CASE REPORT

Hepatic Portal Venous Gas Disappearing within 24 Hours Miyako Niki, Ichiro Shimizu*, Takahiro Horie, Michiyo Okazaki, Tatsuhiko Shiraishi, Hisashi Takeuchi, Soichiro Fujiwara, Masahiko Murata, Koji Yamamoto, Arata Iuchi, Yoshio Atagi** and Susumu Ito*

Abstract the time of the admission, abdominal pain had already disap- peared. Her abdomenwas flat and soft, and neither tenderness Hepatic portal venous gas (HPVG)was detected by CT nor muscular defense was noted. The patient did not complain in a 64-year-old womanwho suddenly complained of lower of fever, and no other specific physical abnormalities were abdominal pain. However, the abdominal symptoms dis- observed. Hematological and biochemical examinations indi- appeared rapidly, and lower gastrointestinal endoscopy in- cated slight leukocytosis (WBC 9,630/|il) with neutrophilia dicated only terminal ileitis. Conservative treatment alone (neutrophil 82.9%), although CRPlevels (0. 1 mg/dl) were nor- was performed, and HPVGcompletely disappeared ap- mal. In addition, anemicfindings were not evident, and both proximately 18 hours later. The use of CTproved to be use- liver and renal functions appeared to be normal. Abdominal ful for following the course of HPVG. ultrasonography demonstrated high spot echo entry findings (Internal Medicine 41: 950-952, 2002) in the portal vein (Fig. 2). Abdominal CT performed at around 5:00 PMdemonstrated a slightly diminished dendritic gas im- Key words: hepatic portal venous gas, 24 hours, ileitis age in the liver, which was observed on CTat a local clinic (Fig. IB). Based on these subjective and objective findings, the patient was diagnosed as having HPVGwithout any ac- companyingsevere pathologic conditions such as intestinal Introduction necrosis that would require emergencysurgery. Therefore, the course of this patient was followed by conservative treatment Since hepatic portal venous gas (HPVG)is a major compli- consisting of fasting and total parental nutrition. WhenCT was cation associated with intestinal necrosis, emergencysurgery performed at around 9:00 AMon the second hospital day the is generally necessary for its treatment (1-3). However, lap- HPVGimage had disappeared (Fig. 1C). Although upper gas- arotomy is not absolutely indicated for all HPVGpatients, since trointestinal (GI) endoscopy did not demonstrate any specific some cases of HPVGwithout accompanying intestinal necro- abnormalities, colonoscopy demonstrated redness in the ileal sis have been reported to date (4-8). In this case, we encoun- terminal suggestive of terminal ileitis (Fig. 3). The results of tered a patient with HPVGin whomtransient ileitis was sus- all the bacteriological studies using feces, urine, and blood pected because the HPVGdisappeared within 24 hours after samples were negative. In addition, echocardiography indicated only conservative treatment. This finding confirmed the im- no abnormalities such as intracardiac thrombosis. Since a small portance of CTin following the course of HPVG(9). bowel follow-through study performed on the 10th hospital day failed to demonstrate any specific abnormalities, including in- flammatory findings in the ileal terminal, the patient was dis- Case Report charged. The patient was a 64-year-old womanwhoconsulted a lo- cal physician at around 4:00 PM on November 12, 2001 be- Discussion cause moderate lower abdominal pain suddenly occurred for a period of several minutes at around 3:00 PMAbdominal CT Wolfe and Evans first reported 6 cases of HPVGin new- demonstrated a dendritic gas image extending to the periphery born infants with necrotic enteritis (10). Thereafter, Susman of the liver (Fig. 1A). As a result, the patient was immediately and Senturia reported HPVGin adult patients (ll). To our admitted after referral to our department on the same day. By knowledge, over 1,000 cases of HPVGhave been reported to From the Department of Internal Medicine, Miyoshi Prefectural Hospital, Tokushima, *the Second Department of Internal Medicine, The University of Tokushima School of Medicine, Tokushima and **Atagi Physical Clinic, Ikeda Received for publication April 4, 2002; Accepted for publication July 25, 2002 Reprint requests should be addressed to Dr. Ichiro Shimizu, the Second Department of Internal Medicine, The University of Tokushima, School of Medicine, Kuramoto-cho, Tokushima 770-8503

