Review Article | Open Access
Yu-Tso Liao, Hong-Shee Lai, Rey-Heng Hu, Po-Huang Lee, Cheng-Maw Ho, "Self-Limited Pneumoporta in the Era of Computed Tomography: A Case Report and Review of the Literature", International Scholarly Research Notices, vol. 2012, Article ID 480795, 7 pages, 2012. https://doi.org/10.5402/2012/480795
Self-Limited Pneumoporta in the Era of Computed Tomography: A Case Report and Review of the Literature
Pneumoporta in patients with abdominal pain has been thought to be suggestive of fatal underlying conditions, such as mesenteric infarct, requiring emergency treatment. Widespread use of computed tomography (CT) has increased the frequency of detection of pneumoporta in patients with diseases other than mesenteric infarct. The natural course of resolution of pneumoporta has been rarely discussed in the literature and mainly focused on patients with iatrogenic diseases. Herein, we report the case of a 64-year-old woman who presented at our emergency department with positive peritoneal signs and pneumoporta. A 10 cm long segment of resolved ischemic bowel was detected on exploratory laparotomy, and bowel resection was not performed. Follow-up CT performed 62 hours later revealed complete resolution of pneumoporta. The patient was discharged uneventfully and was administered short-term prophylactic therapy with enoxaparin for thromboembolism. The epidemiology, etiology, and resolution of pneumoporta are also reviewed.
Pneumoporta has been thought to be an ominous radiological sign. However, the etiology is associated with various diseases ranging from severe fatal conditions requiring rapid surgical intervention to medical diseases with a benign course. Treatment of pneumoporta should be based on the etiology of the condition. The natural course of resolution of pneumoporta has rarely been discussed in the literature. Here, we report a case of a 64-year-old woman with spontaneously resolved ischemic bowel and pneumoporta, and the epidemiology, etiology, and resolution of pneumoporta are reviewed.
2. Case Presentation
A 64-year-old woman presented at our emergency department with intermittent abdominal pain for 3 days without vomiting or dysentery. The patient was otherwise healthy, but had a history of spinal surgery and was a carrier of the hepatitis B virus. She did not have a history of hydrogen peroxide ingestion. Upon arrival at the emergency department, her vital signs were stable and consciousness was clear. Physical examination revealed distended abdomen and diffuse peritoneal sign. Laboratory examination showed no leukocytosis, but a mild left shift. Lactic acid levels were within the normal range. Abdominal CT scan showed the presence of air in the portal venous tree in the left hepatic lobe, patent superior mesenteric artery (SMA), and superior mesenteric vein, and bowel wall thickening and distension of the ileum were noted (Figures 1 and 2). The patent SMA, as detected by the abdominal CT scan, was also observed. The patient underwent emergency exploratory laparotomy. Intraoperative examination revealed a 10 cm long segment of the resolved ischemic ileum with a thickened wall and no transmural infarction. The liver surface was noncontributory. Follow-up abdominal CT performed 62 hours after laparotomy revealed complete resolution of hepatic portal venous gas (Figure 3). A series of workups for the thromboembolic event, including cardiac echography and coagulation studies for autoantibodies, factor VIII, protein C, and protein S, yielded no abnormal data except elevated levels of D-D dimer and factor VIII. The patient was discharged uneventfully and was administered short-term prophylactic therapy with enoxaparin for thromboembolism.
Pneumoporta has been considered to be an ominous radiological sign. However, pneumoporta may be associated with conditions ranging from severe fatal diseases requiring urgent surgical intervention to medical diseases that follow a benign course, such as gastroenteritis, which can be managed with only conservative treatment [1, 2]. A mortality rate as high as 75–90% has been reported, mainly owing to the occurrence of mesenteric infarction [3–5]. Nowadays, the widespread utilization of CT scan has increased the frequency of detection of pneumoporta in the clinical scenario [6, 7]. Indeed, mesenteric infarctions are the main etiological factors that lead to potentially fatal outcomes and should always be considered when diagnosing the cause of pneumoporta [8, 9]. In addition, because of the increased frequency of occurrence of benign diseases [2, 6], prompt clinical evaluation and surgical decision are paramount in cases of pneumoporta.
