“STOP, LOOK, and LISTEN.” Hepatic Portal Venous Gas: Time for Clinical Assessment!

Abstract

Pneumatosis intestinalis and portal venous gas are findings usually associated with intra-abdominal surgical catastrophes that frequently require emergent surgical intervention. Herein we present a case of a patient who presented in septic shock, with extensive portal vein gas, diffuse intestinal wall thickening, and atherosclerotic vascular insufficiency in the absence of pneumatosis intestinalis.

Given his advanced age, multiple comorbidities, magnitude of the initial findings, and his dramatic clinical response to aggressive fluid resuscitation, a cognitive decision was made to continue with nonoperative management. The patient recovered uneventfully and was discharged home in a stable condition.

Keywords

liver - portal vein - gas - air - pneumatosis intestinalis - necrotizing enteritis - mesenteric ischemia - nonoperative treatment - “Foot-of-the-Bed” test

• References

• 1 Liebman PR, Patten MT, Manny J, Benfield JR, Hechtman HB. Hepatic—portal venous gas in adults: etiology, pathophysiology and clinical significance. Ann Surg 1978; 187 (3) 281-287
• 2 Hernanz-Schulman M, Kirkpatrick Jr J, Shwachman H, Herman T, Schulman G, Vawter GF. Pneumatosis intestinalis in cystic fibrosis. Radiology 1986; 160 (2) 497-499
• 3 Andorsky RI. Pneumatosis cystoides intestinalis after organ transplantation. Am J Gastroenterol 1990; 85 (2) 189-194
• 4 Ho LM, Paulson EK, Thompson WM. Pneumatosis intestinalis in the adult: benign to life-threatening causes. AJR Am J Roentgenol 2007; 188 (6) 1604-1613
• 5 Wayne E, Ough M, Wu A , et al. Management algorithm for pneumatosis intestinalis and portal venous gas: treatment and outcome of 88 consecutive cases. J Gastrointest Surg 2010; 14 (3) 437-448
• 6 Nelson AL, Millington TM, Sahani D , et al. Hepatic portal venous gas: the ABCs of management. Arch Surg 2009; 144 (6) 575-581 , discussion 581
• 7 Wiesner W, Mortelé KJ, Glickman JN , et al. Pneumatosis intestinalis and portomesenteric venous gas: correlation of CT findings with severity of ischemia and clinical outcome. AJR 2001; 177: 1319-1323
• 8 Kernagis LY, Levine MS, Jacobs JE. Pneumatosis intestinalis in patients with ischemia: correlation of CT findings with viability of the bowel. AJR Am J Roentgenol 2003; 180 (3) 733-736
• 9 Peloponissios N, Halkic N, Pugnale M , et al. Hepatic portal gas in adults: review of the literature and presentation of a consecutive series of 11 cases. Arch Surg 2003; 138 (12) 1367-1370
• 10 Kinoshita H, Shinozaki M, Tanimura H , et al. Clinical features and management of hepatic portal venous gas: four case reports and cumulative review of the literature. Arch Surg 2001; 136 (12) 1410-1414
• 11 Shaw A, Cooperman A, Fusco J. Gas embolism produced by hydrogen peroxide. N Engl J Med 1967; 277 (5) 238-241
• 12 Quirke TE. Hepatic-portal venous gas associated with ileus. Am Surg 1995; 61 (12) 1084-1086
• 13 Katzgraber F, Glenewinkel F, Fischler S, Rittner C. Mechanism of fatal air embolism after gastrointestinal endoscopy. Int J Legal Med 1998; 111 (3) 154-156
• 14 Hussain A, Mahmood H, El-Hasani S. Portal vein gas in emergency surgery. World J Emerg Surg 2008; 3: 21
• 15 Tsai YM, Hsu KF, Yu JC, Chan DC, Liu YC. Life-threatening signs of ischemic bowel disease-portomesenteric venous gas. J Trauma 2011; 71 (1) E18
• 16 Silen W. Cope's Early Diagnosis of the Acute Abdomen. 22nd ed. New York: Oxford University Press; 2010: p.7