Sonographically Detected Hepatic Portal Venous Gas – Prevalence, Causes, and Clinical Implications

Abstract

Purpose Hepatic portal venous gas (HPVG) is a rare clinical finding, often caused by a severe underlying disease. In the literature as well as in clinical practice, HPVG is considered “signum malum” with a poor prognosis and bowel ischemia as the most common cause. Most studies are based on the results of computed tomography (CT) examinations. The aim of this retrospective study is to report on the prevalence, causes, and clinical course of HPVG in a monocentric cohort of abdominal ultrasound (US) investigations.

Materials and Methods The US database of an academic teaching hospital was searched with specific keywords (timespan 01/2000 to 12/2020). Reports, pictures, and clinical data of all cases with HPVG were re-evaluated.

Results Out of 134 804 US examinations, 8 HPVG cases were identified. There was a wide variety of underlying diseases, with mesenteric ischemia being seen in only 2 cases. 5 patients were discharged in stable condition, with 4 of them having undergone surgical treatment. 2 patients who had rejected further measures died, and one was lost to follow-up.

Discussion HPVG is a rare phenomenon in clinical US. However, ultrasonographic prevalence is comparable to the prevalence in CT studies. Underlying diseases are mostly severe, and in nearly all cases an underlying cause can be found by thorough investigation. In some cases, US may even be superior to CT scans for the detection of HPVG. Despite its rarity, every sonographer should know the typical sonographic presentation of HPVG, and appropriate images should be included in US teaching modules.

Zusammenfassung

Ziel Gas im hepatoportalen System (HPVG) ist ein seltener klinischer Befund, meist durch eine schwerwiegende Erkrankung hervorgerufen. Als häufigste Ursache gilt die mesenteriale Ischämie, weshalb das Phänomen als “Signum malum” mit schlechter Prognose beschrieben wird. Die meisten Studien basieren auf CT-gestützten Untersuchungen. In dieser retrospektiven Studie werden in einer monozentrischen Kohorte Prävalenz, Ursachen und klinische Implikationen von sonografisch diagnostiziertem HPVG untersucht.

Material und Methoden Die Sonografie-Datenbank eines Lehrkrankenhauses wurde mit definierten Stichworten auf die Diagnose von HPVG durchsucht (Zeitraum 01/2000 bis 12/2020). Befunde, Bilder und klinische Daten aller identifizierten Fälle wurden reevaluiert.

Ergebnisse Bei insgesamt 134 804 Ultraschalluntersuchungen konnten 8 Fälle von HPVG detektiert werden. Die zugrunde liegenden Erkrankungen differierten, eine mesenteriale Ischämie zeigte sich in nur 2 Fällen. 5 Patienten wurden in stabilem Allgemeinzustand nach Hause entlassen, 4 von ihnen waren zuvor operiert worden. 2 Patienten verstarben nach Ablehnung aller Interventionen, einer konnte nicht nachverfolgt werden.

Schlussfolgerungen HPVG ist ein selten beschriebener Befund in der klinischen Sonografie. Die Prävalenz ist vergleichbar zu CT-basierten Studien. Zugrunde liegende Erkrankungen sind häufig schwerwiegend; fast immer kann bei gründlicher Untersuchung eine Ursache gefunden werden. In einigen Fällen kann die Sonografie dem CT in der Detektion überlegen sein. Das typische Bild von HPVG sollte trotz seiner Seltenheit allen Ultraschalldiagnostikern bekannt sein und in die Sonografie-Ausbildung integriert werden.