CT scan enables early detection due to high sensitivity for pneumoporta and is superior to other radiological modalities, including ultrasound and abdominal plain film, in diagnosis of underlying abdominal diseases . Since the 1970s, the introduction of the CT scan has gradually advanced the ability of physicians to accurately diagnose pneumoporta, and pneumoporta can now be detected at less advantaged stages . More than half of the etiologies of pneumoporta were mesenteric infarct, reported to account for 61–75% of cases [3, 8, 10]. Other etiologies include gastrointestinal dysmotility, infectious/inflammatory processes, toxicity-related conditions, and iatrogenic lesions [11, 12]. Notably, the appearance of pneumoporta in relation to iatrogenic causes increase in frequency over recent decades .
The correlation of outcomes and the presence of pneumoporta, as well as the duration of pneumoporta, have not been clearly elucidated [3, 9]. The appearance of pneumoporta is associated with poor outcomes in patients experiencing cardiac arrest outside of the hospital . Nevertheless, the notoriously high mortality generally encountered in patients with pneumoporta has decreased to 25–29% in recent reports, mainly due to early detection and incidental findings during the diagnosis of other diseases [9, 14, 15]. Furthermore, the resolution of pneumoporta has been shown to be associated with the improvement of the underlying diseases.
In order to investigate the clinical characteristics of pneumoporta resolution in the era of CT scan, we reviewed the English literature by searching for the keyword “portal venous gas” or “hepatic portal venous gas” in PubMed. The age, sex, etiology, diagnostic modality (including conventional roentgenography, ultrasound, and CT scan), duration of pneumoporta, and patient outcomes were reviewed. Patients who were diagnosed as pneumoporta on CT scan were included in the study. The exclusion criteria were listed as following: the patients died of fulminant mesenteric infarct without CT followup, the unclear recording about resolution of pneumoporta, or the detection of pneumoporta by the radiological modalities other than CT scan. A total of 61 cases were eligible and are listed according to the etiology (Table 1). Several classifications have been proposed in literature, and the system we used here was based on whether the causes were iatrogenic or not because the classification conveyed clinical usefulness and prognostic prediction [12, 16].
|CT: computed tomography; EUS: endoscopic ultrasound.|
—: not mentioned in the literature.
*25 cases were reported.
For demography available in the literature, the male/female ratio was 1.5, with a mean age of 53.4 years (range, 10 to 94 years). Iatrogenic etiologies were the main causes of pneumoporta (61%). The resolution of pneumoporta was associated with the improvement of underlying diseases, and the reported duration of pneumoporta ranged from 20 min to 2 months.
The correlation between lethal potentiality and pneumoporta is unclear. The risk of hepatic flow compromise by air accumulating in the portal systems may be taken into consideration. However, pneumoporta itself rarely affected hepatic flow in both animal and human studies. The observation might be explained by the anatomy of the dual blood supply of liver [17, 18]. Accordingly, researchers have assumed that the pathophysiological mechanism responsible for the onset of pneumoporta is the cause of death, not the air bubbles themselves . The detailed mechanism necessitated further study.
4. Noniatrogenic Causes
For noniatrogenic causes, improvement of pneumoporta in patients with mesenteric infarct was rarely reported, possibly because of the fulminant course of these underlying conditions. The appearance of pneumoporta in mesenteric infarct is associated with high mortality and morbidity . Other diseases in which pneumoporta has been noted include gastrointestinal dysmotility, infection/inflammation, and medication/toxicity-related conditions. The outcomes in these situations were satisfactory following prompt surgical intervention. Notably, various medical diseases are predisposing factors for pneumoporta and do not mandate surgical intervention. In these cases, pneumoporta is usually noticed incidentally, and the course is usually self-limited. Transient ischemic enteritis has been reported to be a cause of pneumoporta and can also be successfully managed conservatively .
5. Iatrogenic Causes
The course of pneumoporta after iatrogenic events is generally benign and transient, lasting no more than 1 day in the majority of cases. Incidental discovery of pneumoporta usually urges clinicians to repeat the imaging examination and followup with the patients closely, as shown in the literature. The appropriate treatment for iatrogenic cases seems to “wait and see,” except in one patient who died of portal vein thrombosis and sepsis after cryotherapy .
