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Abdomen » Hepatobiliary
Transient hepatic portal venous gas in a patient with small bowel dilatation
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Author(s) :
Taco Geertsma, MD
 
Presentation 81 year old male patient who was initially admitted with pain in the abdomen. An ultrasound examination was requested because of impaired renal function. He has a previous history of colon carcinoma for which he has a stoma. The ultrasound examination of the kidneys showed no abnormality
 
 
 
Caption: Longitudinal image of the liver
Description: There are patchy highly reflective areas in the liver
 
 
Caption: Cineloop of the liver and portal vein
Description: There is highly reflective material moving in the portal vein and patchy echogenic areas in the liver. The echogenic structures represent gas
 
 
Caption: Cineloop of the liver and portal vein with color doppler
Description: The air bubbles in the portal vein are very strong acoustic reflectors causing blooming of the color flow in the portal vein.
 
 
 
Caption: Plain abdominal x ray of the patient taken the day before the ultrasound examination
Description: The image shows dilatated small bowel loops
 
 
 
Caption: CT scan image of the liver 15 minutes after the ultrasound examination
Description: There are linear streaks of air visible in the portal veins (arrow)
 
 
 
Caption: CT image of the lower abdomen
Description: The image shows a dilatated small bowel with intramural airbubbles
 
 
 
Caption: CT scan at the level of the stoma
Description: There is a parastomal hernia (arrow)
 
 
 
Caption: Longitudinal image of the liver 2 days after the first examination
Description: The findings are normal
 
 
Caption: Cineloop of the liver and portal vein with color doppler 2 days later
Description: The findings are normal. There is no blooming.
 
Final Diagnosis Transient hepatic portal venous gas in a patient with intermittent small bowel obstruction caused by a parastomal hernia.
 
Discussion

Hepatic portal venous gas can be an ominous prognostic sign or can be associated with benign causes.

Iatrogenic hepatic portal venous gas can be the result of diagnostic or therapeutic procedures. Procedures which can cause hepatic portal venous gas include colonoscopy, liver transplantation and umbilical vein catheterization. In these cases the prognosis is usually good

In patients with hepatic portal venous gas without a history of previous diagnostic or therapeutic intervention, the prognosis is usually more ominous. With a mortality rate according to the literature approaching 75%. Causes for non-iatrogenic hepatic portal venous gas include mesenteric infarction, enterocolitis, intraabdominal abscess, intestinal obstruction, gastric volvulus, intestinal pneumatosis, neonatal necrotizing enterocolitis, or possibly blunt abdominal trauma. Mucosal damage, bowel distention and sepsis predispose to hepatic portal venous gas. However, there are infrequent causes of portal venous gas not associated with poor clinical outcomes. Patients have been described who made uneventful clinical recoveries after presenting hepatic portal venous gas, some of which had distended but non-necrotic bowel at laparotomy.

 

Pan HB, Huang JS, Yang TL, Liang HL have described 3 different patterns of hepatic portal venous gas on ultrasound

1 dot-like pattern

2 streak-like pattern

3 fruit-pulp-like pattern

In the cases of a dot-like pattern, it is usually a benign transient situation; this phenomenon may be only demonstrated on sonograms but not necessarily on CT. The prognosis is more favorable In the cases of streak-like or fruit-pulp-like patterns without localized liver lesions (e.g., abscess), it usually indicates a noxious scenario with worse clinical sequelae. They concluded that the identification of sonographic patterns of HPVG might be important to predict patient's outcome.

Ultrasound and CT are sensitive methods for the detection of hepatic portal venous gas,  CT scan has been shown to be the most suitable method to identify the underlying cause of hepatic portal venous gas.

For other examples of portal venous gas see www.ultrasoundcases.info 


 
Case References

Hepatic-portal venous gas in adults: etiology, pathophysiology and clinical significance. P R Liebman, M T Patten, J Manny, J R Benfield, and H B Hechtman. Ann Surg. 1978 March; 187(3): 281–287  (Portal venous gas may be a benign finding in cases of stable ulcerative colitis)

'Benign' hepatic portal venous gas.  AF Little MB BS, MS, MMed, FRANZCR, FRCR; SJ Ellis MB BS, FRANZCR.  Australasian Radiology. Volume 47 Issue 3, Pages 309 – 312  Published Online: 11 Aug 2003

Hepatic portal venous gas: transient radiographic finding associated with colchicine toxicity. M Saksena, MD, M G Harisinghani, MD, J Wittenberg, MD and P R Mueller, MD.  British Journal of Radiology (2003) 76, 835-837

Pan HB, Huang JS, Yang TL, Liang HL. Hepatic portal venous gas in ultrasonogram--benign or noxious. Ultrasound Med Biol. 2007 Aug;33(8):1179-83.

Chevallier P, Peten E, Souci J, Chau Y, Padovani B, Bruneton JDetection of portal venous gas on sonography, but not on CT.N. Eur Radiol. 2002 May;12(5):1175-8.


 
Follow Up The finding of portal venous gas came as a surprise because the abdominal symptoms had disappeared completely at the time of the ultrasound examination.The indication for the ultrasound examination was his impaired renal function.
Although the CT scan still showed dilatated small bowel loops and a parastomal hernia there were no clinical signs of an incarcerated hernia at that moment.
Because the patient already had a history of several abdominal surgical interventions and showed no ominous clinical symptoms the surgeon decided not to operate, but wait. The patients condition only improved including his renal function.
An ultrasound examination 2 days later showed complete disappearance of the intrahepatic gas
 
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