950 Internal Medicine Vol. 41, No. ll (November 2002) Hepatic Portal VenousGas

Figure 1. Changes in CTimages of HPVG.CT performed during abdominal pain demonstrated a dendritic gas image extending to the periphery of the liver (A). After the disappearance of abdominal pain, CTperformed approximately 2 hours after the onset of disease demonstrated a diminished gas image (B). Furthermore, CT performed approximately 18 hours later demon- strated the complete disappearance of the HPVGimage (C).

date in the English-language literature (8). Since most of the previously reported cases of HPVGwere incidentally detected in patients with intestinal necrosis, the prognosis of HPVGis generally considered to be poor. The report by Liebmanet al on 64 adult patients with HPVGrevealed that 46 cases (72%) occurred in patients with intestinal necrosis, followed by 5 cases (8%) associated with ulcerative colitis, 4 cases (6%) with intraabdominal abscess, and 2 cases (3%) with a small bowel occlusion. Theyalso noted that the mortality rate from HPVG was 75%(1). Thereafter, Bloomet al reported that more than 90%of patients with ischemia-induced necrotic enteritis died when complicated by HPVG(2). Therefore, in principal, lap- arotomy maybe required whenpatients with GI disorders show HPVGcomplications (3). Several recent studies have reported Figure 2. Abdominal ultrasonography of HPVG.A high spot somecases of HPVGintervening underlying diseases that show echo entry finding was observed in the portal vein (arrow). a relatively favorable prognosis other than intestinal necrosis (4-8). It has also been reported that HPVGrelatively frequently

Figure 3. Lower gastrointestinal endoscopy. Mild redness was observed in the ileal terminal (A). Magnified endoscopic view of the mild flare lesion after the spreading of the dye (B).

