SESSION TITLE: Critical Care Student/Resident Case Report Posters III
SESSION TYPE: Medical Student/Resident Case Report
PRESENTED ON: Tuesday, October 29, 2013 at 01:30 PM - 02:30 PM
INTRODUCTION: Hepatic portal venous gas (HPVG) is a rare, but potentially serious finding that has been noted on Computerized Tomography. We are reporting a case where HPVG on chest CT was a preliminary diagnostic clue to the intra-abdominal etiology of the patient’s disease.
CASE PRESENTATION: A 55-year-old Caucasian male with a history of stage IV squamous cell cancer of the head and neck was admitted with progressive diffuse abdominal pain and anorexia for 3 days. His examination revealed mild abdominal tenderness, diminished bowel sounds, and mild hypoxemia. The patient’s condition deteriorated rapidly after admission and he developed acute respiratory failure and circulatory collapse, requiring intubation, mechanical ventilation and aggressive fluid resuscitation. Chest X ray was unremarkable. A spiral chest CT revealed no evidence of pulmonary embolism, but showed an incidental finding of air in the hepatic portal system (Figure 1). The following day, he developed increasing right lower quadrant abdominal pain and hematochezia. Abdominal CT scan was obtained, which revealed air in the wall of the ascending colon, consistent with ischemic colitis (Figure 2). The patient was found to have Pneumatosis Intestinalis with HPVG, requiring emergent right hemi-colectomy with primary anastomosis. He was discharged in good condition one week later.
DISCUSSION: HPVG occurs when gas is noted in the portal system tracking towards the liver (1). Although initially believed to be solely associated with serious intra-abdominal pathology, such as mesenteric ischemia, ulcerative colitis, intra-abdominal abscess, and gastric ulcers, many benign associations have been described as well (1). The pathophysiology of HPVG has been attributed to defects in the mucosa secondary to mechanical breaks vs. entry and gas production by bacteria. There is no consensus on immediate management, although Wayne et. Al proposed an algorithm for PI and HPVG to identify subgroups of patients who require direct surgical intervention. The algorithm first identifies patients who are critically unstable and require resuscitation and immediate surgical intervention, and then differentiates based on radiographic findings of mechanical disease, history of GI trauma and vascular disease score to drive the decision between observation, exploratory laparotomy and minimally invasive surgical strategies (1).
CONCLUSIONS: Findings of HPVG should necessitate further evaluation and clinical assessment to determine the etiology and rule out life threatening causes. Early and aggressive treatment in appropriate cases may improve outcomes and reduce mortality.
Reference #1: Wayne E, Ough M, Wu A, Liao J, Andresen K, Kuchn D, Wilkinson N. Management Algorithm for Pneumatosis Intestinalis and Portal Venous Gas: Treatment and Outcome of 88 Consecutive Cases. J Gastrointest Surg 2010; 437-48
DISCLOSURE: The following authors have nothing to disclose: Shilpi Bajaj, Maher Tabba
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