Hepatic veins gas bubbles in a case of emphysematous pyelonephritis

Abstract

Hepatic portal venous gas (HPVG) has been well documented in medical literature. The term HPVG was introduced in 1955 in infants with necrotizing enterocolitis. 1,2 HPVG used to be considered a sign that requires urgent operative intervention. However, with the advancement in imaging technology, HPVG is now often associated with a range of benign to severe abdominal diseases, such as intestinal ischemia or necrosis, diverticulitis, inflammatory bowel disease, gastric ulcer and duodenal perforation and even benign causes such as post endoscopic procedures complication, ingestion of high concentration of hydrogen peroxide and abdominal trauma. 2 The first reported case of detectable gas in hepatic veins (HV) on ultrasound was in 1989. 3 It was reported that a patient with emphysematous pyelonephritis had intravascular gas that entered the inferior vena cava through the right renal vein and extended into the HV, causing a rare but transient phenomenon. Since then, there has been a few published reports of gas in the HV. [3][4][5][6][7] We present a case study demonstrating a rare sonographic appearance of gas in the inferior vena cava (IVC) extending into the HV and right atrium, due to emphysematous pyelonephritis.