Hepatic Portal Venous Gas: the Abcs of Management

REVIEW ARTICLE Hepatic Portal Venous Gas The ABCs of Management

Aaron L. Nelson, MD, PhD; Timothy M. Millington, MD; Dushyant Sahani, MD; Raymond T. Chung, MD; Christian Bauer, MD; Martin Hertl, MD; Andrew L. Warshaw, MD; Claudius Conrad, MD, PhD, PhD

Objective: To review the use of computed tomogra- Data Synthesis: Early studies of HPVG were based on phy (CT) and radiography in managing hepatic portal plain abdominal radiography and a literature survey in 1978 venous gas (HPVG) at a university-affiliated tertiary found an associated mortality rate of 75%, primarily due care center and in the literature. Hepatic portal venous to ischemic bowel disease. Modern abdominal CT has re- gas is frequently associated with acute mesenteric sulted in the detection of HPVG in more benign condi- ischemia, accounting for most of the HPVG-associated tions, and a second literature survey in 2001 found a total mortality. While early studies were necessarily depen- mortality of only 39%. While the pathophysiology of HPVG dent on plain abdominal radiography, modern high- is, as yet, unclear, changing abdominal imaging technol- resolution CT has revealed a host of benign conditions ogy has altered the significance of this radiologic finding. in which HPVG has been reported that do not require Hepatic portal venous gas therefore predicts high risk of mortality (Ͼ50%) if detected by plain radiography or by emergent surgery. CT in a patient with additional evidence of necrotic bowel. If detected by CT in patients after surgical or endoscopic Data Sources: Patient records from our institution over manipulation, the clinician is advised that there is no evi- the last 10 years and relevant studies from BioMed Cen- dence of increased risk. If HPVG is detected by CT in pa- tral, CENTRAL, PubMed, and PubMed Central. In ad- tients with active peptic ulcer disease, intestinal obstruc- dition, references cited in selected works were also used tion and/or dilatation, or mucosal diseases such as Crohn as source data. disease or ulcerative colitis, caution is warranted, as risk of death may approach 20% to 30%. Study Selection: Patient records were selected if the CT or radiograph findings matched the term hepatic por- Conclusion: The finding of HPVG alone cannot be an tal venous gas. Studies were selected based on the search indication for emergency exploration, and we have de- terms hepatic portal venous gas or portal venous gas. veloped an evidence-based algorithm to guide the clinician in management of patients with HPVG. Data Extraction: Quantitative and qualitative data were quoted directly from cited work. Arch Surg. 2009;144(6):575-581

EPATIC PORTAL VENOUS of imminent death and the correspond- gas (HPVG) was first de- ing maxim that HPVG demands scribed in abdominal laparotomy. plain radiographs in 1955 Hepatic portal venous gas is a rare by Wolfe and Evans1 in 6 radiologic finding, with only 182 cases neonatesH who died secondary to necrotic documented in the literature by 2001.6 Author Affiliations: Tufts bowels, followed by reports of HPVG in Retrospective reviews of computed tomo- University School of Medicine graphic (CT) scans identified 17 cases in (Dr Nelson) and Departments 14 000 at 1 academic medical center7 and of Surgery (Drs Millington, See Invited Critique 11 in 19 000 at another.8 Hepatic portal Hertl, Warshaw, and Conrad), at end of article venous gas is defined radiologically as Radiology (Dr Sahani), and tubular areas of decreased attenuation in Medicine, Gastrointestinal Unit 5 adults who died2,3 and the first reported the liver periphery.9 This definition was (Dr Chung), Massachusetts survivor in 1965.4 Liebman and col- derived from the work of Sisk,10 who General Hospital, Boston, and 5 Section of Gastroenterology, leagues analyzed all cases of HPVG re- injected radiologic contrast into the por- Medizinische Klinik Innenstadt, ported in the literature by 1978 and found tal vein and detected it in the liver University of Munich, Munich, an oft-cited mortality rate of 75%, thereby periphery, within 2 cm of the capsule. Germany (Dr Bauer). codifying the link between HPVG and risk Proof of the localization of HPVG to the

(REPRINTED) ARCH SURG/ VOL 144 (NO. 6), JUNE 2009 WWW.ARCHSURG.COM 575

REPORT OF CASES

CASE 1

A 63-year-old woman presented to the emergency department complaining of constipation and bilious vomiting. She denied bowel movements over the preceding 7 days and had developed escalating, diffuse abdominal pain, bloating, and vomiting. During a prior episode of abdominal discomfort months earlier, CT examination discovered a lung mass, and she was diagnosed with stage IIIB non–small cell lung carcinoma, for which she initi- ated treatment days prior. Her vital signs were within nor- mal limits, but her abdomen was tense and rigid. Labo- ratory analysis was notable for leukocytosis. A plain abdominal radiograph demonstrated diffuse gaseous distention of the small and large bowel, and HPVG was vis- ible (Figure 1). A contrast-enhanced abdominal CT con- firmed diffuse gaseous distention of the small bowel and colon with pneumatosis of the colon and portal and mesenteric venous gas. In addition, free peritoneal air was present, consistent with hollow viscus perforation Figure 1. A frontal plain abdominal radiograph obtained in the supine position (Figure 2). Unfortunately, within hours of the CT scan, demonstrates distended loops of bowel and extensive hepatic portal venous gas (arrows). This finding was missed on the initial read of the plain radiograph. the patient died in shock. The primary cause of her gastrointestinal disease was never elucidated.

