here allows a better understanding of the radiographic diagnosis and underlying aetiology of pneumatosis intestinalis, and may facilitate the decision-making process in this context, thus providing fast and adequate therapy to particular patients.

Fatal systemic venous air embolism during endoscopic retrograde cholangiopancreatography

Hepatic portal venous air embolism is the rarest complication of gastrointestinal endoscopy, resulting from penetration of gas into the portal veins, and may occur during endoscopic retrograde cholangiopancreatography and endoscopic biliary sphincterotomy. The likely mechanism is intramural dissection of insufflated air into the portal venous system through duodenal vein radicles transected during the procedure. Hepatic portal air embolism may be fatal. Cerebral air embolism may also occur. So far 13 cases of air embolism after endoscopic retrograde cholangiopancreatography have been reported, with 4 cases of systemic spread that proved fatal. Death was due to pulmonary air embolism in 2 cases, and cerebral air embolism in another 2. We report on an additional such fatal case, concerning a 78-year-old male patient, who several years previously had undergone surgical gastroduodenal resection with cholecystectomy and papillotomy, and was admitted for recurrent ascending cholangitis secondary to bile duct stones. During the third endoscopic cholangioscopic procedure for removal of bile duct stones, sudden cardiopulmonary arrest occurred. Death was due to massive pulmonary air embolism. Cerebral air embolism was also found. Autopsy was performed. A spontaneous duodenobiliary fistula was found. On the basis of bench radiologic investigation (retrograde suprahepatic venography and anterograde portography), it was demonstrated that the air insufflated during duodenal endoscopy, which entered through the spontaneous duodeno-biliary fistula, penetrated into intrahepatic vein radicles injured secondarily to prolonged impaction of biliary sand and stones and infection, resulting in portal and hepatic venous gas and systemic air embolism.

Pneumatosis intestinalis and portal venous gas without bowel ischemia in a patient treated with irinotecan and cisplatin

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.

Portal venous gas--case report and review of the literature

A 74-year-old man with chronic renal failure was admitted to the renal unit with non-specific symptoms and positive blood cultures. He later deteriorated and was admitted to the Intensive Care Unit with septic shock, respiratory failure and deranged liver function. Initial improvement was followed by abdominal distension and discomfort. Portal venous gas (PVG) and thrombosis were diagnosed on computed tomography. A conservative line of management was adopted. Improvement was soon followed by deterioration with septic shock. Extensive portal venous gas and free intra-abdominal gas were now evident on repeat computed tomography. The patient was too unwell to withstand surgery and a decision was made not to escalate therapy. He died on day 16. Portal venous gas is not a disease; it is a diagnostic clue in patients who may be harbouring an intra-abdominal catastrophe. Successful management of these cases requires early identification of the underlying pathology and can range from simple observation to extensive surgical intervention.

Portal Venous Gas Detected on Computed Tomography in Emergency Situations: Surgery Is Still Necessary

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.

Radiofrequency Ablation of Liver Tumors: A New Cause of Benign Portal Venous Gas

PURPOSE

To retrospectively describe and categorize the presence of portal venous gas (PVG) from radiofrequency (RF) ablation of hepatic tumors.

MATERIALS AND METHODS

The study was HIPAA compliant, and informed consent was waived. Thirty-four consecutive computed tomography (CT)-guided percutaneous RF ablations of liver tumors in 26 patients (13 men, 13 women; mean age, 69 years) with five hepatocellular carcinomas and 21 metastatic liver tumors (13 colon, five other, and three unknown primary tumors) were performed with an institutional review board-approved protocol. Two treatment modalities were used: RF ablation alone (13 procedures) and combined RF ablation and ethanol injection (21 procedures). Presence of PVG was quantified with three parameters: maximum length of a portal venous branch with gas, number of Couinaud segments in which PVG was seen, and total number of portal venous branch points with gas. Then an overall PVG score from 0 to 5 was determined. Also, when tumoral gas was seen on CT scans, the largest cross-sectional area of gas was measured. The two ablation methods were compared for quantities of PVG and tumoral gas. The role of N(2)O anesthetic in PVG and tumoral gas formation during ablation also was studied. Statistical analyses were performed with Wilcoxon rank sum and Student t tests.

RESULTS

In 25 procedures (74%), gas was found in portal vein branches; in 30 procedures (88%), gas was also found in tumoral and peritumoral tissues. There was no significant difference in frequency of PVG between the ablation methods. Combined therapy yielded significantly greater lengths of PVG (P < .002) and more portal venous branch points (P < .001) than did RF ablation alone. Mean PVG score was 2.4 +/- 0.4 (standard error of the mean) for combined therapy and 0.9 +/- 0.2 for RF ablation alone (P < .004). N(2)O anesthetic was associated with greater amounts of tumoral gas (P < .008) and PVG (P < .03). Tumoral gas, peritumoral gas, and PVG dissipated within 20 minutes after ablation in all patients. No morbidity or mortality was associated with PVG.

CONCLUSION

RF ablation is a common yet benign cause of transient PVG, tumoral gas, and peritumoral gas. Combined RF and ethanol ablation was associated with more PVG than was RF ablation alone.

Case report. Hepatic portal venous gas: transient radiographic finding associated with colchicine toxicity

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.

Portal vein air embolization after blunt abdominal trauma: a case report and review of the literature

Gas in the portal vein is a rare and often fatal condition in surgical patients. However, the presence of gas in the mesenteric and portal veins in association with abdominal trauma is a transient incidental finding that resolves spontaneously. We describe a young patient with Crohn's disease who suffered air embolism of the portal veins secondary to blunt abdominal trauma. The condition was clinically benign and resolved spontaneously. The pathogenesis is discussed and a review of the literature is provided.

