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Iskander OA. Unraveling the Mystery of Hepatic Portal Vein Gas: Exploring Its Benign Nature and Surgical Implications. Cureus 2023; 15:e41231. [PMID: 37529512 PMCID: PMC10387453 DOI: 10.7759/cureus.41231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/30/2023] [Indexed: 08/03/2023] Open
Abstract
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.
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2
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Dhakal P, Sharma S, Sharma A, Pandey S, Aryal S, Bhnadari S. Hepatic portal venous gas in the case of superior mesenteric artery thrombosis in a young adult-case report. Clin Case Rep 2023; 11:e6989. [PMID: 36852123 PMCID: PMC9957697 DOI: 10.1002/ccr3.6989] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 01/24/2023] [Accepted: 01/27/2023] [Indexed: 02/27/2023] Open
Abstract
Hepatic portal venous gas is diagnosed via computed tomography due to unusual imaging features. HPVG when linked with pneumatosis intestinalis has a high mortality rate and required urgent intervention. We present a case of a 26-year-old young adult with superior mesenteric artery thrombosis who presented with severe abdominal pain. On imaging, HPVG and pneumatosis intestinalis were seen owing to the urgent intervention of the patient. The reliable interpretation of the imaging findings along with quick intervention led to a favorable outcome in our case. Herein, we present a thorough review of the imaging findings of HPVG to make a reliable diagnosis when presented with such a case.
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Affiliation(s)
- Prakash Dhakal
- Department of Radiology, National Academy of Medical SciencesBir HospitalKathmanduNepal
| | - Suraj Sharma
- Department of Radiology, National Academy of Medical SciencesBir HospitalKathmanduNepal
| | - Abhishek Sharma
- Department of Radiology, National Academy of Medical SciencesBir HospitalKathmanduNepal
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3
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Zorzetti N, Lauro A, Ruffato A, D'Andrea V, Ferruzzi L, Antonacci N, Tranchino RM. Gas in the Portal Vein: An Emergency or Just Hot Air? Dig Dis Sci 2021; 66:3290-3295. [PMID: 34189669 DOI: 10.1007/s10620-021-07126-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/16/2021] [Indexed: 12/17/2022]
Abstract
We report the case of a 87-year-old woman admitted to our Emergency Department for mild abdominal pain associated with vomiting. An abdominal X-ray showed gas present in the portal venules of the left hepatic lobe, a finding associated with numerous surgical and medical conditions. The patient was successfully managed with conservative treatment. Isolated intrahepatic gas is a rare radiologic finding; emergency surgery should be performed only when there are signs of associated acute intestinal infarction.
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Affiliation(s)
- N Zorzetti
- Department of General Surgery, "Ospedale Civile Umberto I", Lugo, Ravenna, Italy.
| | - A Lauro
- Department of Surgical Sciences, Sapienza University, Rome, Italy
| | - A Ruffato
- Department of General Surgery, "Ospedale Civile Umberto I", Lugo, Ravenna, Italy
| | - V D'Andrea
- Department of Surgical Sciences, Sapienza University, Rome, Italy
| | - L Ferruzzi
- Department of General Surgery, "Ospedale Civile Umberto I", Lugo, Ravenna, Italy
| | - N Antonacci
- Department of General Surgery, "Ospedale Civile Umberto I", Lugo, Ravenna, Italy
| | - R M Tranchino
- Department of General Surgery, "Ospedale Civile Umberto I", Lugo, Ravenna, Italy
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4
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Alpuim Costa D, Modas Daniel P, Vieira Branco J. The Role of Hyperbaric Oxygen Therapy in Pneumatosis Cystoides Intestinalis-A Scoping Review. Front Med (Lausanne) 2021; 8:601872. [PMID: 33681242 PMCID: PMC7926085 DOI: 10.3389/fmed.2021.601872] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Accepted: 01/28/2021] [Indexed: 12/24/2022] Open
Abstract
Pneumatosis cystoides intestinalis (PCI) is characterized by gas-filled cysts within gastrointestinal tract wall from esophagus to rectum, with preferential involvement of large and small intestine. PCI is rare with an estimated incidence of 0.03 to 0-2% in general population. PCI can be distinguished into idiopathic (15%) or secondary (85%) and the clinical picture ranges from completely asymptomatic to life-threatening intraabdominal complications. Although etiology of PCI appears to be multifactorial, the exact pathophysiology is poorly understood and two main theories have been proposed (mechanical and bacterial). Over the last decades, an enormous therapeutic armamentarium was considered in PCI's management, including hyperbaric oxygen therapy (HBOT). Treatment comprises conservative treatment in mild cases to surgery in highly symptomatic and complicated PCI. In the late 70s, HBOT started to be used in selected cases of PCI not responding to conservative measures. Since then, several case reports, case series, and reviews have been published in the literature with variable outcomes. The overall response rate and complete response were 92.1% (n = 82/89) and 65.2% (n = 58/89), respectively, with a median follow-up of 7 months. Furthermore, HBOT is extremely safe, with few reported complications in the literature when used for PCI. Nevertheless, a randomized, controlled, and double-blind clinical trial is unlikely to occur given the rarity of PCI, logistical issues of HBOT, and methodological considerations related to adequate blinding with a sham-controlled group. HBOT in combination with personalized diet and antibiotics may be beneficial for moderate to severe PCI in patients with no indication for emergency exploratory laparotomy. The purpose of this article is to synthesize the existing data, analyse results of previous studies, identify gaps in knowledge, and discuss PCI' management, including the proposal of an algorithm, with a special focus on HBOT.
