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He C, Zhang J, Yuan B, Pang Y. Is reoperation required for patients presenting with hepatic portal venous gas after gastrointestinal surgery: a review of the literature. Ann Med 2024; 56:2389293. [PMID: 39115464 PMCID: PMC11312995 DOI: 10.1080/07853890.2024.2389293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 04/29/2024] [Accepted: 06/20/2024] [Indexed: 08/11/2024] Open
Abstract
BACKGROUND AND OBJECTIVE Hepatic portal venous gas(HPVG) represents a rare radiographic phenomenon frequently linked to intestinal necrosis, historically deemed to need immediate surgical intervention. The pivotal query arises about the imperative of urgent surgery when a patient manifests HPVG after gastrointestinal surgery. This inquiry seeks to elucidate whether emergent surgical measures remain a requisite in such cases. METHODS The investigation into 14 cases of HPVG after gastrointestinal procedures was conducted through a comprehensive review of relevant literature. This methodological approach contributes to a nuanced understanding of HPVG occurrences following gastrointestinal surgery, informing clinical considerations and potential therapeutic strategies. RESULTS Among the 14 patients, 12 recovered and 2 died. 6 patients underwent surgical exploration, 4 with negative findings and recovered. 8 cases received conservative treatment, resulting in improvement for 5, and 1 initially treated conservatively, revealed perforation during later surgical exploration, leading to improvement, 1 case ended in mortality. CONCLUSION After gastrointestinal surgery, in Computed Tomography (CT) imaging, the coexistence of HPVG and gastrointestinal dilatation, without signs of peritoneal irritation on abdominal examination, may suggest HPVG due to acute gastrointestinal injury, intestinal gas, and displacement of gas-producing bacteria. These patients can be managed conservatively under close supervision. In cases where HPVG coexists with gastrointestinal dilatation and Pneumatosis intestinalis (PI) without signs of peritoneal irritation, conservative treatment may be continued under close supervision. However, if progressive exacerbation occurs despite close monitoring and the aforementioned treatments, timely surgical exploration is deemed necessary. When HPVG is combined with signs of peritoneal irritation, prompt laparotomy and exploration are preferred.
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Affiliation(s)
- Chanchan He
- Department of General Surgery, The Second Hospital of Lanzhou University, Lanzhou, China
| | - Junqiang Zhang
- Department of General Surgery, The Second Hospital of Lanzhou University, Lanzhou, China
| | - Bo Yuan
- Department of General Surgery, The Second Hospital of Lanzhou University, Lanzhou, China
| | - Yan Pang
- Department of General Surgery, The Second Hospital of Lanzhou University, Lanzhou, China
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Tropeano G, Di Grezia M, Puccioni C, Bianchi V, Pepe G, Fico V, Altieri G, Brisinda G. The spectrum of pneumatosis intestinalis in the adult. A surgical dilemma. World J Gastrointest Surg 2023; 15:553-565. [PMID: 37206077 PMCID: PMC10190725 DOI: 10.4240/wjgs.v15.i4.553] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Revised: 02/10/2023] [Accepted: 03/21/2023] [Indexed: 04/22/2023] Open
Abstract
Pneumatosis intestinalis (PI) is a striking radiological diagnosis. Formerly a rare diagnostic finding, it is becoming more frequently diagnosed due to the wider availability and improvement of computed tomography scan imaging. Once associated only with poor outcome, its clinical and prognostic significance nowadays has to be cross-referenced to the nature of the underlying condition. Multiple mechanisms of pathogenesis have been debated and multiple causes have been detected during the years. All this contributes to creating a broad range of clinical and radiological presentations. The management of patients presenting PI is related to the determining cause if it is identified. Otherwise, in particular if an association with portal venous gas and/or pneumoperitoneum is present, the eventual decision between surgery and non-operative management is challenging, even for stable patients, since this clinical condition is traditionally associated to intestinal ischemia and consequently to pending clinical collapse if not treated. Considering the wide variety of origin and outcomes, PI still remains for surgeons a demanding clinical entity. The manuscript is an updated narrative review and gives some suggestions that may help make the decisional process easier, identifying patients who can benefit from surgical intervention and those who can benefit from non-operative management avoiding unnecessary procedures.