portal sinusoids came from Wiot and Felson,3 who CASE 2 clamped all hepatic vessels during an autopsy, injected barium into the portal circulation, and demonstrated A 56-year-old man presented to the emergency depart- mixture of the gas and contrast. Portal venous gas can be ment complaining of crampy abdominal pain with diar- distinguished from aerobilia, an indication of gallstone rhea, nausea, and vomiting over the preceding 5 days. He ileus, where air is found centrally in the biliary tree,11 described several episodes of melena and admitted to hav- and from pneumoperitoneum, where gas is found out- ing lost 30 lb over preceding months. He denied hemop- side the liver capsule, due to perforation of a hollow tysis, fever, chills, or night sweats. He admitted to fre- viscous.12 quent use of ibuprofen to treat chronic lower back pain. The left lobe of the liver is predisposed to develop Vital signs were stable, and on examination, his abdomen HPVG,8,9 possibly because of peculiarities in hepatic ve- was soft with active bowel sounds and no rebound or guard- nous anatomy. Males and females are equally likely to ing. Rectal examination results were positive for occult develop HPVG.5,6 In approximately 50% of reported cases, blood. Serum lactate level was not elevated. An abdomi- HPVG presents with pneumatosis intestinalis (PI), gas nal CT imaging study was performed, and the results sup- within the intestinal wall.7,13,14 It is generally presumed ported a diagnosis of nonsteroidal anti-inflammatory drug– that PI ascends from the draining venous mesentery and induced gastritis, with a mild pneumatosis of the gastric condenses in the portal venous system15; therefore, PI and wall and HPVG (Figure 3), raising concern of a perfora- HPVG represent progressive steps in a single process.1 tion. Surgical and gastroenterologic services were con- Experimental support for this sequence is scarce, al- sulted, but, given the absence of peritonitis, it was de- though air injected into the submucosa16 or mesenteric cided to treat conservatively. On the fourth hospital day, veins2 of dog intestines was observed in the portal ve- he underwent an upper gastrointestinal tract series, reveal- nous system. ing a 40-mm, nonbleeding, cratered gastric ulcer in the car- Remarkably, in several early works, surgeons dia. The patient was discharged after 2 weeks with signifi- reported air bubbles flowing in the mesenteric veins of cant clinical improvement. patients with preoperative HPVG. In 1 case, the surgeons transilluminated the mesentery and described COMMENT the veins as “resembling the bubbles of gas seen in certain neon light signs.”2(p848) In another, the surgeons noted “intravascular gas seen in all the mesen- RECENT EVIDENCE teric and portal veins” with “a large amount of frothy air bubbles” in a tear in the liver capsule.17 Modern In the half century since HPVG was first described, it has ultrasonography studies have visualized air emboli been reported in many nonfatal conditions, such as Crohn

(REPRINTED) ARCH SURG/ VOL 144 (NO. 6), JUNE 2009 WWW.ARCHSURG.COM 576

Figure 2. Axial (A) and coronal (B) views of contrast-enhanced computed Figure 3. Axial (A) and sagittal (B) computed tomographic images from a tomographic images of the liver with extensive hepatic portal venous gas case with benign portal venous gas in the left lobe of the liver (arrows) with (arrows). Hepatic portal venous gas in a patient with peritonitis is an emphysematous gastritis. Under watchful waiting, the patient did well and ominous finding with a potentially fatal outcome that warrants immediate recovered completely without any untoward sequelae. emergency surgery.

