portal venous gas

Portal Venous GasSUNY Downstate Medical Center

Department of Surgery

Jacob Eisdorfer, DO6/9/2011

www.downstatesurgery.org

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Case56 y/o M presented to ER c/o severe AbdPain, N/V x 4daysPMHx: HIV, HTNHep C, COPD, renal insufficiency– VS: 98.7; 86/60; 96; 16; 99% – Lethargic, but arousable–Abdomen distended and tender

Labs:


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CaseImaging


Case

Imaging


CaseResuscitation in ER & OREx-Lap– Significant amount of small bowel found to be

gangrenous and was resected– 20cm of jejunum, and 120cm of distal Ileum left, some

dusky patches– Good Doppler signal throughout mesentery, no sign

of venous congestion– Left OR on Levophed, Vasopressin, & Epinephrine

drips– Skin closed, fascia left open with plan to come back

to OR for second look laparotomy


Case

POD 0-1– Aggressively resuscitated overnight in

PACU– By 6am all pressors off– Labs:– 2am: -6am:


Case

Second Look– All remaining small and large bowel

appeared viable and well perfused– Small bowel to small bowel anastomosis

created– Abdomen Closed


Case

Hospital course–POD 1-2, intubated in MICU,

resuscitation continued–POD 3 – Extubated–POD 5 continued to pass flatus and

had BM liquid diet started & slowly advanced to regular

–POD 8: Discharged home


Portal Venous Gas

Nelson AL, Millington TM, Sahani D, Chung RT, Bauer C, Hertl M, Warshaw AL, Conrad C. Hepatic portal venous gas: the ABCs of management. Arch Surg. 2009 Jun; 144(6): 575-81 (Tufts)


Portal Venous Gas

Rare Radiologic Finding– Only 182 cases documented in the literature

by 2001– 2 Reviews of CT scans in academic medical

centers:17 / 14,000 scans11 / 19,000 scans

Kinoshita H, Shinozaki M, Tanimura H, et al. Clinical features and management of hepatic portal venous gas: four case reports and cumulative review of the literature. Arch Surg. 2001;136(12):1410-1414 (Japan)

Faberman RS, Mayo-Smith WW. Outcome of 17 patients with portal venous gas detected by CT. AJR Am J Roentgenol. 1997;169(6):1535-1538. (R.I. Hosp., Brown Univ. Med School)

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. (Switzerland)


Portal Venous Gas

Described 1955 by Wolfe and Evans– abdominal plain radiographs– 6 Neonates who died secondary to necrotic

bowelFollowed by a report in 1960 of Hepatic Portal venous gas in 5 adults who died

Wolfe JN, Evans WA. Gas in the portal veins of the liver in infants: a roentgenographic demonstration with postmortem anatomical correlation. Am J Roentgenol Radium Ther Nucl Med. 1955;74(3):486-488.

Susman N, Senturia HR. Gas embolization of the portal venous system. Am JRoentgenol Radium Ther Nucl Med. 1960;83:847-850.


Portal Venous Gas

First reported survivor: 1965Liebman & colleagues analyzed all reported cases by 1978– Mortality 75%– Concluded that the finding of portal venous

gas demands emergent laparotomy

Lazar HP. Survival following portal venous air embolization: report of a case. AmJ Dig Dis. 1965;10:259-264.

Liebman PR, Patten MT, Manny J, Benfield JR, Hechtman HB. Hepatic-portal venous gas in adults: etiology, pathophysiology and clinical significance. Ann Surg. 1978;187(3):281-287


Portal Venous GasDefined by Sisk as tubular areas of decreased attenuation in the liver periphery– Injected contrast into portal vein & detected it

within 2cm of the capsule.– Distinguished from aerobilia which is centrally

located air in the biliary treeSebastià C, Quiroga S, Espin E, Boye R, Alvarez-Castells A, Armengol M. Portomesenteric vein gas: pathologic mechanisms, CT findings, and prognosis. Radiographics. 2000;20(5):1213-1224, discussion 1224-1226 (Spain)

Masannat Y, Masannat Y, Shatnawei A. Gallstone ileus: a review. Mt Sinai JMed.2006;73(8):1132-1134. (UK)


Portal Venous Gaswww.downstatesurgery.org

Portal Venous GasExperimentally– Air injected into submucosa or

mesenteric veins of dog intestines was found in the portal venous system.

– Occlusion of mesenteric arteries in dogs resulting in infarction also results in portal venous air

Berne TV, Meyers HI, Donovan AJ. Gas in the portal vein of adults with necrotizing enteropathy. Am J Surg. 1970;120(2):203-209.

