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Erdem S, Patel SV, Patel D, Patel S, Patel S, Chaudhary AJ. Understanding the Nuances of Hepatic Portal Venous Gas in Pneumatosis Intestinalis: An Indication of Bowel Ischemia? Cureus 2023; 15:e45330. [PMID: 37849594 PMCID: PMC10577153 DOI: 10.7759/cureus.45330] [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: 09/15/2023] [Indexed: 10/19/2023] Open
Abstract
Pneumatosis intestinalis (PI) is a relatively rare gastrointestinal finding that has a wide variety of causes - ranging from benign to life-threatening. It is described as the pathological presence of gas within the bowel wall with multiple hypotheses emerging as to the likely mechanism. An important indicator of a life-threatening source of PI is the presence of gas within the hepatic portal vein, referred to as hepatic portal venous gas (HPVG). While non-specific for isolated PI, HPVG has been reported in PI patients to be associated with bowel ischemia and is thereby considered an indication for emergent management. Herein we report a case involving an atypical presentation of altered mental status in which the patient was found to have PI with contemporaneous HPVG. These findings have been reported to have a high mortality rate. Our patient rapidly deteriorated during their hospital course, expiring shortly after being deemed a poor surgical candidate due to their severe co-morbidity burden. Through this case, we review evidence supporting the management of patients with PI and concurrent HPVG from an extensive review of available literature. While PI is a non-specific finding and commonly a source of diagnostic confusion, a better understanding of its natural course and potentially unorthodox sequela may afford more directed and crucial care for critically ill patients, in which time is often a precious commodity.
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Affiliation(s)
- Saliha Erdem
- Internal Medicine, Wayne State University School of Medicine, Detroit, USA
| | - Suraj V Patel
- Internal Medicine, Ross University School of Medicine, Miramar, USA
| | - Dhruvil Patel
- Internal Medicine, Wayne State University School of Medicine, Detroit, USA
| | - Shivam Patel
- Biomedical Sciences, University of South Florida, Tampa, USA
| | - Shlok Patel
- Pharmaceutical Science, University of Michigan, Ann Arbor, USA
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Furtado T, Domingues P, Piedade A, Parreira L, Natário A. A Rare and Severe Cause of Abdominal Pain in a Hemodialysis Patient. Cureus 2022; 14:e30800. [DOI: 10.7759/cureus.30800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/27/2022] [Indexed: 11/07/2022] Open
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Iatrogenic Hepatic Portal Venous Gas in a Patient With Crohn's Disease After Colonoscopy. ACG Case Rep J 2019; 6:e00150. [PMID: 31737693 PMCID: PMC6791633 DOI: 10.14309/crj.0000000000000150] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 05/17/2019] [Indexed: 12/23/2022] Open
Abstract
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.
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Daniel S, Francis D, Tobin M, Chawla A. Case of hepatic portal venous gas in an infant with hypertrophic pyloric stenosis. BMJ Case Rep 2018; 2018:bcr-2018-224794. [PMID: 29980514 DOI: 10.1136/bcr-2018-224794] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Hepatic portal venous gas is the presence of gas within the portal vein and its branches. A 4-week-old male infant presented with 1-week history of non-bloody, non-bilious projectile emesis. Examination was significant for an olive-shaped mass in the abdomen. Bloodwork showed hypokalaemic metabolic alkalosis. Abdominal ultrasound and radiograph was significant for portal venous gas and did not meet radiographic criteria for pyloric stenosis. He underwent upper endoscopy, which showed a narrowed, hypertrophic pylorus. The child underwent pyloromyotomy with resolution of his emesis. Hepatic portal venous gas (HPVG) is very rare and can be seen in the setting of hypertrophic pyloric stenosis. It is believed that an increase in intraluminal dilation and pressure subsequently moves gas from the intestinal mucosa venous system and lymphatics into the portal veins. The presence of HPVG in a well-appearing patient can be benign and should not prompt further testing nor delay treatment.