disease,19 ulcerative colitis,20,21 graft-vs-host disease,22 ness compared with natural pathologies,14 and in 1986, bowel obstruction, pseudo-obstruction,23 bacterial ab- experts were already urging surgeons to avoid lapa- scesses,22,24-28 diverticulitis,3 paralytic ileus,29 suppura- rotomy in patients without toxic reaction with iatro- tive cholangitis,30 and colovenous fistulae.31 Hepatic por- genic HPVG.54 tal venous gas has been described in a number of In a recent survey of HPVG literature, Kinoshita and nonsurgical conditions, including cystic fibrosis,32 sei- colleagues6 reported 39% mortality among all 182 cases zures,33 and colchicine toxicity,34 although secondary ef- reported by 2001. Although smaller case series cite both fects, such as ileus, cannot be excluded. Frequently, there lower7,8 and higher mortality rates for HPVG-associated is no immediate risk of mortality, for example, in pa- disease,13,55,56 these studies included fewer than 20 tients presenting with inflammatory bowel disease and patients each. This is obviously a significant reduction HPVG.35,36 Finally, a substantial literature exists on iat- from the 75% mortality seen in 1978, itself an rogenic HPVG, with HPVG observed in patients after “improvement” over earlier estimates.5 The observed laproscopy37 and endoscopic retrograde colangiopan- reduction in mortality was driven by an increase in the creatography38-41 as well as other endoscopic proce- proportion of nonfatal conditions reported with HPVG dures,42,43 gastric dilatation,44-46 liver transplantation,47 and a corresponding decrease in the proportion of radiofrequency tumor ablation,48 arterial catheteriza- HPVG associated with mesenteric ischemia. Bowel tion,49 and enema.50-53 As early as 1971, higher survival necrosis accounted for 72% of diagnoses in the Liebman rates were recognized in iatrogenic HPVG-associated ill- et al survey5 in 1978, but only 43% of the diagnoses in

(REPRINTED) ARCH SURG/ VOL 144 (NO. 6), JUNE 2009 WWW.ARCHSURG.COM 577

©2009 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/30/2021 reports of HPVG-positive patients surveyed by cally distinct from swallowed intraluminal air. Indeed, Kinoshita et al6 in 2001, although the mortality in these the cystic gas of pneumatosis cystoids intestinalis has patients remained high (75%, n=79). Kinoshita et al been shown to be hydrogen gas, strongly supporting a found that the mortality of patients with HPVG with bacteriologic etiology for this distinct pathology,67 and Crohn disease, ulcerative colitis, intraperitoneal tumors, similar analyses of HPVG would be convincing sup- cholangitis, pancreatitis, and nonfulminant hepatitis port for a microbial origin. was 0% (n=28). A variety of conditions present interme- The majority of patients in both the Liebman et al5 diate mortality rates: 30% in patients with abscesses and Kinoshita et al6 studies demonstrated ischemic (n=20), 25% with gastric ulcers (n=7), and 21% with bowel, disrupted mucosa, or increased intraluminal digestive tract dilatation (n=21).6 Collectively, the frac- pressure. It is hypothesized that luminal air enters the tion of HPVG cases associated with diseases other than capillary veins either by an impaired epithelial barrier ischemic or necrotic bowel rose from 30%5 to 51%6 or by increased intraluminal pressure. Indeed, in a when the 2 studies were compared. large number of “natural experiments,” HPVG has Hepatic portal venous gas therefore remains an omi- been demonstrated in patients with mucosa disrupted nous sign in the specific context of bowel ischemia or by inflammatory bowel disease and intraluminal pres- necrosis. Hepatic portal venous gas has been identified sures increased by enema19,20,52,68,69 or colonoscopy.21,70 as a risk factor for surgical intervention and increased mor- Pneumatosis intestinalis was generated experimentally tality57 and the degree of bowel ischemia may be corre- in cadavers with ulcerated mucosa by application of lated with the likelihood of HPVG or PI.6,13 Experimen- intraluminal air pressure.14,71 Shaw et al53 were able to tal occlusion of the mesenteric arteries of dogs resulting chemically reproduce these effects in intact dog intes- in infarction also results in HPVG, supporting mucosal tines using hydrogen peroxide enemas, wherein ischemia as playing a mechanistic role.58 Two reports de- hydrogen peroxide bypassed the epithelium and scribe postmortem HPVG after cardiopulmonary resus- released oxygen gas on interacting with intracellular citation,59,60 linking ischemia and HPVG, as cardiac out- catalase enzymes or iron, causing oxygenation of the put during cardiopulmonary resuscitation is poor.61 It is affected tissues and the formation of bubbles in the presumed that ischemic insult or frank necrosis results mucosa, draining mesentery, and portal veins. in mucosal disruption, although this mechanism has not Intraluminal and microbial origins for HPVG are yet been proven. not mutually exclusive. Rather, it is possible that these We propose that the increase in benign HPVG- are separate pathways by which patients can arrive at associated conditions is due to the adoption of CT scan- the radiologic finding of HPVG. In support of this, ning. The original HPVG literature of the 1950s and 1960s sepsis alone was observed in 2 of 64 patients with was based on plain radiographs,1,2 primarily left lateral de- HPVG in the Liebman et al study,5 and 26 of 182 cubitus views.5,16 However, CT is superior for detection of patients in the Kinoshita et al study had an infectious intra-abdominal gas, demonstrated in studies of pneumo- etiology in the absence of other bowel disease.6 These peritoneum. Increased sensitivity with CT has made it pos- data suggest that a microbial origin for HPVG may sible to detect mild HPVG, while reliance on plain radiog- therefore represent an independent mechanism in a raphy captures only scenarios wherein a large volume of minority of patients with HPVG, unrelated to that seen gas accumulates.8,62,63 In addition, remarkable increases in in necrotic bowel. the volume of patients undergoing advanced imaging tech- As noted earlier, HPVG has also been detected by ul- niques over time have been demonstrated,64 increasing the trasonography,18,26,47,72-75 where the HPVG appears as hy- prevalence of HPVG. Digital CT images also provide an op- perechoic foci in the background of the liver paren- portunity to manipulate the images for ideal viewing, and chyma. Ultrasonography has the advantages of low cost, many authors note that a “lung-window” CT setting per- bedside imaging, and a lack of radiation exposure to the mits easy identification of both HPVG and PI,8,9 although patient. It is possible that ultrasonography may prove even other settings are also advised.7 more sensitive than CT,74,75 although this requires for- mal analysis. An even more limited literature exists de- PATHOPHYSIOLOGY scribing magnetic resonance imaging–based identification of HPVG.76 There is no evidence available to date to identify the na- ture of the gas observed in imaging studies. The leading CONCLUSIONS AND RECOMMENDATIONS hypotheses are (1) microbe-derived gas production and (2) absorbed intraluminal air. While HPVG was clearly an ominous radiologic find- No clear experimental or natural data describe how ing in previous decades, today it is a puzzling finding gas production secondary to microbial metabolism that may confound patient management (Table). The results in HPVG.65 Bacteremic liver metastases can development of CT has created more opportunities to result in in situ gas production,24,25 but this is rare. visualize gas in the portal system, revealing a host of Septic phlebitis can result in gaseous accumulations in benign conditions. The main conclusion offered by the portal system, or gas generated in abscesses subja- this review is that radiologic detection of HPVG by CT cent to inflamed mesentery could enter the vascula- should not determine clinical or surgical management ture,3,22,26,27,66 although few data support these models. per se, rather disease severity should. To this effect, a Regardless of anatomical route, microbe-derived gases management algorithm is proposed in Figure 4 and would be hypothesized to be molecularly and atomi- is summarized by the mnemonic “ABC.” Urgent lapa-

