Distinguishing between hepatic portal vein gas and pneumo(aero)bilia

Intrahepatic Gas Caused by Acute Gastroenteritis: Hepatic Portal Venous Gas or Biliary Tract Gas?

Purpose

Hepatic portal venous gas is not a specific disease and is often only an imaging manifestation in patients with acute abdomen. However, its appearance often indicates serious disease and poor prognosis. It is not difficult to distinguish typical portal venous gas from biliary tract gas on computed tomography because of their relatively different distribution within the liver. But the difference is not absolute.

Case Description

An 82-year-old female was admitted to the emergency department due to epigastric pain, nausea and vomiting for 1 day. Intrahepatic gas was found on computed tomography (CT), which was initially diagnosed as portal venous gas, and contrast-enhanced abdominal CT was performed 3 hours after the first plain CT scan and revealed a significant reduction of intrahepatic gas, then diagnosed as biliary tract gas. Two days later, enhanced abdominal CT showed that biliary tract gas had disappeared. Continuous gastrointestinal decompression, anti-infection, rehydration and other treatments were given. After treatment, abdominal pain, nausea, vomiting and other symptoms of the patient were gradually relieved. The patient refused gastroenteroscopy and was discharged after 13 days of hospitalization.

Conclusion

Portal venous gas and biliary tract gas may have similar CT findings and be misdiagnosed, and enhanced CT examination is necessary to confirm the diagnosis.

White spirit poisoning: An unusual cause of hepatic portal venous gas

Traditionally, the presence of air within the hepatic portal venous system has been considered a rather ominous sign as it has been associated with conditions of increased associated morbidity and mortality such as bowel ischemia and intraabdominal sepsis. However, benign conditions, not requiring any particular intervention, have been implemented in the etiology, as well. In the present report, we present the case of the accidental ingestion of white spirit as a rather unusual cause of hepatic portal vein gas. A 32-year-old, otherwise healthy, male was admitted to the emergency department following the accidental ingestion of a “sip,” approximately 15 ml, of white spirit. The patient was complaining of nausea and upper abdominal pain that started soon after the ingestion of caustic agent. An imaging investigation with a computed tomography scan (CT) of the abdomen revealed the presence of hepatic portal vein gas along with a diffuse edema of the gastric wall at the site of the lesser curvature. A follow-up CT, 2 days after the admission, revealed no evidence of hepatic portal venous gas. Based on the patient's good general condition, an expectant management was decided. No intervention was required, oral feeding was recommenced after 6 days of fasting and the patient was discharged 8 days after the admission. Hepatic portal venous gas is a very impressive imaging finding with remarkably diverse etiology and prognostic correspondence. Irrespective of the cause, an approach of managing patients with hepatic portal venous gas according to their clinical condition appears reasonable.

Portal Venous Gas on Point-of-Care Ultrasound in a Case of Cecal Ischemia

BACKGROUND

Portal venous gas has mainly been studied in pediatrics and seen in cases of necrotizing enterocolitis. It is a rare finding in adults and is typically associated with underlying intestinal ischemia or other malignant intra-abdominal pathology. Portal venous gas is seen more readily on ultrasound compared to radiographs in both pediatric and adult patients. Findings include lucencies extending to the periphery of the liver, echogenic bubbles flowing centrifugally throughout the portal venous system, and bidirectional spikes interrupting the monophasic portal venous waveform on spectral analysis.

CASE REPORT

We present a case of a 36-year-old female who presented with abdominal pain. She had findings consistent with portal venous gas on point-of-care ultrasound, prompting computed tomography of her abdomen and surgical consultation. She was ultimately found to have cecal ischemia from cecal volvulus, had surgical resection and anastomosis, and was able to be discharged from the hospital following recovery. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: With the ever-increasing use of point-of-care ultrasound, emergency physicians should be aware of the findings consistent with portal venous gas as well as its implications. Emergency physicians should know portal venous gas is associated with intestinal ischemia and other malignant pathologies and should prompt more advanced imaging or surgical consultation when observed. Emergency physicians should also understand the distinctions between portal venous gas and pneumobilia found on point-of-care ultrasound, given that portal venous gas is typically a malignant finding and pneumobilia is most frequently benign.

Iatrogenic Hepatic Portal Venous Gas in a Patient With Crohn's Disease After Colonoscopy

Hepatic portal venous gas is a radiologic sign and is associated with several abdominal disorders. The prognosis and survival of the patient depends on the underlying etiology. Most cases respond to broad-spectrum antibiotics, but some may need surgical intervention. We report a case of hepatic portal venous gas after colonoscopy in a patient with Crohn's disease.

Hepatic portal venous gas

Differentiating hepatic portal venous gas (HPVG) and pneumobilia on the CT scan can be accomplished by comparing the pattern of intrahepatic air spread. HPVG can be an indicator of significant intra-abdominal pathology and bowel ischaemia is the most common causative etiology for HPVG.

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.