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Affiliation(s)
- Diogo Alpuim Costa
- Centro de Medicina Subaquática e Hiperbárica (CMSH), Portuguese Navy, Lisbon, Portugal
- Centro de Investigação Naval (CINAV), Base Naval Do Alfeite, Portuguese Navy, Almada, Portugal
- CUF Oncology, Haematology and Oncology Department, Lisbon, Portugal
- NOVA Medical School, Faculdade de Ciências Médicas, Lisbon, Portugal
| | - Pedro Modas Daniel
- Centro de Medicina Subaquática e Hiperbárica (CMSH), Portuguese Navy, Lisbon, Portugal
- Centro de Investigação Naval (CINAV), Base Naval Do Alfeite, Portuguese Navy, Almada, Portugal
| | - João Vieira Branco
- Centro de Medicina Subaquática e Hiperbárica (CMSH), Portuguese Navy, Lisbon, Portugal
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Walczak R, Paek M, Suran J, Amory JT, Specchi S, Sanchez M. Radiography and ultrasonography of pneumatosis intestinalis in a cat. Vet Radiol Ultrasound 2018; 61:E26-E30. [DOI: 10.1111/vru.12635] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 01/14/2018] [Accepted: 02/21/2018] [Indexed: 12/22/2022] Open
Affiliation(s)
- Raelyn Walczak
- Department of RadiologyGulf Coast Veterinary Specialists Houston TX 77027
| | - Matthew Paek
- Department of RadiologySynergy Veterinary Imaging Partners Rockville MD 21029
| | - Jantra Suran
- Section of RadiologyUniversity of Pennsylvania Philadelphia PA 19104
| | - Joseph T. Amory
- Department of RadiologyIDEXX Telemedicine Consultants Clackamas OR 97015
| | - Swan Specchi
- Department of Clinical SciencesIstituto Veterinario di Novara Strada Provinciale 9 Granozzo con Monticello Italy
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Ling R, Ren D, Shilton H, Spilias D. Pneumatosis intestinalis related to jejunal feeding post-pancreaticoduodenectomy. ANZ J Surg 2017; 88:E855-E856. [PMID: 28419768 DOI: 10.1111/ans.13952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Revised: 01/16/2017] [Accepted: 01/29/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Rebecca Ling
- Department of UGI Surgery, Monash Medical Centre, Monash Health, Melbourne, Victoria, Australia.,Department of Surgery, Monash University, Melbourne, Victoria, Australia
| | - David Ren
- Department of UGI Surgery, Monash Medical Centre, Monash Health, Melbourne, Victoria, Australia.,Department of Surgery, Monash University, Melbourne, Victoria, Australia
| | - Hamish Shilton
- Department of UGI Surgery, Monash Medical Centre, Monash Health, Melbourne, Victoria, Australia.,Department of Surgery, Monash University, Melbourne, Victoria, Australia
| | - Dean Spilias
- Department of UGI Surgery, Monash Medical Centre, Monash Health, Melbourne, Victoria, Australia.,Department of Surgery, Monash University, Melbourne, Victoria, Australia
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Song JG, Koo JS, Kang HS, Park JY, Kim SY, Hyun JJ, Jung SW, Lee SW. [A case of necrotizing colitis presenting with hepatic portal venous gas and pneumatosis intestinalis]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2015; 65:177-81. [PMID: 25797382 DOI: 10.4166/kjg.2015.65.3.177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
Hepatic portal venous gas is a very rare radiologic sign which is characterized by gas accumulation in the portal venous circulation. Pneumatosis intestinalis is also very rare and is characterized by multiple air cysts in the serosal or submucosal layers of the gastrointestinal tract walls. These two findings are caused by various pathological conditions and can develop individually or simultaneously. The latter is clinically more significant because it is frequently related to bowel ischemia or necrosis, and represents a poor prognosis. However, prognosis is more influenced by the severity of underlying disease rather than hepatic portal venous gas or pneumatosis intestinalis itself. If bowel ischemia or necrosis is the primary cause, emergency operation is very important to improve patient's prognosis. Herein, we report a case of necrotizing colitis presenting as hepatic portal venous gas and pneumatosis intestinalis which was successfully managed by early surgery.