(REPRINTED) ARCH SURG/ VOL 144 (NO. 6), JUNE 2009 WWW.ARCHSURG.COM 578

©2009 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/30/2021 Liebman et al5 and Kinoshita et al6 studies. Case 2 exem- Table. Critical Articles in the Literature of HPVG plifies the difficulty of HPVG observed in a patient with ambiguous findings. This patient was successfully man- Source Key Contribution aged conservatively, despite the fact that HPVG would have Wolfe and Evans,1 1955 First report of HPVG once been an indication for laparotomy. Lazar,4 1965 First report of an HPVG survivor Finally, patients who present with HPVG and nonur- 5 Liebman et al, 1978 Literature survey of HPVG by plain gent conditions, or HPVG postoperatively, should be treated abdominal radiograph Kinoshita et al,6 2001 Literature survey of HPVG by plain conservatively (“conservative management”). In this con- radiograph and CT text, watchful waiting is prudent, as patients have been Wiesner et al,13 2001 Case series with HPVG by CT only shown to resolve their nonurgent HPVG over “extremely Peloponissios et al,56 2003 variable”54 lengths of time—in as short as minutes,54 as long Paran et al,55 2003 as 6 weeks77—with negligible risk of mortality. Schindera et al,8 2006 Sisk,10 1961 Radiologic definition of HPVG Accepted for Publication: May 22, 2008. Abbreviations: CT, computed tomography; HPVG, hepatic portal venous Correspondence: Claudius Conrad, MD, PhD, PhD, Har- gas. vard Medical School and Harvard Stem Cell Institute, Mas- sachusetts General Hospital, Department of Surgery, 55 Fruit St, Boston, MA 02114 ([email protected]). HPVG on radiograph HPVG on CT Author Contributions: Study concept and design: Nel- son, Millington, Bauer, Warshaw, and Conrad. Acquisi- tion of data: Nelson, Millington, Warshaw, and Conrad. Ischemic Bowel? Correctable Asymptomatic Analysis and interpretation of data: Nelson, Sahani, Chung, 1. Supporting problems 1. Rule out bowel ischemia, Bauer, Hertl, Warshaw, and Conrad. Drafting of the manu- CT findings Abscess? perforation, dilatation, script: Nelson, Hertl, Warshaw, and Conrad. Critical re- and/or Ulcer? PUD, abscess, infection 2. Increased Dilatation? and/or vision of the manuscript for important intellectual content: lactate level 2. History of IBD, Nelson, Millington, Sahani, Chung, Bauer, Hertl, War- with anion gap diverticulitis, fistulae, recent procedure shaw, and Conrad. Statistical analysis: Bauer, Warshaw, and Conrad. Obtained funding: Conrad. Administrative, technical, and material support: Bauer, Warshaw, and Con-