Diffuse peritoneal signs and wall thickening of the small bowel revealed by physical examination and CT scan, respectively, in the presence of pneumoporta is a condition that requires urgent surgical intervention . The condition may be suggestive of an underlying clinical condition, such as mesenteric ischemia/infarction. However, in our case, only one segment of the thickened small bowel, which seemed to be the resolved ischemic bowel, was observed during the intraoperative examination. This patient is alive, and bowel resection was not required.
The natural course of pneumoporta is rarely discussed systemically in the literature and is only sporadically reported in patients with iatrogenic diseases [24, 29, 44]. In our case, sequential CT scan performed 62 hours after laparotomy revealed complete resolution of pneumoporta. This observation implies that pneumoporta may be a paraphenomenon that disappears when the underlying pathology is improved.
There were some limitations in our review. First, the duration of pneumoporta was ambiguous, lacking a clear definition and strict control. Actually the duration recorded in the paper indicated a potential period that the pneumoporta may exist. Second, the appearance of pneumoporta was regarded as a paraphenomenon in benign diseases; therefore, the follow-up modalities depended on clinicians’ judgment in the absence of standard protocol. Third, the real incidence of self-limited pneumoporta might be underestimated because the “benign” pneumoporta would disappear spontaneously. We believed the occurrence of pneumoporta would outnumber the cases recorded in the literature. In despite of the above-mentioned limitations, we are convinced that our study offers a general description of current self-limited pneumoporta reported in the English literature. The overall survey pointed out some undiscovered issues concerning the pathophysiology and clinical outcomes of pneumoporta.
Mesenteric infarct should always be considered when diagnosing the cause of pneumoporta accompanied by positive peritoneal signs. The diagnosis of pneumoporta merely based on radiological findings is an intriguing possibility, and the management of pneumoporta should be based on etiological findings. In our case, spontaneous resolution of pneumoporta was observed.
|SMA:||Superior mesenteric artery.|
Conflict of Interests
The authors declare that there is no conflict of interests.
C.-M. Ho and Y.-T. Liao participated in the patient’s care, including the operative procedures. Y.-T. Liao drafted the paper. H.-S. Lai, R.-H. Hu, and P.-H. Lee supervised and directed the review of the literature.
- A. Mancebo, E. Álvarez-Hornia, M. Rodríguez-Peláez, M. Ibáñez, L. H. Luyando, and M. Varela, “Indolent evolution of an episode of acute gastroenteritis complicated with portal pneumatosis,” Revista Espanola de Enfermedades Digestivas, vol. 102, no. 9, pp. 557–559, 2010.
- A. L. Nelson, T. M. Millington, D. Sahani et al., “Hepatic portal venous gas: the ABCs of management,” Archives of Surgery, vol. 144, no. 6, pp. 575–581, 2009.
- P. R. Liebman, M. T. Patten, and J. Manny, “Hepatic-portal venous gas in adults: etiology, pathophysiology and clinical significance,” Annals of Surgery, vol. 187, no. 3, pp. 281–287, 1978.
- W. C. G. Peh and M. Muttarak, “Clinics in diagnostic imaging (53). Hepatic portal venous gas due to mesenteric infarction,” Singapore Medical Journal, vol. 41, no. 9, pp. 471–473, 2000.
- R. A. Bloom, P. D. Lebensart, P. Levy, E. Craciun, H. Anner, and J. Manny, “Survival after ultrasonographic demonstration of portal venous gas due to mesenteric artery occlusion,” Postgraduate Medical Journal, vol. 66, no. 772, pp. 137–139, 1990.
- E. Wayne, M. Ough, A. Wu et al., “Management algorithm for pneumatosis intestinalis and portal venous gas: treatment and outcome of 88 consecutive cases,” Journal of Gastrointestinal Surgery, vol. 14, no. 3, pp. 437–448, 2010.
- S. T. Schindera, J. Triller, P. Vock, and H. Hoppe, “Detection of hepatic portal venous gas: its clinical impact and outcome,” Emergency Radiology, vol. 12, no. 4, pp. 164–170, 2006.