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Affiliation(s)
- Jong Gyu Song
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Ja Seol Koo
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Hyo Sung Kang
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Jin Yong Park
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Seoung Young Kim
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Jong Jin Hyun
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Sung Woo Jung
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Sang Woo Lee
- Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
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Feuerstein JD, White N, Berzin TM. Pneumatosis intestinalis with a focus on hyperbaric oxygen therapy. Mayo Clin Proc 2014; 89:697-703. [PMID: 24797647 DOI: 10.1016/j.mayocp.2014.01.026] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2013] [Revised: 01/12/2014] [Accepted: 01/14/2014] [Indexed: 12/16/2022]
Abstract
Pneumatosis intestinalis is a rare condition of air in the bowel wall. Pneumatosis intestinalis is most often secondary to another medical condition. The diagnosis is most often made radiologically with a computed tomography scan. The disease severity ranges from benign to life-threatening. Predictors of poor outcomes include pH less than 7.3, bicarbonate level of less than 20 mEq/L, lactate level of more than 2 mmol/L, amylase level of more than 200 U/L, and portal venous gas on imaging. Early recognition of life-threatening signs and symptoms is critical. Treatment options include bowel rest, antibiotics, surgery, and, more recently, the use of hyperbaric oxygen therapy. Hyperbaric oxygen therapy is extremely safe, with no reported complications in the literature when used for pneumatosis intestinalis. When surgery is not emergently needed, symptomatic pneumatosis intestinalis can be safely treated with hyperbaric oxygen with a high likelihood of success without any considerable adverse effects.
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Affiliation(s)
- Joseph D Feuerstein
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, and Harvard Medical School, Boston, MA.
| | - Nicole White
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, and Harvard Medical School, Boston, MA
| | - Tyler M Berzin
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center, and Harvard Medical School, Boston, MA
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Rankin I, Sheth H. Hepatic portal venous gas: comparison of two cases. Case Rep Surg 2013; 2013:637951. [PMID: 24223320 PMCID: PMC3816040 DOI: 10.1155/2013/637951] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2013] [Accepted: 09/11/2013] [Indexed: 12/28/2022] Open
Abstract
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.
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Affiliation(s)
- Iain Rankin
- Department of Upper GI and Laparoscopic Surgery, Ealing Hospital NHS Trust, London, Uxbridge Road, Southall, UB1 3HW, UK
| | - Hemant Sheth
- Department of Upper GI and Laparoscopic Surgery, Ealing Hospital NHS Trust, London, Uxbridge Road, Southall, UB1 3HW, UK
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Kyriazanos ID, Bazinas TΑ, Tsoukalos GG, Stoidis CN. Unusual radiological finding of lethal pneumatosis intestinalis and portomesenteric vein gas. World J Radiol 2010; 2:233-6. [PMID: 21160636 PMCID: PMC2999321 DOI: 10.4329/wjr.v2.i6.233] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2010] [Revised: 06/01/2010] [Accepted: 06/08/2010] [Indexed: 02/06/2023] Open
Abstract
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.
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11
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Abboud B, El Hachem J, Yazbeck T, Doumit C, Hechtman HB. Hepatic portal venous gas: Physiopathology, etiology, prognosis and treatment. World J Gastroenterol 2009; 15:3585-90. [PMID: 19653334 PMCID: PMC2721230 DOI: 10.3748/wjg.15.3585] [Citation(s) in RCA: 171] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
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.
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12
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Ortega-Deballon P, Radais F, Facy O. Aeroportia and acute abdominal pain: ischemic bowel necrosis. Clin J Gastroenterol 2008; 1:157-159. [PMID: 26193695 DOI: 10.1007/s12328-008-0026-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2008] [Accepted: 07/07/2008] [Indexed: 11/30/2022]
Abstract
Pneumatosis intestinalis and aeroportia are typical findings of mesenteric ischemia. The second carries a worse prognosis than the former. We report the case of a patient presenting with acute abdominal pain and acidosis after admission to the coronary unit for myocardial infarction. An emergent abdominal CT scan showed aeroportia. Laparotomy confirmed extended bowel necrosis. Aeroportia is a typical feature of ischemic bowel necrosis, often associated with advanced disease and bad prognosis. In the presence of acute abdominal pain, aeroportia should be considered as a sign of ischemic bowel necrosis. Emergent laparotomy is warranted.
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Affiliation(s)
- Pablo Ortega-Deballon
- Department of Surgery, University Hospital of Dijon, Dijon Cedex, France. .,Service de Chirurgie Digestive et Thoracique, 1, bd Jeanne d'Arc, 21079, Dijon Cedex, France.
| | - François Radais
- Department of Surgery, University Hospital of Dijon, Dijon Cedex, France
| | - Olivier Facy
- Department of Surgery, University Hospital of Dijon, Dijon Cedex, France
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