A “Aggressive” B “Be careful” C “Conservative” rad. Study supervision: Chung, Warshaw, and Conrad. Financial Disclosure: None reported. ABCs Emergent Extensive Conservative of HPVG laparatomy investigation management Mortality Mortality Mortality about 75% < 30% about 0% REFERENCES

1. Wolfe JN, Evans WA. Gas in the portal veins of the liver in infants: a roentgeno- Figure 4. Proposed clinical algorithm for management of patients in whom graphic demonstration with postmortem anatomical correlation. Am J Roent- hepatic portal venous gas (HPVG) is found by plain abdominal radiograph or genol Radium Ther Nucl Med. 1955;74(3):486-488. abdominal computed tomographic (CT) scan. IBD indicates inflammatory bowel disease; PUD, peptic ulcer disease. 2. Susman N, Senturia HR. Gas embolization of the portal venous system. Am J Roentgenol Radium Ther Nucl Med. 1960;83:847-850. 3. Wiot JF, Felson B. Gas in the portal venous system. Am J Roentgenol Radium rotomy (“aggressive management”) is recommended Ther Nucl Med. 1961;86:920-929. for (1) patients in whom HPVG is detected by CT with 4. Lazar HP. Survival following portal venous air embolization: report of a case. Am concurrent signs of bowel necrosis or ischemia and (2) J Dig Dis. 1965;10:259-264. patients in whom HPVG is detected by plain abdomi- 5. Liebman PR, Patten MT, Manny J, Benfield JR, Hechtman HB. Hepatic-portal venous gas in adults: etiology, pathophysiology and clinical significance. Ann Surg. nal radiograph, as decades of study have demonstrated 1978;187(3):281-287. serious risks, with mortality approximated at 75% for 6. Kinoshita H, Shinozaki M, Tanimura H, et al. Clinical features and management both groups. Case 1 represents this scenario, present- of hepatic portal venous gas: four case reports and cumulative review of the ing with HPVG on both abdominal radiography and literature. Arch Surg. 2001;136(12):1410-1414. CT scan with signs of peritonitis. It is possible that the 7. Faberman RS, Mayo-Smith WW. Outcome of 17 patients with portal venous gas patient’s life could have been saved had she been taken detected by CT. AJR Am J Roentgenol. 1997;169(6):1535-1538. to the operating room instead of the CT scanner, as 8. Schindera ST, Triller J, Vock P, Hoppe H. Detection of hepatic portal venous gas: its clinical impact and outcome. Emerg Radiol. 2006;12(4):164-170. CT served only to confirm the extent of her disease. 9. Sebastià C, Quiroga S, Espin E, Boye R, Alvarez-Castells A, Armengol M. Porto- Therefore, this patient exemplifies the value of careful mesenteric vein gas: pathologic mechanisms, CT findings, and prognosis. examination of abdominal plain radiographs, often Radiographics. 2000;20(5):1213-1224, discussion 1224-1226. overlooked by physicians accustomed to reliance on 10. Sisk PB. Gas in the portal venous system. Radiology. 1961;77:103-106. the sensitivity of the CT scanner. 11. Masannat Y, Masannat Y, Shatnawei A. Gallstone ileus: a review. Mt Sinai J Med. Patients with more equivocal presentation and HPVG— 2006;73(8):1132-1134. mucosal disruption, bowel distention, abscesses, or gas- 12. Kasznia-Brown J, Cook C. Radiological signs of pneumoperitoneum: a pictorial review. Br J Hosp Med (Lond). 2006;67(12):634-639. tric ulcers, as examples—should be monitored intensely 13. Wiesner W, Mortele KJ, Glickman JN, Ji H, Ros PR. Pneumatosis intestinalis and with a reduced threshold for surgical correction under ap- portomesenteric venous gas in intestinal ischemia: correlation of CT findings with propriate conditions (“be careful”). These patients may be severity of ischemia and clinical outcome. AJR Am J Roentgenol. 2001;177 at risk for mortality as high 20% to 30%, based on the (6):1319-1323.

