Gas in the portal vein of adults with necrotizing enteropathy

Conservative treatment of hepatic portal venous gas consecutive to a complicated diverticulitis: A case report and literature review

INTRODUCTION AND PRESENTATION OF CASE

Eight days after being diagnosed with multiple small strokes a 71year old male patient is readmitted with suspicion of a petit mal seizure also complained of diarrhoea and abdominal pain. The patient was stable, not febrile and neurologically intact with a slight tenderness in the left lower quadrant. An ultrasound revealed presence of air in the hepatic portal venous system and a suspicion for sigmoid diverticulitis. A CT-scan confirmed both diagnoses. We proceeded with a conservative regimen under close observation. The clinical course and laboratory results were unremarkable.

DISCUSSION

The review of the literature (PubMed database) triggered 685 items with only one clinical trial establishing a scoring system to detect adult individuals, which need operation.

CONCLUSION

A pneumoportogram (hepatic portal venous gas, HPVG) is a very rare and usually associated with bowel ischemia and from poor prognosis. The last decades saw the emergence of numerous other aetiologies (also benign) with a shift of paradigm from systematic emergency laparotomies to individual patient selection.

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.

[Hepatic portal venous gas. Clinical significance and review of the literature]

Hepatic portal venous gas in adults is a rare entity. The most frequent cause is intestinal ischemia. However, an increasing number of cases associated with benign conditions suitable for conservative treatment are being reported. We review the literature to define the clinical significance of portal venous gas, the role of computed tomography, and the need to perform emergency exploratory laparotomy.

Early recognition of hepatic portal vein gas on CT with appropriate surgical intervention improves patient survival

Historically, hepatic portal vein gas has been linked with a dismal prognosis. However, in the last 3 decades, identification of hepatic portal vein gas has undergone a transition from late recognition on roentgenograms to earlier identification on computed tomography scan. The 5 patients in this case series were found to harbor hepatic portal vein gas identified using computed tomography scan. Eighty percent of the patients had concomitant pathology identified by computed tomography, felt to be the cause of the hepatic portal vein gas. All patients were taken to the operating room for exploration and resection of the offending pathology. All 5 patients survived. We suggest that early recognition using computed tomography scan, with appropriate operative intervention, improves the chance for patient survival when hepatic portal vein gas is identified.

Massive gas embolism in E. coli septicemia

The case of an elderly women with radiographic evidence of gas within her portal vein as well as the iliac and femoral arteries is presented. The underlying cause proved to be E. coli septicemia. Differential diagnosis and clinical significance of intravascular gas are reviewed.

Hepatic--portal venous gas in adults: etiology, pathophysiology and clinical significance

The roentgenographic finding hepatic--portal venous gas (HPVG) has been reported extensively in the pediatric and radiology literature. The surgical implications and clinical significance have yet to be fully defined. This study reviews the 60 reported cases in the literature and adds four new cases. HPVG appears as a branching radiolucency extending to within 2 cm of the liver capsule. HPVG is associated with necrotic bowel (72%), ulcerative colitis (8%), intra abdominal abscess (6%), small bowel obstruction (3%), and gastric ulcer (3%). Mucosal damage, bowel distention and sepsis predispose to HPVG. The current mortality rate of 75% represents an improvement from previous experience. Analysis of survivors indicates that the finding of HPVG requires urgent surgical exploration except when it is observed in patients with stable ulcerative colitis.

Hepatic--portal venous gas in adults: etiology, pathophysiology and clinical significance

The roentgenographic finding hepatic--portal venous gas (HPVG) has been reported extensively in the pediatric and radiology literature. The surgical implications and clinical significance have yet to be fully defined. This study reviews the 60 reported cases in the literature and adds four new cases. HPVG appears as a branching radiolucency extending to within 2 cm of the liver capsule. HPVG is associated with necrotic bowel (72%), ulcerative colitis (8%), intra abdominal abscess (6%), small bowel obstruction (3%), and gastric ulcer (3%). Mucosal damage, bowel distention and sepsis predispose to HPVG. The current mortality rate of 75% represents an improvement from previous experience. Analysis of survivors indicates that the finding of HPVG requires urgent surgical exploration except when it is observed in patients with stable ulcerative colitis.

Bypass enteritis. A new complication of jejunoileal bypass for obesity

Four patients who had jejunoileal bypass for morbid obesity had increased frequency of diarrhea, diffuse abdominal tenderness and distention, and fever to 104 degrees F. Roentgenographic studies disclosed multiple distended loops in the bypassed bowel with few air fluid levels. Two of these patients underwent operation for suspected peritonitis from abscess or obstruction. No abscess or mechanical obstruction was found. The bypassed bowel contained many subserosal gas-filled blebs. The remaining two patients were treated with antibiotics and showed prompt improvement. "Bypass enteritis" must be considered in the postoperative period in patients undergoing surgery for morbid obesity. It responds to antibiotics and appropriate electrolyte therapy. The presumed factor is overgrowth of enteric bacteria in the distal portion of the bypassed bowel. Accurate diagnosis will obviate the need for surgical exploration to exclude peritonitis.