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Affiliation(s)
- Giuseppe Tropeano
- Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome 00168, Italy
| | - Marta Di Grezia
- Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome 00168, Italy
| | - Caterina Puccioni
- Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome 00168, Italy
| | - Valentina Bianchi
- Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome 00168, Italy
| | - Gilda Pepe
- Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome 00168, Italy
| | - Valeria Fico
- Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome 00168, Italy
| | - Gaia Altieri
- Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome 00168, Italy
| | - Giuseppe Brisinda
- Emergency Surgery and Trauma Center, Fondazione Policlinico Universitario A Gemelli IRCCS, Rome 00168, Italy
- Department of Surgery, Università Cattolica del Sacro Cuore, Rome 00168, Italy
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Zhang Y, Liu HL, Tang M, Wang H, Jiang HH, Lin MB. Clinical features and management of 20 patients with hepatic portal venous gas. Exp Ther Med 2022; 24:525. [PMID: 35837035 PMCID: PMC9257953 DOI: 10.3892/etm.2022.11452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 06/08/2022] [Indexed: 11/06/2022] Open
Abstract
The present study investigated the characteristics, diagnosis, treatment and prognosis of hepatic portal venous gas (HPVG) using the data of 20 patients from the Tongji University School of Medicine Affiliated with Yangpu Hospital (Shanghai, China). The aim of the present study was to optimize the management method and improve the prognosis of patients with HPVG. A total of 20 patients were selected using a CT scan to confirm HPVG. All patients were enrolled and identified via a search engine, which examined all CT radiology reports containing the words pneumatosis and/or portal venous gas/air. Data were collected and analyzed, including sex, age, laboratory evidence, etiologies at admission, therapeutic method and in-hospital mortality. The patients consisted of 14 women (mean age, 79.1 years) and six men (mean age, 67.8 years). The results demonstrated that HPVG indicated a higher inflammatory index. The etiologies of HPVG included abdominal infection, pulmonary infection and hemorrhage, whereas the comorbidities included hypertension, diabetes, coronary disease, cerebrovascular disease and renal insufficiency. The present study determined that intestinal obstruction, acute enteritis and pulmonary infection were the main causes of HPVG. Of the 20 patients enrolled in the present study, four patients received surgery and 16 patients received conservative treatment. The overall in-hospital mortality was 25%. The present study indicated that the causes of HPVG may be closely related to inflammation and blood vessel injury. It was also determined that hemodynamic disorders of the intestinal tract and the combination of different types of infection were important contributors towards patient mortality.
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Affiliation(s)
- Yuan Zhang
- Department of General Surgery, Yangpu Hospital, School of Medicine, Tongji University, Shanghai 200090, P.R. China
| | - Hai-Long Liu
- Department of General Surgery, Yangpu Hospital, School of Medicine, Tongji University, Shanghai 200090, P.R. China
| | - Min Tang
- Department of General Surgery, Yangpu Hospital, School of Medicine, Tongji University, Shanghai 200090, P.R. China
| | - Hui Wang
- Department of General Surgery, Yangpu Hospital, School of Medicine, Tongji University, Shanghai 200090, P.R. China
| | - Hui-Hong Jiang
- Department of General Surgery, Yangpu Hospital, School of Medicine, Tongji University, Shanghai 200090, P.R. China
| | - Mou-Bin Lin
- Department of General Surgery, Yangpu Hospital, School of Medicine, Tongji University, Shanghai 200090, P.R. China
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Sun S, Zheng X, Zhang H, Han C, Zhao G. Hepatic portal venous gas associated with rapid infusion of postoperative early enteral nutrition after radical total gastrectomy. Nutrition 2022; 101:111685. [DOI: 10.1016/j.nut.2022.111685] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 04/01/2022] [Accepted: 04/03/2022] [Indexed: 11/25/2022]
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Della Seta M, Kloeckner R, Pinto Dos Santos D, Walter-Rittel TC, Hahn F, Henze J, Gropp A, Pratschke J, Hamm B, Geisel D, Auer TA. Pneumatosis intestinalis and porto-mesenteric venous gas: a multicenter study. BMC Med Imaging 2021; 21:129. [PMID: 34429069 PMCID: PMC8383372 DOI: 10.1186/s12880-021-00651-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 07/26/2021] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Estimating the prognosis of patients with pneumatosis intestinalis (PI) and porto-mesenteric venous gas (PMVG) can be challenging. The purpose of this study was to refine prognostication to improve decision making in daily clinical routine. METHODS A total of 290 patients with confirmed PI