(REPRINTED) ARCH SURG/ VOL 144 (NO. 6), JUNE 2009 WWW.ARCHSURG.COM 579

©2009 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/30/2021 14. Arnon RG, Fishbein JF. Portal venous gas in the pediatric age group: review of 43. Pfaffenbach B, Wegener M, Bohmeke T. Hepatic portal venous gas after trans- the literature and report of twelve new cases. J Pediatr. 1971;79(2):255-259. gastric EUS-guided fine-needle aspiration of an accessory spleen. Gastrointest 15. See C, Elliott D. Images in clinical medicine: pneumatosis intestinalis and portal Endosc. 1996;43(5):515-518. venous gas. N Engl J Med. 2004;350(4):e3. 44. Benson MD. Adult survival with intrahepatic portal venous gas secondary to acute 16. Berne TV, Meyers HI, Donovan AJ. Gas in the portal vein of adults with necro- gastric dilatation, with a review of portal venous gas. Clin Radiol. 1985;36(4): tizing enteropathy. Am J Surg. 1970;120(2):203-209. 441-443. 17. Sibbald WJ, Sweeney JP, Inwood MJ. Portal venous gas (PVG) as an indication 45. Hughes DG, Barker CS. Adult survival with portal venous gas secondary to acute for heparinization. Am J Surg. 1972;124(5):690-693. gastric dilation. Clin Radiol. 1986;37(6):603. 18. Kriegshauser JS, Reading CC, King BF, Welch TJ. Combined systemic and por- 46. Radin DR, Rosen RS, Halls JM. Acute gastric dilatation: a rare cause of portal tal venous gas: sonographic and CT detection in two cases. AJR Am J Roentgenol. venous gas. AJR Am J Roentgenol. 1987;148(2):279-280. 1990;154(6):1219-1221. 47. Chezmar JL, Nelson RC, Bernardino ME. Portal venous gas after hepatic trans- 19. Katz BH, Schwartz SS, Vender RJ. Portal venous gas following a barium enema plantation: sonographic detection and clinical significance. AJR Am J Roentgenol. in a patient with Crohn’s colitis: a benign finding. Dis Colon Rectum. 1986; 1989;153(6):1203-1205. 29(1):49-51. 48. Oei T, vanSonnenberg E, Shankar S, Morrison PR, Tuncali K, Silverman SG. 20. Birnberg FA, Gore RM, Shragg B, Margulis AR. Hepatic portal venous gas: a be- Radiofrequency ablation of liver tumors: a new cause of benign portal venous nign finding in a patient with ulcerative colitis. J Clin Gastroenterol. 1983;5 gas. Radiology. 2005;237(2):709-717. (1):89-91. 49. Schmidt AG. Portal vein gas due to administration of fluids via the umbilical vein. 21. Haber I. Hepatic portal vein gas following colonoscopy in ulcerative colitis: re- Radiology. 1967;88(2):293-294. port of a case. Acta Gastroenterol Belg. 1983;46(1-2):14-17. 50. Bull MJ, Kaye B. Portal vein gas following double-contrast barium enema. Br J 22. Wiesner W, Mortele KJ, Glickman JN, Ji H, Ros PR. Portal-venous gas unrelated Radiol. 1985;58(695):1129-1130. to mesenteric ischemia. Eur Radiol. 2002;12(6):1432-1437. 51. Kees CJ, Hester CL Jr. Portal vein gas following barium enema examination. 23. Celoria G, Coe NP. Does the presence of hepatic portal venous gas mandate an Radiology. 1972;102(3):525-526. operation? A reassessment. South Med J. 1990;83(5):592-594. 52. Stein MG, Crues JV III, Hamlin JA. Portal venous air associated with barium enema. 24. Foster SC, Schneider B, Seaman WB. Gas-containing pyogenic intrahepatic AJR Am J Roentgenol. 1983;140(6):1171-1172. abscesses. Radiology. 1970;94(3):613-618. 53. Shaw A, Cooperman A, Fusco J. Gas embolism produced by hydrogen peroxide. 25. Yoshida M, Mitsuo M, Kutsumi H, et al. A successfully treated case of multiple N Engl J Med. 1967;277(5):238-241. liver abscesses accompanied by portal venous gas. Am J Gastroenterol. 1996; 54. Griffiths DM, Gough MH. Gas in the hepatic portal veins. Br J Surg. 1986;73(3): 91(11):2423-2425. 172-176. 26. Zielke A, Hasse C, Nies C, Rothmund M. Hepatic-portal venous gas in acute co- 55. Paran H, Epstein T, Gutman M, Shapiro Feinberg M, Zissin R. Mesenteric and lonic diverticulitis. Surg Endosc. 1998;12(3):278-280. portal vein gas: computerized tomography findings and clinical significance. Dig 27. Tedesco FJ, Stanley RJ. Hepatic portal vein gas without bowel infarction or necrosis. Surg. 2003;20(2):127-132. Gastroenterology. 1975;69(1):240-243. 56. Peloponissios N, Halkic N, Pugnale M, et al. Hepatic portal gas in adults: review 28. Nakao A, Iwagaki H, Isozaki H, et al. Portal venous gas associated with splenic of the literature and presentation of a consecutive series of 11 cases. Arch Surg. abscess secondary to colon cancer. Anticancer Res. 1999;19(6C):5641-5644. 2003;138(12):1367-1370. 