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Affiliation(s)
- Sherin Daniel
- Pediatric Gastroenterology, Stony Brook Children's Hospital, Stony Brook, New York, USA
| | - Denease Francis
- Pediatric Gastroenterology, Stony Brook Children's Hospital, Stony Brook, New York, USA
| | - Michelle Tobin
- Pediatric Gastroenterology, Stony Brook Children's Hospital, Stony Brook, New York, USA
| | - Anupama Chawla
- Pediatric Gastroenterology, Stony Brook Children's Hospital, Stony Brook, New York, USA
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Maezawa S, Fujita M, Sato T, Kushimoto S. Delayed intestinal stricture following non-resectional treatment for non-occlusive mesenteric ischemia associated with hepatic portal venous gas: a case report. BMC Surg 2015; 15:37. [PMID: 25885337 PMCID: PMC4392740 DOI: 10.1186/s12893-015-0028-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2014] [Accepted: 03/24/2015] [Indexed: 12/19/2022] Open
Abstract
Background Hepatic portal venous gas associated with non-occlusive mesenteric ischemia is indicative of a serious pathology that leads to bowel necrosis and it has a high mortality rate. Although non-occlusive mesenteric ischemia is acknowledged as a condition that requires early surgical treatment, it has been reported that bowel necrosis and surgical resection of the gangrenous lesion may be avoided if the condition is identified quickly and the cause is detected at an early phase. However, no reports or guidelines have been published that describe the management of patients in whom bowel necrosis and surgical treatment were avoided. We report the case of a patient who presented with non-occlusive mesenteric ischemia who was managed with non-resectional treatment at an early phase and had a delayed small-bowel stricture. Case presentation A 24-year-old man presented to the hospital with fever, abdominal pain, and vomiting. Abdominal computed tomography confirmed a diffuse gaseous distention with small-bowel pneumatosis and hepatic portal venous gas. An urgent laparotomy was performed, because septic shock associated with diffuse peritonitis and bowel necrosis was strongly suspected. Although we found purulent ascites and a perforated appendix at the time of surgery, gangrenous and transmural ischemic changes were not evident in the small bowel and colon. We performed an appendectomy without a bowel resection, and the patient was discharged on an oral diet. However, he was re-admitted to hospital, because 4 days after discharge he developed postoperative paralytic ileus. Non-operative management was chosen, but his symptoms did not improve. We decided to perform a laparotomy 40 days after the initial operation, and a considerable adhesion was detected. Therefore, only a synechotomy was performed. On day 57, he experienced symptoms that were associated with bowel obstruction once again. On day 59, a partial resection of the jejunum was performed. Severe luminal strictures were apparent within the jejunum, and marked structural changes were evident. Conclusion While non-surgical management can be chosen for selected patients with non-occlusive mesenteric ischemia, continuous observation to evaluate the development of delayed strictures that lead to bowel obstructions is required in patients who undergo non-resectional treatment.
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Affiliation(s)
- Shota Maezawa
- Department of Emergency and Critical Care Medicine/Emergency Center, Tohoku University Hospital, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Motoo Fujita
- Department of Emergency and Critical Care Medicine/Emergency Center, Tohoku University Hospital, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Takeaki Sato
- Department of Emergency and Critical Care Medicine/Emergency Center, Tohoku University Hospital, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan
| | - Shigeki Kushimoto
- Department of Emergency and Critical Care Medicine/Emergency Center, Tohoku University Hospital, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan. .,Division of Emergency and Critical Care Medicine, Tohoku University Graduate School of Medicine, 1-1 Seiryo-machi, Aoba-ku, Sendai, 980-8574, Japan.
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Kearns K, Tran Van D, Alberti N, Fontaine B, Fritsch N. [Hepatic portal venous gas: surgery or not surgery?]. ACTA ACUST UNITED AC 2013; 32:803-6. [PMID: 24161290 DOI: 10.1016/j.annfar.2013.08.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2013] [Accepted: 08/20/2013] [Indexed: 10/26/2022]
Abstract
Finding hepatic portal venous gas with pneumatosis intestinalis on computed tomography (CT) represents diagnostic and therapeutic challenge. The intestinal necrosis, particularly associated with acute mesenteric ischemia, is the very first hypothesis to assess, with the underlying question of an urgent surgery. However, knowing the non-surgical causes that have been identified in the last decade seems necessary to better assess the risk-benefit ratio of emergency surgery. Among these causes, we report the case of the acute colonic pseudo-obstruction, also known as Ogilvie's syndrome, whose first line treatment is medical.