Key words

ultrasound - retrospective study - hepatic portal venous gas

Publication History

Received: 06 July 2021

Accepted: 08 March 2022

Article published online:
28 April 2022

• References

• 1 Wolfe JN, Evans WA. Gas in the portal veins of the liver in infants; a roentgenographic demonstration with postmortem anatomical correlation. Am J Roentgenol 1955; 74 (03) 486-488
• 2 Liebman PR, Patten MT, Manny J. et al. Hepatic-portal venous gas in adults: etiology, pathophysiology and clinical significance. Ann Surg 1978; 187: 281-287 DOI: 10.1097/00000658-197803000-00012.
• 3 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: 1410-1414 DOI: 10.1001/archsurg.136.12.1410.
• 4 Abboud B, El Hachem J, Yazbeck T. et al. Hepatic portal venous gas: Physiopathology, etiology, prognosis and treatment. World J Gastroenterol 2009; 15 (29) 3585-3590 DOI: 10.3748/wjg.15.3585.
• 5 Koizumi C, Michihata N, Matsui H. et al. In-Hospital Mortality for Hepatic Portal Venous Gas: Analysis of 1590 Patients Using a Japanese National Inpatient Database. World J Surg 2018; 42 (03) 816-822 DOI: 10.1007/s00268-017-4189-y.
• 6 Liu C, Wu CH, Zheng XD. et al. Hepatic portal venous gas: A case report and analysis of 131 patients using PUBMED and MEDLINE database. Am J Emerg Med 2021; 45: 506-509 DOI: 10.1016/i.aiem.2020.06.085.
• 7 Shah PA, Cunningham SC, Morgan TA. et al. Hepatic gas: widening spectrum of causes detected at CT and US in the interventional era. Radiographics 2011; 31 (05) 1403-1413 DOI: 10.1148/rg.315095108.
• 8 Takahashi F, Tominaga K, Hiraishi H. Hepatic Portal Venous Gas Caused by Endoscopic Balloon Dilatation for Crohn's Stenosis. Clin Gastroenterol Hepatol 2016; 14 (12) A23-A24 DOI: 10.1016/j.cgh.2016.08.029.
• 9 Goto A, Tanaka Y, Suetsugu T. et al. Hepatic Portal Vein Gas during Chemotherapy for Esophageal Cancer-A Report of Four Cases. Gan To Kagaku Ryoho 2020; 47 (05) 823-825
• 10 Kim HJ, Kim HJ. Idiopathic Hepatic Portal Venous Gas in a Healthy Young Man. Int J Gen Med 2020; 13: 687-692 DOI: 10.2147/IJGM.S276438.
• 11 Schindera S, Triller J, Vock P. et al. Detection of hepatic portal venous gas: its clinical impact and outcome. Emerg Radiol 2006; 12 (04) 164-170 DOI: 10.1007/s10140-006-0467-y.
• 12 Metzler B, Blank W, Horn H. et al. Gas in the portal vein system of the liver. Value of ultrasound. Z Gastroenterol 1993; 31 (10) 617-620
• 13 Kaga M, Yamashita E, Ueda T. Ultrasound Detection of the Aquarium Sign at the Bedside. Eur J Case Rep Intern Med 2020; 7 (12) DOI: 10.12890/2020_002047.
• 14 Gonda M, Osuga T, Ikura Y. et al. Optimal treatment strategies for hepatic portal venous gas: A retrospective assessment. World J Gastroenterol 2020; 26 (14) 1628-1637 DOI: 10.3748/wjg.v26.i14.1628.
• 15 Fujii M, Yamashita S, Tanaka M. et al. Clinical features of patients with hepatic portal venous gas. BMC Surg 2020; 20 (01) 300 DOI: 10.1186/s12893-020-00973-8.
• 16 Seak CJ, Hsu KH, Wong YC. et al. The prognostic factors of adult patients with hepatic portal venous gas in the ED. Am J Emerg Med 2014; 32 (09) 972-975 DOI: 10.1016/j.ajem.2014.05.016.
• 17 Nelson AL, Milington TM, Sahani D. et al. Hepatic portal venous gas: the ABCs of management. Arch Surg 2009; 144 (06) 575-581 DOI: 10.1001/archsurg.2009.88.
• 18 Monneuse O, Pilleul F, Barth X. et al. Portal venous gas detected on computed tomography in emergency situations: surgery is still necessary. World J Surg 2007; 31 (05) 1065-1071 DOI: 10.1007/s00268-006-0589-0.
• 19 World Medical Association. World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. JAMA 2013; 310 (20) 2191-2194 DOI: 10.1001/jama.2013.281053.
• 20 Krüger AK, Schmidt C, Lock G. Portal venous gas – always an ominous sign?. Ultraschall in Med 2014; 35 (06) 495-496 DOI: 10.1055/s-0034-1366731.
• 21 Liang KW, Huang HH, Tyan YS. et al. Hepatic Portal Venous Gas: Review of Ultrasonographic Findings and the Use of the “Meteor Shower” Sign to Diagnose It. Ultrasound Q 2018; 34 (04) 268-271 DOI: 10.1097/RUQ.0000000000000376.
• 22 Pan HB, Huang JS, Yang TL. et al. Hepatic portal venous gas in ultrasonogram – benign or noxious. Ultrasound Med Biol 2007; 33 (08) 1179-1183 DOI: 10.1016/j.ultrasmedbio.2007.01.014.
• 23 Lafortune M, Trinh BC, Burns PN. et al. Air in the portal vein: sonographic and Doppler manifestations. Radiology 1991; 180: 667-670 DOI: 10.1148/radiology.180.3.1871276.
• 24 Khalil PN, Huber-Wagner S, Ladurner R. et al. Natural history, clinical pattern, and surgical considerations of pneumatosis intestinalis. Eur J Med Res 2019; 14 (06) 231-239 DOI: 10.1186/2047-783x-14-6-231.
• 25 Treyaus MO, Duran R, Zins M. et al. Clinical significance of pneumatosis intestinalis-correlations of MDCT-findings with treatment and outcome. Eur Radiol 2017; 27 (01) 70-79 DOI: 10.1007/s00330-016-4348-9.
• 26 Heye T, Bernhard M, Mehrabi A. Portomesenteric venous gas: is gas distribution linked to etiology and outcome?. Eur J Radiol 2012; 81 (12) 3862-3869 DOI: 10.1016/j.ejrad.2012.07.017.
• 27 Moussa M, Marzok I, Abelmouda K. et al. Role of Computed tomography in predicting prognosis of Hepatic portal venous gas. Int J Surg Case Rep 2017; 30: 177-182 DOI: 10.1016/i.iiscr.2016.11.055.
• 28 Safioleas MC, Moulakakis KG, Papavassiliou VG. Acute mesenteric ischaemia, a highly lethal disease with a devastating outcome. Vasa 2006; 35 (02) 106-111 DOI: 10.1024/0301-1526.35.2.106.
• 29 Capolupo GT, Mascianà G, Carannante F. et al. Hepatic portal venous gas after colonoscopy: A case report and review. Int J Surg Case Rep 2018; 51: 54-57 DOI: 10.1016/j.ijscr.2018.06.041.