29. Quirke TE. Hepatic-portal venous gas associated with ileus. Am Surg. 1995;61(12): 57. Kennedy J, Holt CL, Ricketts RR. The significance of portal vein gas in necrotiz- 1084-1086. ing enterocolitis. Am Surg. 1987;53(4):231-234. 30. Lee CS, Kuo YC, Peng SM, et al. Sonographic detection of hepatic portal venous 58. Marston A. Causes of death in mesenteric arterial occlusion, I: local and general gas associated with suppurative cholangitis. J Clin Ultrasound. 1993;21(5): effects of devascularization of the bowel. Ann Surg. 1963;158:952-959. 331-334. 59. Lai CF, Chang WT, Liang PC, Lien WC, Wang HP, Chen WJ. Pneumatosis intes- 31. Sonnenshein MA, Cone LA, Alexander RM. Diverticulitis with colovenous fistula tinalis and hepatic portal venous gas after CPR. Am J Emerg Med. 2005;23 and portal venous gas: report of two cases. J Clin Gastroenterol. 1986;8(2): (2):177-181. 195-198. 60. Shiotani S, Kohno M, Ohashi N, Yamazaki K, Nakayama H, Watanabe K. Post- 32. Mallens WM, Schepers-Bok R, Nicolai JJ, Jacobs FA, Heyerman HG. Portal and mortem computed tomographic (PMCT) demonstration of the relation between systemic venous gas in a patient with cystic fibrosis: CT findings. AJR Am J gastrointestinal (GI) distension and hepatic portal venous gas (HPVG). Radiat Roentgenol. 1995;165(2):338-339. Med. 2004;22(1):25-29. 33. Chen KW, Shin JS, Chi CH, Cheng L. Seizure: a rare and transient cause of portal 61. Barsan WG, Levy RC, Weir H. Lidocaine levels during CPR: differences after pe- venous gas. Am J Gastroenterol. 1997;92(2):351-352. ripheral venous, central venous, and intracardiac injections. Ann Emerg Med. 1981; 34. Saksena M, Harisinghani MG, Wittenberg J, Mueller PR. Case report: hepatic por- 10(2):73-78. tal venous gas. Transient radiographic finding associated with colchicine toxicity. 62. Earls JP, Dachman AH, Colon E, Garrett MG, Molloy M. Prevalence and duration Br J Radiol. 2003;76(911):835-837. of postoperative pneumoperitoneum: sensitivity of CT vs left lateral decubitus 35. Delamarre J, Capron JP, Dupas JL, Deschepper B, Jouet-Gondry C, Rudelli A. radiography. AJR Am J Roentgenol. 1993;161(4):781-785. Spontaneous portal venous gas in a patient with Crohn’s ileocolitis. Gastro- 63. Schulze CG, Blum U, Haag K. Hepatic portal venous gas: imaging modalities and intest Radiol. 1991;16(1):38-40. clinical significance. Acta Radiol. 1995;36(4):377-380. 36. Niki M, Shimizu I, Horie T, et al. Hepatic portal venous gas disappearing within 64. Brenner DJ, Hall EJ. Computed tomography—an increasing source of radiation 24 hours. Intern Med. 2002;41(11):950-952. exposure. N Engl J Med. 2007;357(22):2277-2284. 37. Mognol P, Chosidow D, Marmuse JP. Hepatic portal gas due to gastro-jejunal 65. Jones B. Massive gas embolism in E. coli septicemia. Gastrointest Radiol. 1981; anastomotic leak after laparoscopic gastric bypass. Obes Surg. 2005;15(2): 6(2):161-163. 278-281. 66. Chau TN, Loke TK, Leung VK, Law ST, Lai MH, Ho YW. Hepatic portal venous 38. Herman JB, Levine MS, Long WB. Portal venous gas as a complication of ERCP gas complicating septic thrombophlebitis of the superior mesenteric vein. Hong and endoscopic sphincterotomy. Am J Gastroenterol. 1995;90(5):828-829. Kong Med J. 2007;13(1):69-72. 39. Barthet M, Membrini P, Bernard JP, Sahel J. Hepatic portal venous gas after en- 67. Yale CE, Balish E, Wu JP. The bacterial etiology of pneumatosis cystoides intestinalis. doscopic biliary sphincterotomy. Gastrointest Endosc. 1994;40(2, pt 1):261- Arch Surg. 1974;109(1):89-94. 263. 68. Christensen MA, Lu CH. Gas in the portal vein after air-contrast barium enema 40. Blind PJ, Oberg L, Hedberg B. Hepatic portal vein gas following endoscopic ret- in a patient with inflammatory colitis. South Med J. 1982;75(10):1291-1292. rograde cholangiography with sphincterotomy: case report. Eur J Surg. 1991; 69. Sadhu VK, Brennan RE, Madan V. Portal vein gas following air-contrast barium 157(4):299-300. enema in granulomatous colitis: report of a case. Gastrointest Radiol. 1979; 41. Simmons TC. Hepatic portal venous gas due to endoscopic sphincterotomy. Am 4(2):163-164. J Gastroenterol. 1988;83(3):326-328. 70. Huycke A, Moeller DD. Hepatic portal venous gas after colonoscopy in granulo- 42. Nguyen HN, Purucker E, Riehl J, Matern S. Hepatic portal venous gas following matous colitis. Am J Gastroenterol. 1985;80(8):637-638. emergency endoscopic sclerotherapy of gastric varices. Hepatogastroenterology. 71. Bilger M. Pneumatosis cystoides intestinalis in children; report of a case com- 1998;45(23):1767-1769. plicated with fatal pneumoperitoneum. J Pediatr. 1956;49(4):445-449.

