Portal Venous Gas Detected by Computed Tomography: Is Surgery Imperative?

Abstract

Background: Portal vein gas (PVG) has historically been associated with mortality rates of 75% or higher and mandatory abdominal exploration. The following study reassesses the clinical significance of gas in the portal venous system detected by computed tomography (CT) and reevaluates the need for surgical intervention in that setting. Methods: We performed a retrospective chart review of 26 patients presenting with gas in the portal venous system as imaged by CT between August 1, 1993 and April 8, 2001. Characteristics assessed included age, sex, clinical presentation and course, additional CT findings, diagnosis, surgical versus non-surgical management, surgical findings, pathologic correlation, and mortality. Results: Of the 26 patients who had gas in the portal venous system by CT, 11 underwent surgery to determine underlying pathology. Of those who underwent surgery, 8 survived to be discharged while 3 died (73% surgical survival). The survivors presented with gastrointestinal related signs/symptoms and were found at the time of surgery to have adhesions, non-surgically treated inflammation, unclear pathology, or resectable lesions. Those who died all demonstrated marked bowel ischemia intraoperatively. Among patients who did not undergo surgery, 9 survived and 6 died (60% nonsurgical survival). Those who survived presented either asymptomatically or with pathology including acute pancreatitis, recent hypotensive episode, uncomplicated diverticulitis, unresectable colon cancer, or infectious etiology. Those who died were poor surgical candidates or status postvascular procedure. The overall survival in patients with portal venous gas by CT was 65%. Conclusion: Portal venous gas on CT is associated with a wide range of pathologies that do not necessarily warrant surgical management. Clinical presentation should be correlated with the presence of PVG and other associated CT findings prior to deciding whether surgery should be performed.

Management Algorithm for Pneumatosis Intestinalis and Portal Venous Gas: Treatment and Outcome of 88 Consecutive Cases

“…The more pressing clinical dilemma is deciding how to manage the patient with newly diagnosed PI/PVG. 5,[19][20][21] Surgical exploration will be therapeutic in a large percentage of patients with mechanical and ischemic causes, as we clearly demonstrated. If the CT scan demonstrates pathology of a mechanical nature, standard surgical management is strongly advocated.…”

“…New clinical recommendations are needed in the medical and surgical literature to better distinguish patients with PI and PVG that require urgent intervention from those with benign causes. 4,5,[18][19][20][21] Reviews of PI and PVG exist in the medical literature (Table 9). Unfortunately, these historical series and case reports only add to the current misunderstanding of PI and PVG.…”

Medical management of pneumatosis intestinalis in patients undergoing allogeneic blood and marrow transplantation

“…21 This conservative approach to PI management, consisting of non surgical management initially compared favorably with historical mortality rates of 35-75% when many cases were managed with a surgery. [22][23][24] The majority of our patients died of GI GvHD or other GI complications suggesting that PI represents a poor prognostic factor. Surveillance for PI in the setting of GI GvHD may be indicated for patients with prolonged treatment with immunosuppressive therapy, especially glucocorticoids.…”

A Rare Case of Hepatic Portal and Mesenteric Venous Gas in a Patient with Gastric Dilatation Secondary to Gastroparesis and Gastric Bezoar

“…It is associated with a wide range of pathologies including mesenteric ischemia, post-procedural complications, Crohn's disease, intra-abdominal abscess and bowel obstruction. Less common pathologies include colon cancer, gastric ulceration, acute pancreatitis, portal pyelophlebitis, infectious causes and sigmoid diverticulitis [1]. In a review of 64 cases by Liebman et al, HPVG was associated with necrotic bowel (72%), ulcerative colitis (8%), intra-abdominal abscess (6%), small bowel obstruction (3%) and gastric ulcer (3%) [3].…”