Scholarly article on topic 'Hepatic Portal Venous Gas in a COPD Patient'

Hepatic Portal Venous Gas in a COPD Patient Academic research paper on "Clinical medicine"

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Journal of Medical Ultrasound
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Keywords
{"chronic obstructive pulmonary disease (COPD)" / "hepatic portal venous gas (HPVG)"}

Abstract of research paper on Clinical medicine, author of scientific article — Mei-Fwa Wong, Wan-Ching Lien

Although hepatic portal venous gas (HPVG) is usually associated with a grave prognosis, favorable outcomes have been reported in some conditions. A rare case demonstrates the transient occurrence of HPVG in a patient with aerophagia when chronic obstructive pulmonary disease (COPD) occurred, and disappearance after symptoms resolved. The patient's recovery was uneventful and he did not suffer from any abdominal catastrophe. These findings may support the mechanical theory for the occurrence of benign HPVG.

Academic research paper on topic "Hepatic Portal Venous Gas in a COPD Patient"

Journal of Medical Ultrasound (2013) xx, 1-4

Available online at www.sciencedirect.com

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journal homepage: www.jmu-online.com

CASE REPORT

Hepatic Portal Venous Gas in a COPD Patient

Mei-Fwa Wong 1, Wan-Ching Lien 2*

1 Department of Emergency Medicine, Far Eastern Memorial Hospital, New Taipei City, Taiwan, and

2 Department of Emergency Medicine, National Taiwan University and National Taiwan University Hospital, Taipei, Taiwan

Received 29 January, 2013; accepted 29 March, 2013

KEY WORDS

chronic obstructive pulmonary disease (COPD), hepatic portal venous gas(HPVG)

Although hepatic portal venous gas (HPVG) is usually associated with a grave prognosis, favorable outcomes have been reported in some conditions. A rare case demonstrates the transient occurrence of HPVG in a patient with aerophagia when chronic obstructive pulmonary disease (COPD) occurred, and disappearance after symptoms resolved. The patient's recovery was uneventful and he did not suffer from any abdominal catastrophe. These findings may support the mechanical theory for the occurrence of benign HPVG.

© 2013, Elsevier Taiwan LLC and the Chinese Taipei Society of Ultrasound in Medicine. All rights reserved.

Introduction

Hepatic portal venous gas (HPVG) was first reported in six infants with necrotizing enterocolitis in 1955 [1]. There were more than 1,000 cases in the literature, and the condition was considered to be associated with a high mortality rate (approximately 75%) [2]. Therefore, emergent surgical intervention is required in most patients with HPVG. However, HPVG has occurred during procedures such as nasogastric tube insertion, barium enema, and colofi-broscopy [3—5]. We report a case of HPVG that was found

* Correspondence to: Dr Wan-Ching Lien, Department of Emergency Medicine, National Taiwan University and National Taiwan University Hospital, Taipei, Taiwan.

E-mail address: wanchinglien@ntu.edu.tw (W.-C. Lien).

during chronic obstructive pulmonary disease (COPD) exacerbation. HPVG spontaneously disappeared within 24 hours after the patient's dyspnea resolved.

Case report

A 70-year-old man who had a medical history of COPD without regular control visited our emergency department because of shortness of breath and mild abdominal distention for 1 day. There was no fever, abdominal pain, vomiting, or change in bowel habits. The patient's vital signs upon arrival to the emergency department were: body temperature 36.5 °C, heart rate 106 beats/minute, respiratory rate 24 breaths/minute, and blood pressure 172/ 100 mmHg. The patient was dyspneic with oral breathing. His initial physical examination was unremarkable except for wheezing over bilateral lung fields. A chest X-ray

0929-6441/$36 © 2013, Elsevier Taiwan LLC and the Chinese Taipei Society of Ultrasound in Medicine. All rights reserved. http://dx.doi.Org/10.1016/j.jmu.2013.10.002

M.-F. Wong, W.-C. Lien

Fig. 1 Abdominal echogram reveals poorly defined, echogenic patches within the hepatic parenchyma, especially in the nondependent part, suggestive of hepatic portal venous gas.

revealed no evidence of pulmonary infiltrates. An abdominal radiograph showed an air-fluid level suggestive of ileus. Bronchodilator and steroid were given for the patient's acute exacerbation of COPD. The laboratory data disclosed no leukocytosis (8820/ml).

Abdominal echogram revealed multiple hyperechoic dots moving within the portal vein system and poorly defined, echogenic patches within the hepatic parenchyma, especially in the nondependent part, suggestive of HPVG (Fig. 1). Abdominal computed tomography (CT), performed to rule out ischemic bowel, showed marked air in the intrahepatic portal vein (Fig. 2) and the superior

mesenteric vein (Fig. 3), without bowel obstruction or ischemia.

The patient's symptoms were relieved soon after treatment. Follow-up abdominal echogram within 24 hours

Fig. 2 Abdominal computed tomography showing air in the intrahepatic portal vein (arrow).

Fig. 3 Abdominal computed tomography showing air in the superior mesenteric vein (arrow).

Hepatic Portal Venous Gas in a COPD Patient

Fig. 4 (A) Abdominal echogram showing the presence of hepatic portal venous gas. (B) Follow-up echogram within 24 hours revealed disappearance of hepatic portal vein gas.

revealed the disappearance of HPVG (Fig. 4). He was discharged 3 days after arrival to the emergency department. No bacteria grew from the blood cultures.

