Intestinal necrosis cannot be neglected in a patient with hepatic portal vein gas combined with appendicitis: a rare case report and literature review

Healthcare professionals' knowledge, attitude and practice towards ischemic bowel disease

BACKGROUND

Ischemic bowel disease (IBD) is a critical condition caused by reduced blood flow to the intestines, leading to tissue damage and potentially severe complications. Early recognition and timely management are essential for improving patient outcomes and reducing morbidity and mortality associated with IBD.

AIM

To evaluate the knowledge, attitude and practice (KAP) of healthcare professionals regarding IBD.

METHODS

This cross-sectional study was conducted among healthcare professionals in China from November 2023 to December 2023 using a self-designed questionnaire.

RESULTS

A total of 315 valid questionnaires were analyzed, with 215 participants (68.25%) being female. The mean KAP scores were 17.55 ± 5.35 (range: 0-24), 27.65 ± 2.77 (range: 8-40), and 18.88 ± 4.23 (range: 6-30), respectively. Multivariate linear regression analysis revealed the following factors to be independently associated with knowledge: Age 26-35 years (β = 2.80, 95%CI: 0.31-5.30, P = 0.028), professional title (β = 2.66, 95%CI: 0.91-4.41, P = 0.003), position (β = -3.78, 95%CI: -5.45 to -2.11, P < 0.001), participation in IBD-related training (β = 3.45, 95%CI: 2.39-4.51, P < 0.001), and admission of more than five IBD cases in the past month (β = 3.25, 95%CI: 1.58-4.92, P < 0.001). Attitude was independently associated with knowledge (β = 0.20, 95%CI: 0.15-0.26, P < 0.001) and being a nurse or nursing supervisor (β = -1.30, 95%CI: -2.16 to -0.40, P = 0.003). Practice was independently associated with knowledge (β = 0.20, 95%CI: 0.10-0.30, P < 0.001) and attitude (β = 0.24, 95%CI: 0.06-0.42, P = 0.007). Structural equation modeling demonstrated direct effects of knowledge on attitude (β = 0.24, P < 0.001) and practice (β = 0.26, P < 0.001), as well as of attitude on practice (β = 0.22, P = 0.012).

CONCLUSION

Healthcare professionals demonstrated adequate knowledge but moderate attitude and inactive practice regarding IBD. Addressing the gaps in attitude and practice through targeted training programs and interventions is essential for improving patient care and outcomes.

Thyrotoxicosis Presenting as an Acute Abdomen

Abdominal pain continues to be a common chief complaint in the emergency setting. While this presentation can be non-specific, there are certain findings that warrant immediate surgical intervention. Portal venous gas on imaging in the setting of peritonitis and sepsis is one such finding. Thyrotoxicosis on the other hand is an uncommon diagnosis that is associated with non-specific symptoms resulting in delayed diagnosis, a clinical scenario that can lead to significant morbidity and mortality. Here, we present a rare case of a patient who presented with signs and symptoms of peritonitis and portal venous gas on CT scan that was taken emergently to the operating room. No intraabdominal pathology was identified. The patient was later diagnosed with thyrotoxicosis, the presumed cause of the acute abdomen presentation.

Hepatic portal venous gas after ingesting glyphosate: A case report and literature review

Background

Glyphosate is a widely used herbicide. Clinical presentations of glyphosate intoxication show variation, but hepatic portal venous gas(HPVG) caused by glyphosate poisoning is rarely reported. Herein, we report a rare case of ominous HPVG after ingesting glyphosate. HPVG, which used to be an ominous abdominal radiologic sign, is associated with numerous underlying abdominal pathologies, ranging from benign conditions that require no invasive treatment to potentially lethal diseases that necessitate prompt surgical intervention.

Case summary

A young woman who ingested 100 mL glyphosate 6-h prior was admitted to the emergency intensive care unit. Before admission to our hospital, the patient was administered gastric lavage treatment with 10000 mL of normal saline in the local hospital. After 14 h, her laboratory examinations showed systemic inflammatory response syndrome and multiple organ dysfunction syndrome, while the condition deteriorated. Computed tomography of the abdomen showed multilinear air densities in the portal vein, hepatic branches, and mesenteric vessels, intestinal obstruction, and intestinal necrosis. Septic shock and a severe abdominal infection were diagnosed. The patient was treated conservatively as they could not tolerate surgery and, after 20 h died of septic shock.

Conclusion

We reviewed 289 cases of "hepatic portal venous gas" in PUBMED and analyzed the etiology and treatment of HPVG accompanied by the underlying pathology. We concluded that HPVG is a radiological sign associated with various diseases, and the prognosis mainly depends on the underlying cause and clinical condition. As glyphosate may erode the digestive tract, attention should be paid to the volume, pressure, and speed of gastric lavage in treating glyphosate poisoning to avoid fatal complications such as HPVG. Abdominal symptoms need to be closely observed, and changes in the early onset of the condition in clinical practice need to be responded to promptly.