- A. Hussain, H. Mahmood, and S. El-Hasani, “Portal vein gas in emergency surgery,” World Journal of Emergency Surgery, vol. 3, no. 1, article 21, 2008.
- H. Kinoshita, M. Shinozaki, H. Tanimura et al., “Clinical features and management of hepatic portal venous gas: four case reports and cumulative review of the literature,” Archives of Surgery, vol. 136, no. 12, pp. 1410–1414, 2001.
- N. Peloponissios, N. Halkic, M. Pugnale et al., “Hepatic portal gas in adults: review of the literature and presentation of a consecutive series of 11 cases,” Archives of Surgery, vol. 138, no. 12, pp. 1367–1370, 2003.
- B. Abboud, J. El Hachem, T. Yazbeck, and C. Doumit, “Hepatic portal venous gas: physiopathology, etiology, prognosis and treatment,” World Journal of Gastroenterology, vol. 15, no. 29, pp. 3585–3590, 2009.
- P. A. Shah, S. C. Cunningham, T. A. Morgan, and B. D. Daly, “Hepatic gas: widening spectrum of causes detected at ct and us in the interventional era,” Radiographics, vol. 31, pp. 1403–1413, 2011.
- W. C. Lien, W. T. Chang, S. P. Huang et al., “Hepatic portal venous gas associated with poor outcome in out-of-hospital cardiac arrest patients,” Resuscitation, vol. 60, no. 3, pp. 303–307, 2004.
- R. S. Faberman and W. W. Mayo-Smith, “Outcome of 17 patients with portal venous gas detected by CT,” American Journal of Roentgenology, vol. 169, no. 6, pp. 1535–1538, 1997.
- W. Wiesner, K. J. Mortelé, J. N. Glickman, H. Ji, and P. R. Ros, “Portal-venous gas unrelated to mesenteric ischemia,” European Radiology, vol. 12, no. 6, pp. 1432–1437, 2002.
- J. J. Hong, D. Gadaleta, P. Rossi, J. Esquivel, and J. M. Davis, “Portal vein gas, a changing clinical entity: report of 7 patients and review of the literature,” Archives of Surgery, vol. 132, no. 10, pp. 1071–1075, 1997.
- B. D. Butler, C. Fife, T. Sutton, M. Pogodsky, and P. Chen, “Hepatic portal venous gas with hyperbaric decompression: ultrasonographic identification,” Journal of Ultrasound in Medicine, vol. 14, no. 12, pp. 967–970, 1995.
- I. Gersh and H. R. Catchpole, “Appearance and distribution of gas bubbles in rabbits decompressed to altitude,” Journal of Cellular and Comparative Physiology, vol. 28, no. 3, pp. 253–269, 1946.
- K. Ohtsubo, T. Okai, Y. Yamaguchi et al., “Pneumatosis intestinalis and hepatic portal venous gas caused by mesenteric ischemia in an aged person,” Journal of Gastroenterology, vol. 36, no. 5, pp. 338–340, 2001.
- D. Fukumori, T. Sasaki, H. Matsumoto, H. Ohmori, T. Kakazu, and F. Yamamoto, “Necrotizing enteritis with hepatic portal venous gas and pneumatosis intestinalis: report of a case,” European Journal of Gastroenterology and Hepatology, vol. 15, no. 2, pp. 201–203, 2003.
- Y. Morimoto, T. Yamakawa, Y. Tanaka, T. Hiranaka, and M. Kim, “Recurrent hepatic portal venous gas in a patient with hemodialysis-dependent chronic renal failure,” Journal of Hepato-Biliary-Pancreatic Surgery, vol. 8, no. 3, pp. 274–278, 2001.
- A. Hashimoto, H. Fuke, A. Shimizu, and K. Shiraki, “Hepatic portal venous gas caused by non-obstructive mesenteric ischemia,” Journal of Hepatology, vol. 37, no. 6, p. 870, 2002.