Discussion

Although HPVG is usually considered an ominous sign, various conditions can cause HPVG, including digestive tract dilatation, gastric ulcer, ulcerative colitis, Crohn's disease, and complications of endoscopic procedures [3,6-15].

Two possible mechanisms of the occurrence of HPVG were proposed: gas transmigration through the bowel lumen due to the increased intraluminal pressure, and sepsis caused by gas-producing bacteria [2]. In the current case, no bowel ischemia was detected by imaging modalities. The absence of bacterial growth from the blood culture did not support the bacterial hypothesis in this case. The patient's shortness of breath and dyspnea (causing more gas to be ingested into the gastrointestinal tract) and bowel distention, along with mucosal tears (allowing the entry of air into the intramural part of bowel that later migrated into portal circulation), may have contributed to the development of HPVG [16].

Although HPVG may be diagnosed by conventional abdominal radiography, it is often overlooked [17]. However, with the advances of imaging modalities, the diagnosis of HPVG can be made even when the amount of accumulated gas is small [18]. The characteristic sonographic findings of HPVG are highly echogenic particles, flowing within the portal vein; or poorly defined, highly echogenic patches within the hepatic parenchyma, which are most apparent in the nondependent part [19]. HPVG is characteristically associated with peripheral gas lucencies on CT scans. Additionally, a CT scan can disclose gas in the bowel wall (pneumatosis intestinalis) and in the extrahe-patic portal vein or its splanchnic vasculature [17]. In our case, HPVG was initially detected by ultrasound and confirmed by CT. In addition, no bowel ischemia was found by CT.

Although HPVG is usually considered to be related to poor prognosis, favorable outcomes were reported in some conditions [3,6-15]. The patient had an uneventful recovery and did not suffer from any abdominal catastrophe.

This rare case demonstrates the occurrence of HPVG in a

patient with COPD exacerbation. It may support the mechanical theory for the occurrence of HPVG.

References

[1] Wolfe JN, Evans WA. Gas in the portal vein of the liver in infant. AJR Am J Roentgenol Radium Ther Nucl Med 1955;74: 486-9.

[2] Liebman PR, Patten MT, Manny J, et al. Hepatic-portal venous gas in adults: etiology, pathophysiology and clinical significance. Ann Surg 1978;187:281-7.

[3] Schulze CG, Blum U, Haag K. Hepatic portal venous gas: imaging modalities and clinical significance. Acta Radiol 1995;36: 377-80.

[4] Stein MG, Crues JV, Hamlin JA. Portal venous air associated with barium enema. Am J Roentgenol 1983;140:1171-2.

[5] Venkatesh B, Tesar P. Hepatic portal venous gas in a critically ill patient. Anesth Intensive Care 1998;26:575-8.

[6] Benson MD. Adult survival with intrahepatic portal venous gas secondary to acute gastric dilatation, with a review of portal venous gas. Clin Radiol 1985;36:441-3.

[7] Haswell DM, Carsky EW. Hepatic portal venous gas and gastric emphysema with survival. AJR Am J Roentgenol 1979;133: 1183-5.

[8] Chang YS, Wang HP, Huang GT, et al. Sonographic "gastric corona sign": diagnosis of gastric pneumatosis caused by a penetrating gastric ulcer. J Clin Ultrasound 1999;27: 409-12.

[9] Bodewes HW, Puylaert JB. Ultrasound in detection of portal venous gas in adults. Gastrointest Radiol 1991;16:35-7.

[10] Birnberg FA, Gore RM, Shragg B, et al. Hepatic portal venous gas: a benign finding in a patient with ulcerative colitis. J Clin Gastroenterol 1983;5:89-91.

[11] Al-Jahdali H, Pon C, Thompson WG, et al. Non-fatal portal pyaemia complicating Crohn's disease of the terminal ileum. Gut 1994;35:560-1.

[12] Gosink BB. Intrahepatic gas: differential diagnosis. Am J Roentgenol 1981;137:763-7.

[13] Nguyen HN, Purucker E, Riehl J, et al. Hepatic portal venous gas following emergency endoscopic sclerotherapy of gastric varices. Hepatogastroenterology 1998;45:1767-9.

[14] Pfaffenbach B, Wegener M, Bohmeke T. Hepatic portal venous gas after transgastric EUS-guided fine-needle aspiration of an accessory spleen. Gastrointest Endosc 1996;43:515-8.

[15] Herman JB, Levine MS, Long WB. Portal venous gas as a complication of ERCP and endoscopic sphincterotomy. Am J Gastroenterol 1995;90:828-9.

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[16] Radin DR, Rosen RS, Halls JM. Acute gastric dilatation: a rare cause of portal venous gas. AJR Am J Roentgenol 1987;148: 279-80.

[17] Abboud B, El Hachem J, Yazbeck T, et al. Hepatic portal venous gas: physiopathology, etiology, prognosis and treatment. World J Gastroenterol 2009;15:3585-90.

M.-F. Wong, W.-C. Lien

[18] Fukumori D, Sasaki T, Matsumoto H, et al. Necrotizing enteritis with hepatic portal venous gas and pneumatosis intestinalis: report of a case. Eur J Gastroenterol Hepatol 2003;15:201-3.

[19] Pan HB, Huang JS, Yang TL, et al. Hepatic portal venous gas in ultrasonogram-benign or noxious. Ultrasound Med Biol 2007; 33:1179-83.