Internal Medicine Vol. 41 , No. ll (November 2002) 951 Niki et al intervenes ischemic enteritis (12), in addition to intestinal ne- lower than that reported previously because only 5 (29%) of crosis. Moreover, complication by HPVGhas also been reported 17 patients, in whomHPVGwas detected by CT, had died (9). in patients with acute gastric dilatation (4), fecal impaction ( 1 3), The reason for this is that the use of CT, which is more sensi- or pseudoobstruction (14) as cases of HPVGintervening GI tive to HPVGthan plain X-ray, increased the probability of disorders without mucosal lesions. However, surgery is not in- detecting HPVGas an incidental finding. In the present pa- dicated for all such cases in principle because favorable out- tient, CTwas useful for accurately following the course of comes have been obtained by conservative treatment alone. HPVG.In the future, the use of CTmay increase the probabil- Gas production at bacterial infection foci in the intestinal ity of detecting HPVGthat disappears within a short period of wall and abdominal cavity or gas transmigration through the time. intestine from a mucosal damagesite maycause HPVG(ll, 15). In addition, since 85%of patients with HPVGshow find- References ings of gas-induced intestinal dilatation, increased intestinal pressure may also play an important role in the development 1) Liebman PR, Patten MT, Manny J, Ben field JR, Hechtman HB. Hepatic- portal venous gas in adults: etiology, pathophysiology and clinical sig- of HPVG(1). In patients with ischemic enteritis, both a vascu- nificance. Ann Surg 187: 281-287, 1978. lar factor predisposing such patients to thrombosis and increased 2) Bloom RA, Lebensart PD, Levy P, Craciun E, Anner H, Manny J. Sur- intestinal pressure due to constipation or the use of cathartics vival after ultrasonographic demonstraction of portal venous gas due to are mutually involved in the development of HPVG.In the mesentric artery occlusion. Postgrad MedJ 66: 137-139, 1990. 3) Friedman D, Flancbaum L, Ritter E, Trooskin SZ. Hepatic portal venous present case, our patient did not have abnormal bowel move- gas identified by computed tomography in a patient with blunt abdominal mentsuch as constipation. Fecesand blood cultures werenega- trauma: a case report. J Trauma 31: 290-292, 1991. tive for pathogens. The only pathological lesion in the patient 4) BensonMD.Case report: adult survival with intrahepatic portal venous in this case mayhave been somemucosal damagein the ileal gas secondary to acute gastric dilatation, with a review of portal venous terminal. Although the detailed etiology of HPVGremains gas. Clin Radiol 36: 441-443, 1985. 5) Katz BH, Schwartz SS, Vender RJ. Portal venous gas following a barium unclear in patients with ileitis, including this patient, HPVGin enema in a patient with Crohn's colitis: a benign finding. Dis Colon Rec- such patients maybe caused by increased intestinal pressure tum 29: 49-51, 1986. for some reason beginning from minute mucosal damage( 14). 6) Simmons TC. Hepatic portal venous gas due to endoscopic sphinctero- HPVGfrequently intervenes intestinal cases of necrosis that tomy. AmJ Gastroenterol 83: 326-328, 1988. 7) Chen KW,Shin JS, Chi CH, Cheng L. Seizure: a rare and transient cause show the poorest prognosis. Currently, however, there is no of portal venous gas. AmJ Gastroenterol 92: 351-352, 1997. appropriate procedure for facilitating a secure diagnosis of in- 8) Ohtsubo K, Okai T, Yamaguchi Y, et al. Pneumatosis intestinalis and he- testinal necrosis. Thus, laparotomy is generally recommended patic portal venous gas caused by mesenteric ischemia in an aged person. when HPVGis detected by CT. However, the course of HPVG J Gastroenterol 36: 338-340, 2001. should be followed by conservative treatment when detected 9) Faberman RS, Mayo-Smith WW.Outcome of 17 patients with portal during examinations that include barium enema (5) and GI venous gas detected by CT. AJRAMJ Roentgenol 169: 1535-1538, 1997. 10) Wolfe JN, Evans WA. Gas in the portal veins of the liver in infants. AmJ endoscopy (6) or whenno apparently abnormal findings are Roentgenol Radium Ther Nucl Med 74: 486-489, 1955. observed in the abdominal cavity, as in our patient (16). 1 1) Susman N, Senturia HR. Gas embolization of the portal venous system. No previous studies reported on the evaluation of the dura- Am J Roentegenol 83: 847-850, 1960. tion of HPVGin detail, although Lazar reported that HPVG 12) Kirsch M, Bozdech J, Gardner DA. Hepatic portal venous gas: An un- usual presentation ofCrohn's disease. AmJ Gastroenterol 85: 1521-1523, wasdetected in a patient with ulcerative colitis simultaneously 1990. with the sudden occurrence of abdominal pain, and that HPVG 13) Mallens WM, Schepers-Bok R, Nicolai JJ, Jacobs FA, Heyerman HG. in this patient completely disappeared within 5 days (17). When Portal and systemic venous gas in a patient with cystic fibrosis: CT find- the course of HPVGwas followed by CT in our patient, HPVG ings. AmJ Roentegenol 165: 338-339, 1995. completely disappeared in approximately 18 hours after its 14) Celoria G, Coe NP. Does the presence of hepatic portal venous gas man- onset. WhenHPVGdisappears within 24 hours after onset, the date an operation? A reassessment. South MedJ 83: 592-594, 1990. 15) Wiot JF, Felson B. Gas in the portal venous system. AmJ Roentegenol prognosis of such patients, including our patient, has been re- 86: 920-929, 1961. ported to be favorable (4-8). 16) YamamuroM, Ponsky JL. Hepatic portal venous gas: report of a case. Although most previously reported cases of HPVGhave been Surg Today 30: 647-650, 2000. detected by plain X-ray, somestudies have reported on the utility 17) Lazar HP. Survival following portal venous air embolization. AmJ Dig of abdominal ultrasonography and CT for detecting HPVG. Dis 10: 259-264, 1965. Fabermanet al reported that the mortality rate from HPVGis

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