Korean J Hepatobiliary Pancreat Surg.  2015 Nov;19(4):181-187. 10.14701/kjhbps.2015.19.4.181.

Clinical outcomes in surgical and non-surgical management of hepatic portal venous gas

• Yoo SK
• Park JH
• Kwon SH

• KMID: 2130971
• DOI: http://doi.org/10.14701/kjhbps.2015.19.4.181

Abstract

BACKGROUNDS/AIMS
Hepatic portal venous gas (HPVG) is a rare condition, with poor prognosis and a mortality rate of up to 75%. Indications for surgical and non-surgical management of HPVG including associated complications and mortality remain to be clarified.
METHODS
From January 2008 to December 2014, 18 patients with HPVG diagnosed through abdominal computed tomography (CT) imaging were retrospectively identified. Clinical symptoms, laboratory data, underlying diseases, treatment, and mortality rate were analyzed. Patients were classified into 2 groups: surgical management recommended (SR, n=10) and conservative management (CM, n=8). The SR group was further subdivided into patients who underwent surgical management (SM-SR, n=5) and those who were managed conservatively (NS-SR, n=5).
RESULTS
Conditions underlying HPVG included mesenteric ischemia (38.9%), intestinal obstruction (22.2%), enteritis (22.2%), duodenal ulcer perforation (5.6%), necrotizing pancreatitis (5.6%), and diverticulitis (5.6%). In terms of mortality, 2 patients (40%) died in the SM-SR group, 1 (12.5%) in the CM group, and 100% in the NS-SR group. Higher scores from Acute Physiology and Chronic Health Evaluation (APACHE) II predicted the mortality rates of the NS-SR and CM groups.
CONCLUSIONS
Identification of HPVG requires careful consideration for surgical management. If surgical management is indicated, prompt laparotomy should be performed. However, even in the non-surgical management condition, aggressive laparotomy can improve survival rates for patients with high APACHE II scores.

Keyword

Portal venous gas; Pneumatosis intestinalis; Mesenteric ischemia; Computed tomography; APACHE II

MeSH Terms

APACHE
Diverticulitis
Duodenal Ulcer
Enteritis
Humans
Intestinal Obstruction
Ischemia
Laparotomy
Mortality
Pancreatitis
Prognosis
Retrospective Studies
Survival Rate

Figure

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  Fig. 1 Allocation of the 18 patients for the primary analysis based on need for surgery and treatment method. SR, Surgical recommended; CM, Conservative management; SM-SR, Surgical management - Surgical recommended; NS-SR, Non-surgical management - Surgical recommended.

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  Fig. 2 Portomesenteric venous gas at different anatomical locations in various patients. Computed tomography reveals massive hepatic portal venous gas (A: arrow) and main portal venous gas (B: arrow), superior mesenteric venous gas (C: arrow), mesenteric venous branch gas (C: arrow head), and pneumatosis intestinalis (D: arrow).

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  Fig. 3 A 77-year-old man with superior mesenteric artery occlusion underwent ascending colon and small bowel resection and loop ileostomy. Before operation, computed tomography demonstrates hepatic portal venous gas (A: arrow), pneumatosis intestinalis (B: arrow head). Computed tomography performed at postoperative day 12 shows absence of hepatic portal venous gas (C and D).

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  Fig. 4 An 81-year-old woman with small bowel enteritis underwent medical management. Before treatment, computed tomography shows hepatic portal venous gas (A: arrow), main portal venous gas (A: arrow head), and pneumatosis intestinalis (B: dashed arrow). Computed tomography performed at day 3 of medical treatment shows radiologic improvement (C and D).

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