were included in the final analysis. The presence of PMVG and mortality (90d follow-up) were evaluated with regard to the influence of possible risk factors. Furthermore, a linear estimation model was devised combining significant parameters to calculate accuracies for predicting death in patients undergoing surgery by means of a defined operation point (ROC-analysis). RESULTS Overall, 90d mortality was 55.2% (160/290). In patients with PI only, mortality was 46.5% (78/168) and increased significantly to 67.2% (82/122) in combination with PMVG (median survival: PI: 58d vs. PI and PMVG: 41d; p < 0.001). In the entire patient group, 53.5% (155/290) were treated surgically with a 90d mortality of 58.8% (91/155) in this latter group, while 90d mortality was 51.1% (69/135) in patients treated conservatively. In the patients who survived > 90d treated conservatively (24.9% of the entire collective; 72/290) PMVG/PI was defined as "benign"/reversible. PMVG, COPD, sepsis and a low platelet count were found to correlate with a worse prognosis helping to identify patients who might not profit from surgery, in this context our calculation model reaches accuracies of 97% specificity, 20% sensitivity, 90% PPV and 45% NPV. CONCLUSION Although PI is associated with high morbidity and mortality, "benign causes" are common. However, in concomitant PMVG, mortality rates increase significantly. Our mathematical model could serve as a decision support tool to identify patients who are least likely to benefit from surgery, and to potentially reduce overtreatment in this subset of patients.
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Affiliation(s)
- Marta Della Seta
- Department for Radiology, Charité - University Medicine Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Roman Kloeckner
- Department for Radiology, University Hospital Mainz, Mainz, Germany
| | | | - Thula Cannon Walter-Rittel
- Department for Radiology, Charité - University Medicine Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Felix Hahn
- Department for Radiology, University Hospital Mainz, Mainz, Germany
| | - Jörn Henze
- Department for Radiology, University Hospital of Cologne, Cologne, Germany
| | - Annika Gropp
- Department for Radiology, Charité - University Medicine Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Johann Pratschke
- Department of General, Visceral and Transplant Surgery, Charité - University Medicine Berlin, Berlin, Germany
| | - Bernd Hamm
- Department for Radiology, Charité - University Medicine Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Dominik Geisel
- Department for Radiology, Charité - University Medicine Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Timo Alexander Auer
- Department for Radiology, Charité - University Medicine Berlin, Campus Virchow-Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany. .,Berlin Institute of Health (BIH), Berlin, Germany.
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Ryan JL, Dandridge LM, Andrews WS, Daniel JF, Fischer RT, Rivard DC, Wieser AB, Kane BJ, Hendrickson RJ. Conservative Management of Pneumatosis Intestinalis and Portal Venous Gas After Pediatric Liver Transplantation. Transplant Proc 2020; 52:938-942. [PMID: 32122661 DOI: 10.1016/j.transproceed.2020.01.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 12/10/2019] [Accepted: 01/02/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Pneumatosis intestinalis (PI) is a rare pathologic finding in pediatric liver transplant (PLT) recipients. The presentation and course of PI can range from asymptomatic and clinically benign to life threatening, with no consensus regarding management of PI in children. We aim to review the clinical presentation and radiologic features of PLT recipients with PI and to report the results of conservative management. METHODS A retrospective medical chart review was conducted on PLT recipients between November 1995 and May 2016. Parameters evaluated at PI diagnosis included pneumatosis location, presence of free air or portal venous gas (PVG), symptoms, laboratory findings, and medication regimen. RESULTS PI developed in 10 of 130 PLT patients (7.7%) between 8 days and 7 years (median: 113 days) posttransplant. Five of the patients were male, and the median age was 2 years (range, 1-17 years). PI was located in 1 to 2 abdominal quadrants in 6 patients, and 3 patients had PVG. At diagnosis, all patients were on steroids and immunosuppressant medication and 6 patients had a concurrent infection. Laboratory findings were unremarkable. Symptoms were present in 7 patients. Nine patients were managed conservatively, and 1 patient received observation only. All patients had resolution of PI at a median of 7 days (range, 2-14 days). CONCLUSIONS PI can occur at any time after PLT and appears to be associated with steroid use and infectious agents. If PI/PVG is identified and the patient is clinically stable, initiation of a standard management algorithm may help treat these patients conservatively, thus avoiding surgical intervention.