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Affiliation(s)
- K Kearns
- Département d'anesthésie-réanimation, hôpital d'instruction des armées Robert-Picqué, 351, route de Toulouse, 33140 Villenave-d'Ornon, France.
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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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Oliveira E, Manuel P, Alexandre J, Coelho I, Girão F. Abdominal pain, pneumatosis intestinalis and aeroportia in a hemodialyzed patient. Rev Clin Esp 2013. [DOI: 10.1016/j.rce.2012.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Mayet M, Hardcastle TC, Muckart DJJ. Benign portal venous gas after blunt abdominal trauma. ACTA ACUST UNITED AC 2011. [DOI: 10.1016/j.injury.2011.06.422] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Pain and chronic diarrhea in an elderly cancer patient. JAAPA 2011; 24:61-2. [DOI: 10.1097/01720610-201108000-00015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Bodlet A, Tintillier M. Aeroportia and Pneumatosis Intestinalis in a Hemodialysis Patient. Int J Organ Transplant Med 2011. [DOI: 10.1016/s1561-5413(11)60006-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
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Boucher N, Blanpain S, Brochart C, Chivot C, Robert B, Degremont R, Yzet T, Deramond H. [Mechanical gastric distension: a rare cause of portal venous gas]. JOURNAL DE RADIOLOGIE 2010; 91:1269-1271. [PMID: 21242905 DOI: 10.1016/s0221-0363(10)70187-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
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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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Ait Ali A, Elkaoui H, Bouchentouf SM, Zentar A, Sair K. [A lethal hepatic portal venous gas]. Presse Med 2009; 39:156-8. [PMID: 19376681 DOI: 10.1016/j.lpm.2008.11.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2008] [Revised: 10/31/2008] [Accepted: 11/06/2008] [Indexed: 11/17/2022] Open
Affiliation(s)
- Abdelmounaim Ait Ali
- Service de chirurgie viscérale I, Hôpital militaire d'instruction Mohamed V, Rabat, Maroc
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Zalinski S, Scatton O, Jacqmin S, Tacher V, Brézault C, Soubrane O. Portal venous gas following chemotherapy for colorectal cancer liver metastasis. Eur J Surg Oncol 2008; 35:557-60. [PMID: 18950980 DOI: 10.1016/j.ejso.2008.09.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2008] [Revised: 08/29/2008] [Accepted: 09/02/2008] [Indexed: 01/02/2023] Open
Abstract
The standard of care for patients with colorectal liver metastases is a combination of chemotherapy and surgery. New chemotherapy regimens with biologic agents (cetuximab, bevacizumab) have been shown to increase tumor response rates. Although this might be beneficial and this is an expected endpoint, it should be noted that patients with synchronous colorectal and liver metastases are at risk of septic complications. We recently encountered a case of hepatic portal venous gas after two cycles of chemotherapy in a patient with right colon cancer liver metastases. Complete necrosis of the liver metastasis subsequently turned into a liver abscess, which fistulized in the right portal vein. Infection of the necrotized metastasis was thought to be promoted by the colic tumor. Although this is a dramatic situation, it does not contraindicate a curative surgical resection.
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Affiliation(s)
- S Zalinski
- Department of Hepatobiliary Surgery and Liver Transplantation, Cochin Hospital, Paris, France
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Prost à la Denise J, Kianmanesh R, Castel B, Flamant Y, Msika S. Syndrome septique après cholécystectomie…. ACTA ACUST UNITED AC 2008; 145:278-83. [DOI: 10.1016/s0021-7697(08)73760-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Affiliation(s)
- D Nasr
- Service de chirurgie digestive, Hôpital des Chanaux - Mâcon, France.
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