- S. H. Jung, K. M. Lee, W. C. Chung, C. N. Paik, J. D. Kim, and J. W. Kwak, “Ischemic colitis and portal venous gas,” Gastrointestinal Endoscopy, vol. 71, no. 7, pp. 1302–1303, 2010.
- B. Coulier, S. Van den Broeck, and J. P. Coppens, “Transient and rapidly resolving intrahepatic portal gas: CT findings,” Journal Belge de Radiologie, vol. 91, no. 5, pp. 214–216, 2008.
- M. Yamamuro and J. L. Ponsky, “Hepatic portal venous gas: report of a case,” Surgery Today, vol. 30, no. 7, pp. 647–650, 2000.
- J. Rod, S. Sarnacki, T. Petit, and P. Ravasse, “Portal venous gas and thrombosis complicating superior mesenteric artery syndrome (Wilkie's syndrome) in a child,” Journal of Pediatric Surgery, vol. 45, no. 4, pp. 826–829, 2010.
- Y. C. Mao, J. D. Wang, and L. M. Wang, “Hepatic portal venous gas caused by emphysematous pyelonephritis,” Clinical Gastroenterology and Hepatology, vol. 7, no. 10, article A25, 2009.
- T. N. Chau, T. K. L. Loke, V. K. S. Leung, S. T. Law, M. H. Y. Lai, and Y. W. Ho, “Hepatic portal venous gas complicating septic thrombophlebitis of the superior mesenteric vein,” Hong Kong Medical Journal, vol. 13, no. 1, pp. 69–72, 2007.
- M. Niki, I. Shimizu, T. Horie et al., “Hepatic portal venous gas disappearing within 24 hours,” Internal Medicine, vol. 41, no. 11, pp. 950–952, 2002.
- M. Kirsch, J. Bozdech, and D. A. Gardner, “Hepatic portal venous gas: an unusual presentation of Crohn's disease,” American Journal of Gastroenterology, vol. 85, no. 11, pp. 1521–1523, 1990.
- J. Delamarre, J. P. Capron, J. L. Dupas, B. Deschepper, C. Jouet-Gondry, and A. Rudelli, “Spontaneous portal venous gas in a patient with Crohn's ileocolitis,” Gastrointestinal Radiology, vol. 16, no. 1, pp. 38–40, 1991.
- H. Al-Jahdali, C. Pon, W. G. Thompson, and F. R. Matzinger, “Non-fatal portal pyaemia complicating Crohn's disease of the terminal ileum,” Gut, vol. 35, no. 4, pp. 560–561, 1994.
- S. G. Chang, S. C. Lee, D. H. Hong, and S. E. Chai, “Portal and superior mesenteric venous gas with retroperitoneal abscess—CT diagnosis (case report),” Journal of Korean medical science, vol. 7, no. 1, pp. 62–65, 1992.
- T. Ochiai, K. Igri, Y. Kumagai, M. Iida, and S. Yamazaki, “Gastrointestinal: massive portal venous gas and pneumatosis intestinalis,” Journal of Gastroenterology and Hepatology, vol. 25, no. 6, p. 1178, 2010.
- L. K. French, B. Z. Horowitz, and N. J. McKeown, “Hydrogen peroxide ingestion associated with portal venousgas and treatment with hyperbaric oxygen: a case seriesand review of the literature,” Clinical Toxicology, vol. 48, no. 6, pp. 533–538, 2010.
- F. Volonte, P. Gervaz, P. A. Poletti, and P. Morel, “Portal vein gas embolism following oxygen peroxide enema,” Colorectal Disease, vol. 12, no. 10, pp. e335–e336, 2010.
- S. Ghai and M. E. O'Malley, “Portal vein gas resulting from ingestion of hydrogen peroxide,” American Journal of Roentgenology, vol. 181, no. 6, pp. 1719–1720, 2003.
- M. Lewin, M. Pocard, S. Caplin, A. Blain, J. M. Tubiana, and R. Parc, “Benign hepatic portal venous gas following caustic ingestion,” European Radiology, vol. 12, no. 3, pp. S59–S61, 2002.
- M. Saksena, M. G. Harisinghani, J. Wittenberg, and P. R. Mueller, “Hepatic portal venous gas: transient radiographic finding associated with colchicine toxicity,” British Journal of Radiology, vol. 76, no. 911, pp. 835–837, 2003.