Pneumatosis intestinalis and portomesenteric venous gas in intestinal ischemia: correlation of CT findings with severity of ischemia and clinical outcome

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.

Hepatic portal venous gas: report of a case

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.

Portomesenteric vein gas: pathologic mechanisms, CT findings, and prognosis

Portomesenteric vein gas is a rare condition whose pathogenesis is not fully understood. Portomesenteric vein gas is most commonly caused by mesenteric ischemia but may have a variety of other causes. The primary factors that favor the development of this pathologic entity are intestinal wall alterations, bowel distention, and sepsis. Portomesenteric vein gas is idiopathic in approximately 15% of cases. Advanced imaging techniques such as computed tomography (CT) have increased the sensitivity for detection of portomesenteric vein gas. At CT, portal vein gas appears as tubular areas of decreased attenuation in the liver, predominantly in the left lobe. Gas in the great mesenteric veins can easily be demonstrated with contrast material-enhanced CT, whereas gas in the small mesenteric veins appears as tubular or branched areas of decreased attenuation in the mesenteric border of the bowel. Findings of portomesenteric vein gas at CT should be carefully evaluated in the context of clinical findings. In the majority of cases, the prognosis is favorable and surgery is not required. However, when CT demonstrates portomesenteric vein gas and clinical findings suggest the presence of mesenteric ischemia, surgery is mandatory.

[Hepatic portal venous gas]

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.

Sonographic "gastric corona sign": diagnosis of gastric pneumatosis caused by a penetrating gastric ulcer

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.

[Hepatic portal venous gas: is it always a sign of severity and surgical emergency?]

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.

Hepatic portal venous gas in a critically ill patient

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.

[Lethal portal venous gas after cardiopulmonary arrest]

We report the case of a 51-year-old patient admitted after a transient cardiorespiratory arrest. The abdominal CT scan revealed the presence of hepatic portal venous gas. At laparotomy, a diffuse mesenteric ischaemia was diagnosed. The patient died from multiple organ failure in the subsequent hours. Necrotic bowel is associated with hepatic portal venous gas in 50% of the cases and the current mortality rate is 85%. Gas originates either through intestinal transmucosal passage, either by intraportal bacterial gas production, or through both mechanisms.

Hepatic portal venous gas associated with cholangitis following pancreaticoduodenectomy: report of a case

A 63-year-old an developed fever and shock 2 weeks after undergoing a pancreaticoduodenectomy for carcinoma of the gallbladder with duodenal involvement. Computed tomography (CT) of the abdomen showed transient hepatic portal venous gas in the right lobe of the liver, which had probably been induced by obstruction of the bilioenteric anastomosis by the biliary drain. The gas and bacteria, both of which are commonly observed in cases of bilioenteric anastomosis, may have been diffused through the sinusoid into the portal venous system. Thus, hepatic portal venous gas could be a serious sign when it develops in patients with cholangitis following bilioenteric anastomosis.

Portal vein reflectors: duplex sonographic appearance

Duplex sonography has established utility in the noninvasive evaluation of the portal venous system. Recently, the duplex sonographic features of suspected portal venous air have been described. We report on an experimental study in dogs undertaken to establish if the same sonographic features could be reproduced in a laboratory setting and to determine if small fragments of clot emboli could produce similar gray-scale and Doppler findings. Injections of microbubbles of air and clot fragments into the portal venous system were monitored using duplex ultrasound. The gray-scale and Doppler features of flow in the main portal vein were indistinguishable in both microbubble and clot injections. Superimposition of high-amplitude spikes on the normal portal venous waveform was seen in 19 of 24 (79%) microbubble and 13 of 23 (56%) clot fragment injections. We conclude that the appearance of rapidly moving, bright intraluminal echoes coupled with spike-like aberrations of the portal venous waveform can be associated with portal venous air bubbles or small blood clot emboli.

Ultrasound in detection of portal venous gas in adults

Three patients with sonographically demonstrated portal venous gas are presented. Two patients were also studied using computed tomography (CT). Both techniques had superior sensitivity compared to plain radiographs. Scattered echogenic patches in the liver parenchyma, and centrifugal flow of echogenic patches in the portal vein and its branches, are typical ultrasound findings of portal vein gas. Evaluation of ultrasound findings and coordination with clinical history differentiate portal vein gas from biliary gas.

Sonographic demonstration of septicaemia with gas-forming organisms after liver transplantation

Sepsis with gas-forming organisms, e.g. Clostridium perfringens and anaerobic streptococci occurred in three of 120 liver-transplant recipients (2.5%). The diagnosis was made in all three patients by bedside ultrasound, before blood cultures revealed bacterial growth. Floating high amplitude echoes within the extra- and intrahepatic portal veins and persistent small high amplitude echoes in the non-dependent portion of the liver are indicative of portal venous gas and should prompt further laboratory investigations.

Survival after ultrasonographic demonstration of portal venous gas due to mesenteric artery occlusion

Portal vein gas as a result of bowel necrosis following occlusion of the superior mesenteric artery has an extremely grave prognosis. Only two previous cases have been recorded as having survived. In both those cases the diagnosis of portal vein gas was made on an abdominal radiograph. The present report is of the first such case surviving after ultrasonic demonstration of portal gas. In this case, no evidence of portal gas was seen on the abdominal radiograph. The increased sensitivity of ultrasound over plain radiography mandates urgent liver and portal ultrasound in all cases of suspected mesenteric event.

Ultrasound demonstration of gas in hepatic veins

We report a case of a gas forming renal abscess in which real time ultrasound demonstrated intravascular gas originating in the abscess passing into the inferior vena cava and hepatic veins.