Ultrasound and computed tomography findings of hepatic portal venous gas associated with acute appendicitis in a paediatric patient: A case report

Introduction

Hepatic portal venous gas is a rare and life-threatening condition characterised by the presence of gas in the portal vein. Hepatic portal venous gas is frequently associated with intestinal ischaemia and necrosis. We present the case of a paediatric patient with acute appendicitis with hepatic portal venous gas detected using ultrasonography.

Case report

A 5-year-old boy was admitted to our hospital with a respiratory tract infection. The boy started vomiting on day 2 of hospitalisation. He did not complain of any symptoms due to developmental retardation. We performed bedside point-of-care ultrasound, which detected hepatic portal venous gas, although the appendix could not be detected due to an acoustic shadow associated with bowel gas. Contrast-enhanced computed tomography revealed perforated appendicitis and pneumatosis intestinalis associated with paralytic ileus. An emergency laparoscopic appendectomy was performed. He was discharged on day 25 of hospitalisation after antibiotic therapy.

Discussion

The present case suggests that the mechanism of hepatic portal venous gas was paralytic ileus, which caused gas-forming bacterial proliferation. The gas produced by bacteria and/or the gas-forming bacteria entered the bowel wall, which caused pneumatosis intestinalis. The bubbles in the intestinal wall floated in the portal system and were detected as hepatic portal venous gas. Perforated appendicitis and paralytic ileus seemed to be caused by a delayed diagnosis of appendicitis. The point-of-care ultrasound examination was useful for detecting hepatic portal venous gas and for helping establish the diagnosis of appendicitis.

Conclusion

Hepatic portal venous gas is a rare finding associated with appendicitis in children. In addition, point-of-care ultrasound is useful for detecting hepatic portal venous gas in paediatric patients.

A healthy young patient with hepatic portal vein gas due to acute gastric dilatation: a case report

Hepatic portal vein gas (HPVG) is caused by the influx of gastrointestinal gas into the intrahepatic portal vein as a result of gastrointestinal wall fragility due to ischemia or necrosis. Gastrointestinal tract necrosis is fatal in severe cases. We observed a case of food intake-induced acute gastric dilatation (AGD) in a healthy young male who developed HPVG and underwent conservative treatment. A 25-year-old male presented to our hospital with epigastric pain and nausea the day after excessive food intake. Computed tomography (CT) revealed gas along the intrahepatic portal vein and marked gastric dilatation with large food residue. AGD-induced HPVG was considered. Esophagogastroduodenoscopy (EGD) was not performed at this stage because of the risk of HPVG and AGD exacerbation, and the patient was followed up with intragastric decompression via a nasogastric tube. Food residue and approximately 2 L of liquid without blood were vomited 1 h after the nasogastric tube placement. His symptoms improved after the vomiting episode. An EGD was performed 2 days after undergoing CT. Endoscopic findings revealed extensive erosions and the presence of a whitish coat extending from the fornix to the lower body of the stomach, indicating AGD. HPVG disappeared on the CT scan taken during EGD. Thereafter, symptom relapse and HPVG recurrence were not observed.

Gas in the Portal Vein: An Emergency or Just Hot Air?

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.

Clinical features of patients with hepatic portal venous gas

BACKGROUND

Hepatic portal venous gas (HPVG) is a rare clinical condition that is caused by a variety of underlying diseases. However, the factors that would permit accurate identification of bowel ischemia, requiring surgery, in patients with HPVG have not been fully investigated.

METHODS

Thirty patients that had been diagnosed with HPVG using computed tomography between 2010 and 2019 were allocated to two groups on the basis of clinical and intraoperative findings: those with (Group 1; n = 12 [40%]) and without (Group 2; n = 18 [60%]) bowel ischemia. Eleven patients underwent emergency surgery, and bowel ischemia was identified in eight of these (73%). Four patients in Group 1 were diagnosed with bowel ischemia, but treated palliatively because of their general condition. We compared the characteristics and outcomes of Groups 1 and 2 and identified possible prognostic factors for bowel ischemia.

RESULTS

At admission, patients in Group 1 more commonly showed the peritoneal irritation sign, had lower base excess, higher lactate, and higher C-reactive protein, and more frequently had comorbid intestinal pneumatosis. Of the eight bowel ischemia surgery patients, four (50%) died, mainly because of anastomotic leak following bowel resection and primary anastomosis (3/4, 75%). All except one patient in Group 2, who presented with aspiration pneumonia, responded better to treatment.

CONCLUSIONS

Earlier identification and grading of bowel ischemia according to the findings at admission should benefit patients with HPVG by reducing the incidence of unnecessary surgery and increasing the use of safer procedures, such as prophylactic stoma placement.