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Affiliation(s)
- Jamie L Ryan
- Division of Pediatric Gastroenterology, Children's Mercy Kansas City, Kansas City, Missouri, USA; Division of Developmental and Behavioral Sciences, Children's Mercy Kansas City, Kansas City, Missouri, USA
| | - Laura M Dandridge
- Division of Pediatric Gastroenterology, Children's Mercy Kansas City, Kansas City, Missouri, USA; Division of Developmental and Behavioral Sciences, Children's Mercy Kansas City, Kansas City, Missouri, USA
| | - Walter S Andrews
- Department of Surgery, Children's Mercy Kansas City, Kansas City, Missouri, USA
| | - James F Daniel
- Division of Pediatric Gastroenterology, Children's Mercy Kansas City, Kansas City, Missouri, USA
| | - Ryan T Fischer
- Division of Pediatric Gastroenterology, Children's Mercy Kansas City, Kansas City, Missouri, USA
| | - Douglas C Rivard
- Department of Radiology, Children's Mercy Kansas City, Kansas City, Missouri, USA
| | - Andrea B Wieser
- Department of Surgery, Children's Mercy Kansas City, Kansas City, Missouri, USA
| | - Bartholomew J Kane
- Department of Transplantation, Lahey Hospital & Medical Center, Burlington, Massachusetts, USA
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Murzi M, Gordillo J, Oblitas E, Soriano G, Pernas JC, Posso M, Garcia-Planella E. Spontaneous hepatic portal venous gas in a patient with ulcerative colitis. A case report and a review. GASTROENTEROLOGIA Y HEPATOLOGIA 2019; 43:22-25. [PMID: 31640909 DOI: 10.1016/j.gastrohep.2019.08.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2019] [Revised: 08/16/2019] [Accepted: 08/22/2019] [Indexed: 01/14/2023]
Affiliation(s)
- Marianette Murzi
- Gastroenterology and Hepatology Unit. Hospital de la Santa Creu i Sant Pau (IIB Sant Pau), Barcelona, Catalonia, Spain
| | - Jordi Gordillo
- Gastroenterology and Hepatology Unit. Hospital de la Santa Creu i Sant Pau (IIB Sant Pau), Barcelona, Catalonia, Spain.
| | - Elida Oblitas
- Gastroenterology and Hepatology Unit. Hospital de la Santa Creu i Sant Pau (IIB Sant Pau), Barcelona, Catalonia, Spain
| | - German Soriano
- Gastroenterology and Hepatology Unit. Hospital de la Santa Creu i Sant Pau (IIB Sant Pau), Barcelona, Catalonia, Spain; Centro de Investigaciones Biomédicas en Red en Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto de Salud Carlos III, Madrid, Spain
| | - Juan Carlos Pernas
- Radiology Department, Abdominal Section. Hospital de la Santa Creu i Sant Pau (IIB Sant Pau), Barcelona, Catalonia, Spain
| | - Margarita Posso
- Service of Clinical Epidemiology and Public Health, Hospital de la Santa Creu i Sant Pau (IIB Sant Pau), Barcelona, Spain
| | - Esther Garcia-Planella
- Gastroenterology and Hepatology Unit. Hospital de la Santa Creu i Sant Pau (IIB Sant Pau), Barcelona, Catalonia, Spain
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Treyaud MO, Duran R, Zins M, Knebel JF, Meuli RA, Schmidt S. Clinical significance of pneumatosis intestinalis - correlation of MDCT-findings with treatment and outcome. Eur Radiol 2016; 27:70-79. [PMID: 27106233 PMCID: PMC5127863 DOI: 10.1007/s00330-016-4348-9] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2015] [Revised: 03/14/2016] [Accepted: 03/29/2016] [Indexed: 12/18/2022]
Abstract
Objectives To evaluate the clinical significance of pneumatosis intestinalis (PI) including the influence on treatment and outcome. Method and Materials Two radiologists jointly reviewed MDCT-examinations of 149 consecutive emergency patients (53 women, mean age 64, range 21-95) with PI of the stomach (n = 4), small (n = 68) and/or large bowel (n = 96). PI extension, distribution and possibly associated porto-mesenteric venous gas (PMVG) were correlated with other MDCT-findings, risk factors, clinical management, laboratory, histopathology, final diagnosis and outcome. Results The most frequent cause of PI was intestinal ischemia (n = 80,53.7 %), followed by infection (n = 18,12.1 %), obstructive (n = 12,8.1 %) and non-obstructive (n = 10,6.7 %) bowel dilatation, unknown aetiologies (n = 8,5.4 %), drugs (n = 8,5.4 %), inflammation (n = 7,4.7 %), and others (n = 6,4 %). Neither PI distribution nor extension significantly correlated with underlying ischemia. Overall mortality was 41.6 % (n = 62), mostly related to intestinal ischemia (p = 0.003). Associated PMVG significantly correlated with underlying ischemia (p = 0.009), as did the anatomical distribution of PMVG (p = 0.015). Decreased mural contrast-enhancement was the only other MDCT-feature significantly associated with ischemia (p p < 0.001). Elevated white blood count significantly correlated with ischemia (p = 0.03). Conclusion In emergency patients, ischemia remains the most common aetiology of PI, showing the highest mortality. PI with associated PMVG is an alerting sign. PI together with decreased mural contrast-enhancement indicates underlying ischemia. Key Points • In emergency patients, PI may be caused by various disorders. • Intestinal ischemia remains the most common cause of PI in acute situations. • PI associated with decreased mural contrast-enhancement indicates acute intestinal ischemia. • PI associated with PMVG should alert the radiologist to possible underlying ischemia.
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Affiliation(s)
- Marc-Olivier Treyaud
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Rafael Duran
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Marc Zins
- Department of Radiology, Fondation Hôpital St Joseph, 185 Rue Raymond Losserand, 75014, Paris, France
| | - Jean-Francois Knebel
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Reto A Meuli
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital, Rue du Bugnon 46, 1011, Lausanne, Switzerland
| | - Sabine Schmidt
- Department of Diagnostic and Interventional Radiology, Lausanne University Hospital, Rue du Bugnon 46, 1011, Lausanne, Switzerland.
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Castren EE, Hakeem AR, Mahmood NS, Aryal K. Case of pneumatosis intestinalis and hepatic portal venous gas following a laparoscopic right hemicolectomy. BMJ Case Rep 2016; 2016:bcr-2016-214431. [PMID: 27001599 DOI: 10.1136/bcr-2016-214431] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Hepatic portal venous gas (HPVG) in most cases signifies either mechanical migration of air into the portal system due to bowel ischaemia (pneumatosis intestinalis) or portal sepsis due to gas-forming organisms. Successful management of portal sepsis involves early identification of the condition, intensive resuscitation, broad-spectrum antibiotics and a laparotomy for possible bowel ischaemia. In this report, we discuss the case of a patient with pneumatosis intestinalis and HPVG after an elective laparoscopic right hemicolectomy. After an initial slow recovery, on postoperative day seven, the patient had profuse diarrhoea and confusion, and was hyponatraemic. A CT scan revealed pneumatosis intestinalis and HPVG. A laparotomy showed no obvious cause for HPVG and there was no ischaemic bowel. She was managed with intensive care, hyperbaric oxygen therapy, broad-spectrum antibiotics and total-parenteral nutrition. She has made a good recovery. This case highlights the presenting features, differential diagnoses, and management of pneumatosis intestinalis and HPVG.
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Affiliation(s)
- Edit Elisa Castren
- Department of General and Colorectal Surgery, James Paget University Hospitals NHS Foundation Trust, Great Yarmouth, Norfolk, UK
| | - Abdul R Hakeem
- Department of General and Colorectal Surgery, James Paget University Hospitals NHS Foundation Trust, Great Yarmouth, Norfolk, UK
| | - Nabil S Mahmood
- Department of Radiology, James Paget University Hospital, Gorleston, UK
| | - Kamal Aryal
- Department of General and Colorectal Surgery, James Paget University Hospitals NHS Foundation Trust, Great Yarmouth, Norfolk, UK
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