(REPRINTED) ARCH SURG/ VOL 144 (NO. 6), JUNE 2009 WWW.ARCHSURG.COM 580

©2009 American Medical Association. All rights reserved. Downloaded From: https://jamanetwork.com/ on 09/30/2021 72. Karaosmanog˘lu D, Oktar SO, Arac M, Erbas G. Case report: portal and systemic 75. Ruı´z DS, de Perrot T, Majno PE. A case of portal venous gas secondary to acute venous gas in a patient after lumbar puncture. Br J Radiol. 2005;78(932):767- appendicitis detected on gray scale sonography but not computed tomography. 769. J Ultrasound Med. 2005;24(3):383-386. 73. Negro U, Verdecchia M, Paci E, et al. Hepatic portal venous gas in a patient with 76. Patriquin L, Kassarjian A, Barish M, et al. Postmortem whole-body magnetic reso- enterovascular fistula. Abdom Imaging. 2006;31(6):706-709. nance imaging as an adjunct to autopsy: preliminary clinical experience. J Magn 74. Oktar SO, Karaosmanoglu D, Yucel C, et al. Portomesenteric venous gas: imaging Reson Imaging. 2001;13(2):277-287. findings with an emphasis on sonography. J Ultrasound Med. 2006;25(8): 77. Huurman VA, Visser LG, Steens SC, Terpstra OT, Schaapherder AF. Persistent 1051-1058. portal venous gas. J Gastrointest Surg. 2006;10(5):783-785.

INVITED CRITIQUE

elson and colleagues describe an important and As stated in the present article, the finding of HPVG potentially life-threatening clinical condition— by CT “should not determine clinical or surgical man- N HPVG. They present a clearly written and very agement per se.” In emergency situations with a criti- educational overview. cally ill patient (acute abdomen) and the finding of HPVG, According to the given algorithm, the finding of emergency surgery is still mandatory.4 But in all other HPVG in abdominal radiographs should lead directly conditions, in particular in cases where bowel ischemia to an emergency laparotomy. This assumption is based can be excluded, a conservative management of patients on the results of historical reports, in particular the with HPVG might also be appropriate.3 review of the literature by Liebman et al1 with a mortality rate of 75% in patients with HPVG detected on Moritz N. Wente, MD, MSc abdominal radiographs published in 1978. It is ques- Markus W. Büchler, MD tionable if this guideline is still applicable because in most departments a CT scan is available in the emer- Correspondence: Dr Büchler, Department of General Sur- gency setting and will be included in the diagnostic gery, University of Heidelberg, Im Neuenheimer Feld 110, workup for most patients before an emergency lapa- D-69120 Heidelberg, Germany (markus.buechler@med rotomy should be performed. .uni-heidelberg.de). The given “ABCs” are in concordance with other treat- Author Contributions: Study concept and design: Wente ment guidelines in patients with HPVG. It is important and Büchler. Drafting of the manuscript: Wente and to discriminate patients with radiologic and clinical find- Büchler. Critical revision of the manuscript for important ings of HPVG if intestinal ischemia or infarction is the intellectual content: Wente and Büchler. underlying disease in order to select the appropriate pa- Financial Disclosure: None reported. tients to undergo an emergency laparotomy. The given “ABCs of management” can be used as a mnemonic trick 1. Liebman PR, Patten MT, Manny J, Benfield JR, Hechtman HB. Hepatic-portal in this rare but important clinical situation; however, more venous gas in adults: etiology, pathophysiology, and clinical significance. Ann Surg. 1978;187(3):281-287. distinct treatment pathways have been published in the 2. Hou SK, Chern CW, How CK, Chen JD, Wang LM, Lee CH. Hepatic portal literature recently.2,3 In flowcharts presented by Hou et venous gas: clinical significance of computed tomography findings. Am J Emerg 2 3 Med. 2004;22(3):214-218. al and Iannitti et al, more detailed clinical recommen- 3. Iannitti DA, Gregg SC, Mayo-Smith WW, Tomolonis RJ, Cioffi WG, Pricolo dations are given regarding the diagnostic workup, the VE. Portal venous gas detected by computed tomography: is surgery imperative? necessity of immediate surgical intervention based on ra- Dig Surg. 2003;20(4):306-315. 4. Monneuse O, Pilleul F, Barth X, et al. Portal venous gas detected on com- diological and clinical findings, and the nonsurgical treat- puted tomography in emergency situations: surgery is still necessary. World ment (antibiotics, endoscopy, drainage) options. J Surg. 2007;31(5):1065-1071.

(REPRINTED) ARCH SURG/ VOL 144 (NO. 6), JUNE 2009 WWW.ARCHSURG.COM 581