Marston A. Causes of death in mesenteric arterial occlusion, I: local and general effects of devascularization of the bowel. Ann Surg. 1963;158:952-959


Portal Venous Gas

Pathophysiology (Hypothesis)– Microbe-derived gas production – Absorbed Intraluminal air through

disrupted mucosaNo actual experimental evidence

Jones B. Massive gas embolism in E. coli septicemia. Gastrointest Radiol. 1981; 6(2):161-163


Portal Venous Gas

Crohn’s DiseaseUlcerative ColitisGastric UlcerGraft-vs-Host DiseaseUncomplicated Bowel ObstructionPseudo-obstructionBacterial AbscessesDiverticulitisParalytic IleusSuppurative CholangitisColovenous FistulaeCystic FibrosisSeizuresColchicine Toxicity

Nelson AL, Millington TM, Sahani D, Chung RT, Bauer C, Hertl M, Warshaw AL, Conrad C. Hepatic portal venous gas: the ABCs of management. Arch Surg. 2009 Jun; 144(6): 575-81

– Iatrogenic:LaparoscopyEndoscopy

– ERCP– Gastric Dilitation

Liver TransplantRFAArterial Cath

Portal venous gas has also been reported in many nonfatal conditions


Portal Venous GasNewer data reports the mortality associated to be 39%– Decrease thought to be due to change in diagnostic

imagingCT scanning

– More sensitive for portal venous gas – and also diagnostic for non fatal etiologies

A direct correlation is also made with the frequency of bowel ischemia as an etiology

– 72% in 1978– 43% in 2001

When Bowel ischemia is the cause mortality remains high (~75%)

Kinoshita H, Shinozaki M, Tanimura H, et al. Clinical features and management of hepatic portal venous gas: four case reports and cumulative review of the literature. Arch Surg. 2001;136(12):1410-1414 (Japan)


Portal Venous Gas

Nelson AL, Millington TM, Sahani D, Chung RT, Bauer C, Hertl M, Warshaw AL, Conrad C. Hepatic portal venous gas: the ABCs of management. Arch Surg. 2009 Jun; 144(6): 575-81 (Tufts)


Portal Venous GasReferences

Nelson AL, Millington TM, Sahani D, Chung RT, Bauer C, Hertl M, Warshaw AL, Conrad C. Hepatic portal venous gas: the ABCs of management. Arch Surg. 2009 Jun; 144(6): 575-81Wolfe JN, Evans WA. Gas in the portal veins of the liver in infants: a roentgenographic demonstration with postmortem anatomical correlation. Am J Roentgenol Radium Ther Nucl Med. 1955;74(3):486-488.Susman N, Senturia HR. Gas embolization of the portal venous system. Am J Roentgenol Radium Ther Nucl Med. 1960;83:847-850.Lazar HP. Survival following portal venous air embolization: report of a case. Am J Dig Dis. 1965;10:259-264.Liebman PR, Patten MT, Manny J, Benfield JR, Hechtman HB. Hepatic-portal venous gas in adults: etiology, pathophysiology and clinical significance. Ann Surg. 1978;187(3):281-287Kinoshita H, Shinozaki M, Tanimura H, et al. Clinical features and management of hepatic portal venous gas: four case reports and cumulative review of the literature. Arch Surg. 2001;136(12):1410-1414Faberman RS, Mayo-Smith WW. Outcome of 17 patients with portal venous gas detected by CT. AJR Am J Roentgenol. 1997;169(6):1535-1538.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.Wiesner W, Mortele KJ, Glickman JN, Ji H, Ros PR. Pneumatosis intestinalis and portomesenteric venous gas in intestinal ischemia: correlation of CT findings with severity of ischemia and clinical outcome. AJR Am J Roentgenol. 2001;177 (6):1319-1323 (Brigham, Boston)Wolfe JN, Evans WA. Gas in the portal veins of the liver in infants: a roentgenographic demonstration with postmortem anatomical correlation. Am J Roentgenol Radium Ther Nucl Med. 1955;74(3):486-488.Berne TV, Meyers HI, Donovan AJ. Gas in the portal vein of adults with necrotizing enteropathy. Am J Surg. 1970;120(2):203-209.Marston A. Causes of death in mesenteric arterial occlusion, I: local and general effects of devascularization of the bowel. Ann Surg. 1963;158:952-959 Jones B. Massive gas embolism in E. coli septicemia. Gastrointest Radiol. 1981; 6(2):161-163Kinoshita H, Shinozaki M, Tanimura H, et al. Clinical features and management of hepatic portal venous gas: four case reports and cumulative review of the literature. Arch Surg. 2001;136(12):1410-1414


portal venous gas

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