title: Hepatic portal venous gas: clinical significance of computed tomography findings.
abstract: Hepatic portal venous gas (HPVG) is a rare radiographic finding of significance. Most cases with HPVG are related to mesenteric ischemia that have been associated with extended bowel necrosis and fatal outcome. With the help of computed tomography (CT) in early diagnosis of HPVG, the clinical outcome of patients with mesenteric ischemia has improved. There has been also an increasing rate of detection of HPVG with certain nonischemic conditions. In this report, we present two cases demonstrating HPVG unrelated to mesenteric ischemia. One patient with cholangitis presented abdominal pain with local peritonitis and survived after appropriate antibiotic treatment. Laparotomy was avoided as a result of lack of CT evidence of ischemic bowel disease besides the presence of HPVG. The other case had severe enteritis. Although his CT finding preluded ischemic bowel disease, conservative treatment was implemented because of the absence of peritoneal signs or clinical toxic symptoms. Therefore, whenever HPVG is detected on CT, urgent exploratory laparotomy is only mandatory in a patient with whom intestinal ischemia or infarction is suspected on the basis of radiologic and clinical findings. On the other hand, unnecessary exploratory laparotomy should be avoided in nonischemic conditions that are usually associated with a better clinical outcome if appropriate therapy is prompted for the underlying diseases. Patients with radiographic diagnosis of HPVG should receive a detailed history review and physical examination. The patient's underlying condition should be determined to provide a solid ground for exploratory laparotomy. A flow chart is presented for facilitating the management of patients with HPVG in the ED.
authors.affiliation: Emergency Department, Veterans General Hospital-Taipei, National Yang-Ming University Taipei, Taiwan.
authors.forename: Sen-Kuang
authors.initials: SK
authors.lastname: Hou
authors.forename: Chii-Hwa
authors.initials: CH
authors.lastname: Chern
authors.forename: Chorng-Kuang
authors.initials: CK
authors.lastname: How
authors.forename: Jen-Dar
authors.initials: JD
authors.lastname: Chen
authors.forename: Lee-Min
authors.initials: LM
authors.lastname: Wang
authors.forename: Chen-Hsen
authors.initials: CH
authors.lastname: Lee
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000465:Algorithms; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D015984:Causality; D002761:Cholangitis / Q000150:complications; D003131:Combined Modality Therapy; D003663:Decision Trees; D004322:Drainage; D004618:Embolism, Air; D004638:Emergency Treatment / Q000379:methods; D004751:Enteritis / Q000150:complications; D005260:Female; D005414:Flatulence / Q000000981:diagnostic imaging* / Q000209:etiology / Q000628:therapy; D006503:Hepatic Veins; D006801:Humans; D007441:Intubation, Gastrointestinal; D007511:Ischemia / Q000150:complications; D008297:Male; D008487:Medical History Taking / Q000379:methods; D008641:Mesenteric Vascular Occlusion / Q000150:complications; D010538:Peritonitis / Q000150:complications; D010808:Physical Examination / Q000379:methods; D011006:Pneumatosis Cystoides Intestinalis / Q000150:complications; D011169:Portal Vein; D014057:Tomography, X-Ray Computed / Q000379:methods / Q000592:standards
chemical_list: D000900:Anti-Bacterial Agents