Hepatobiliary and Pancreatic: Hepatic portal vein gas accompanied by acute enterocolitis improved with non‐surgical treatment

Abstract

Hepatobiliary and Pancreatic: Hepatic portal vein gas accompanied by acute enterocolitis improved with non-surgical treatment A 72-year-old woman presented with 3-day history of abdominal pain, watery diarrhea, hematochezia, and fever. This patient had history of hypertension, diabetes mellitus, and chronic hepatitis B. Vitals at presentation were pulse rate 88/min, blood pressure 130/80 mmHg, respiratory rate 18/min, temperature 38.1°C. Physical examination revealed grossly distended abdomen with mild tenderness on right lower quadrant but without rebound tenderness or rigidity. Bowel sounds were sluggish. Laboratory data revealed an elevated white blood cell count (24 520/uL) and C-reactive protein level (19.448 mg/dL), but liver function, kidney function, anion gap, and lactate were within normal limit. Abdominal X-ray showed diffuse distended small bowel without remarkable evidence of obstruction ( Fig. 1a). Abdominal computed tomography (CT) revealed multiple tubular tree-like branching lucencies in bilateral hepatic lobes regarded as hepatic portal venous gas (HPVG) and inflammatory change in distal ileum and cecum base (Fig. 1b,c). Colonoscopy showed changes of moderate colitis at the rectosigmoid colon. Supportive care with intravenous piperacillin/ tazobactam (4.5 g q 8 h) and nutritional support were given. On the fifth day, fever subsided, and bowel sound returned. Oral intake was permitted on the ninth day. On the 14th day, repeat colonoscopy showed whitish exudate and edematous mucosa on cecum and terminal ileum ( Fig. 1d) and normal mucosa on descending colon. Patient's condition improved gradually with conservative management and discharged on 17th day with advice for regular follow-up. On the 48th day at outpatient, abdominal CT revealed loss of HPVG and improving enterocolitis (Fig. 2).Hepatic portal venous gas was first reported in 1955 in patient with neonatal necrotizing enterocolitis. HPVG was regarded as a sign of mesenteric ischemia or bowel necrosis that requires emergent operation. A wide use of abdominal CT enabled to detect HPVG at the early stage: characteristic finding of branching radiolucency extending to liver periphery, within 2 cm beneath the liver capsule. Recently, HPVG has been recognized to be associated with not only ischemic but also non-ischemic causes, such as bowel ileus, intra-abdominal infection, peptic ulcer, and iatrogenic events, after intra-abdominal operation or procedure. In our case, the cause of HPVG is presumed to be originated from enterocolitis on terminal ileum to cecum. The inflammation of bowel lesion might lead to ileus and intestinal distention with mucosal damage and migration of gas into portal venous circulation. In summary, the presence of HPVG itself is not an indicator of poor prognosis so that finding the pathophysiology of HPVG and consideration of patient's overall clinical, radiological, and laboratory findings are utmost important for decision-making for optimal treatment. Figure 1 Abdominal X-ray revealed diffuse distended small bowel withou...

Transient hepatic portal venous gas secondary to acute ischemic necrotic colitis in a lymphoma patient during chemotherapy: A case report and review

“…To the Editor: Hepatic portal venous gas (PVG) is a rare imaging sign that is associated with certain abdominal disorders such as intestinal necrosis and mesenteric ischemia. 1,2 Secondary PVG is associated with critical illness and alarmingly high mortality. 2 Here we reported the imaging features, diagnosis, and treatment of a patient with lymphoma who presented with transient PVG related to ischemic necrotic colitis after chemotherapy.…”

“…1,2 Secondary PVG is associated with critical illness and alarmingly high mortality. 2 Here we reported the imaging features, diagnosis, and treatment of a patient with lymphoma who presented with transient PVG related to ischemic necrotic colitis after chemotherapy.…”

“…3 PVG is usually a secondary disease to benign and malignant gastrointestinal disorders, such as intestinal necrosis, intestinal obstruction, acute pancreatitis, ulcerative colitis, and tumors. 1,2,4,5 The clinical manifestations and symptoms of PVG are associated with its concomitant diseases, including fever, vomiting, nausea, abdominal pain, abdominal distention, bloody stool, and signs of peritoneal irritation.…”