Disappearing portal venous gas in acute pancreatitis and small bowel ischemia

Arterial Gas Emboli Secondary to Portal Venous Gas Diagnosed With Point-of-Care Ultrasound: Case Report and Literature Review

BACKGROUND

Portal venous gas (PVG) is a rarely observed clinical finding generally associated with intestinal ischemia. The proper clinical response to the finding of PVG depends somewhat on the setting in which it is observed. Here we describe a case in which extensive arterial gas emboli (AGE) were encountered during point-of-care ultrasound (POCUS) and subsequent computed tomography (CT) identified PVG secondary to gastric wall ischemia as the likely source.

CASE REPORT

A 69-year-old woman with history of metastatic colon cancer presented to the emergency department (ED) with altered mental status. On arrival, she was hypotensive, hypothermic, cachectic, and with abdominal distension. POCUS was performed to evaluate the source of the patient's hypotension, revealing the presence of PVG, as well as gas bubbles in all four chambers of the heart and the aorta. CT scan revealed gastric wall ischemia and confirmed the presence of significant air emboli throughout the portal venous system. Given the overall poor prognosis, the decision was made to forego further chemotherapy or surgery and the patient died later that week while under hospice care. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: AGE can occur in the setting of PVG. This may cause multi-organ failure by disrupting blood flow to organs, especially in patients with circulatory dysfunction, such as shock. Depending on the setting in which it is diagnosed, early detection of PVG may expedite earlier assessments of a patient's negative prognosis or initiation of attempted life-saving treatment. In this case report, we show that POCUS can be used to obtain an expedited diagnosis in a critically ill patient.

Transient venous air embolism after ERCP: worrisome or not?

The paper describes the occurrence of a rare complication – portal and systemic venous air embolism – after endoscopic retrograde cholangiopancreatography, related to the endoscopic procedure. It can be associated with the more frequently encountered post-endoscopic retrograde cholangiopancreatography complications pancreatitis or cholangitis. However, it can also be noted with perforation. The presented case suggests that in the clinical context an early abdominal ultrasound examination confirming hepatic portal venous gas and/or systemic venous air embolism could be useful for the diagnosis of post-endoscopic retrograde cholangiopancreatography retroduodenal perforation, and thus highlights the need for a high index of suspicion should this occurrence be noted post-procedurally, in order to ensure the best care of patients.

Hepatic portal venous gas after colonoscopy: A case report and review

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Here we reported a rare case of hepatic portal venous gas with a relevant review of literature.

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Actually the mechanism of HPVG is still unknown.

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The case present in literature are few and the mortality, generally caused by complications like necrotizing enterocolitis, is still high.

Introduction

Hepatic portal venous gas (HPVG) is a rare radiological finding in which gas enters the portal venous system and it is associated in case of necrotizing colitis with a mortality of 75%. We report a case of iatrogenic HPVG with a review of literature.

Presentation of case

A 41 years old patient underwent total colectomy and ileal pouch- anal anastomosis with derivative ileostomy for a familiar adenomatous polyposis coli in June 2008. A stenosis of the pouch-anal anastomosis developed. The patient underwent several endoscopic dilations. A recurrence of the stenosis was observed. The patient underwent to several endoscopic procedure. After the last colonoscopy the patient showed a fever with abdominal pain. A CT scan showed little peri-anastomotic collections and massive hepatic portal venous gas.

Discussion

The management of HPVG varied from surgical intervention to non-operative procedure. The surgical approach it's reserved to clinically unstable patients or those with evidence of peritonitis or bowel perforation. Stable patients, like those with an HPVG consequence of an endoscopic procedure, can be treated with non- operative management.

Conclusion

Our experience confirm that hepatic portal venous gas can be related to endoscopic procedure; thus, it can be managed on the basis of patient's general clinical conditions, and in selected cases it will disappear without therapeutic interventions with a good outcome.

S100A9 gene silencing inhibits the release of pro-inflammatory cytokines by blocking the IL-17 signalling pathway in mice with acute pancreatitis

The study aimed to investigate whether S100A9 gene silencing mediating the IL‐17 pathway affected the release of pro‐inflammatory cytokines in acute pancreatitis (AP). Kunming mice were assigned to the normal, AP, AP + negative control (NC), AP + shRNA, AP + IgG and AP + anti IL‐17 groups. ELISA was applied to measure expressions of AMY, LDH, CRP, TNF‐α, IL‐6 and IL‐8. The cells were distributed into the control, blank, NC, shRNA1 and shRNA2 groups. MTT assay, flow cytometry, RT‐qPCR and Western blotting were used to evaluate cell proliferation, cell cycle and apoptosis, and expressions of S100A9, TLR4, RAGE, IL‐17, HMGB1 and S100A12 in tissues and cells. Compared with the normal group, the AP group displayed increased expressions of AMY, LDH, CRP, TNFα, IL‐6, IL‐8, S100A9, TLR4, RAGE, IL‐17, HMGB1 and S100A12. The AP + shRNA and AP + anti IL‐17 groups exhibited an opposite trend. The in vivo results: Compare with the control group, the blank, NC, shRNA1 and shRNA2 groups demonstrated increased expressions of S100A9, TLR4, RAGE, IL‐17, HMGB1 and S100A12, as well as cell apoptosis and cells at the G1 phase, with reduced proliferation. Compared with the blank and NC groups, the shRNA1 and shRNA2 groups had declined expressions of S100A9, TLR4, RAGE, IL‐17, HMGB1 and S100A12, as well as cell apoptosis and cells at the G1 phase, with elevated proliferation. The results indicated that S100A9 gene silencing suppressed the release of pro‐inflammatory cytokines through blocking of the IL‐17 pathway in AP.