- S. Alqahtani, C. S. Coffin, K. Burak, F. Chen, J. MacGregor, and P. Beck, “Hepatic portal venous gas: a report of two cases and a review of the epidemiology, pathogenesis, diagnosis and approach to management,” Canadian Journal of Gastroenterology, vol. 21, no. 5, pp. 309–313, 2007.
- C. Konoeda, K. Adachi, and Y. Morita, “Pneumatosis cystoides intestinalis presenting with portal vein gas and pneumoperitoneum,” American Surgeon, vol. 77, no. 6, pp. E119–E120, 2011.
- T. Oei, E. VanSonnenberg, S. Shankar, P. R. Morrison, K. Tuncali, and S. G. Silverman, “Radiofrequency ablation of liver tumors: a new cause of benign portal venous gas,” Radiology, vol. 237, no. 2, pp. 709–717, 2005.
- M. J. Alfredson, A. J. Brooks, M. L. Talbot, and D. L. Morris, “Hepatic portal vein gas as a complication of cryotherapy,” HPB, vol. 7, no. 2, pp. 159–160, 2005.
- S. M. Kuo, W. K. Chang, C. Y. Yu, and C. B. Hsieh, “Silent hepatic portal venous gas following upper gastrointestinal endoscopy,” Endoscopy, vol. 41, supplement 2, pp. E121–E122, 2009.
- C. G. Lee, H. W. Kang, M. K. Song et al., “A case of hepatic portal venous gas as a complication of endoscopic balloon dilatation,” Journal of Korean Medical Science, vol. 26, no. 8, pp. 1108–1110, 2011.
- K. Ahmed, M. Atiq, E. Richer, G. Neff, N. Kemmer, and K. Safdar, “Careful observation of hepatic portal venous gas following esophageal variceal band ligation,” Endoscopy, vol. 40, supplement 2, p. E103, 2008.
- C. G. Schulze, U. Blum, and K. Haag, “Hepatic portal venous gas imaging modalities and clinical significance,” Acta Radiologica, vol. 36, no. 4, pp. 377–380, 1995.
- D. Zhang, D. Weltman, and A. Baykal, “Portal vein gas and colonic pneumatosis after enema, with spontaneous resolution,” American Journal of Roentgenology, vol. 173, no. 4, pp. 1140–1141, 1999.
- D. Karaosmanoǧlu, S. Ö. Oktar, M. Araç, and G. Erbaş, “Portal and systemic venous gas in a patient after lumbar puncture,” British Journal of Radiology, vol. 78, no. 932, pp. 767–769, 2005.
- F. Artunc, S. Heller, M. Heuschmid, R. Riessen, and M. Haap, “Gastrointestinal: hepatic portal venous gas after cardiogenic shock and intraaortic ballon pulsation therapy,” Journal of Gastroenterology and Hepatology, vol. 25, no. 3, p. 644, 2010.
- T. Tsubono, K. Sato, and M. Fukuda, “Hepatic portal venous gas associated with cholangitis following pancreaticoduodenectomy: report of a case,” Surgery Today, vol. 24, no. 4, pp. 375–377, 1994.
- H. Reuter, C. Bangard, F. Gerhardt, S. Rosenkranz, and E. Erdmann, “Extensive hepatic portal venous gas and gastric emphysema after successful resuscitation,” Resuscitation, vol. 82, no. 2, pp. 238–239, 2011.
- J. M. Wu, M. S. Tsai, M. T. Lin, Y. W. Tien, and T. H. Lin, “High APACHE II score and long length of bowel resection impair the outcomes in patients with necrotic bowel induced hepatic portal venous gas,” BMC Gastroenterology, vol. 11, article 18, 2011.
- T. Morisaki, K. Ohba, A. Yoshida, Y. Mizuta, and K. Nakao, “A case of hepatic portal venous gas caused by transient type ischemic enteritis,” Journal of Japanese Society of Gastroenterology, vol. 107, no. 3, pp. 407–415, 2010.
Copyright © 2012 Yu-Tso Liao et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.