Buscar en
Gastroenterología y Hepatología (English Edition)
Toda la web
Inicio Gastroenterología y Hepatología (English Edition) Spontaneous hepatic portal venous gas in a patient with ulcerative colitis. A ca...
Journal Information
Vol. 43. Issue 1.
Pages 22-25 (January 2020)
Share
Share
Download PDF
More article options
Visits
177
Vol. 43. Issue 1.
Pages 22-25 (January 2020)
Scientific letter
Full text access
Spontaneous hepatic portal venous gas in a patient with ulcerative colitis. A case report and a review
Gas venoso portal hepático espontáneo en un paciente con colitis ulcerosa. Reporte de un caso y revisión
Visits
...
Marianette Murzia, Jordi Gordilloa,
Corresponding author
jgordillo@santpau.cat

Corresponding author.
, Elida Oblitasa, German Sorianoa,b, Juan Carlos Pernasc, Margarita Possod, Esther Garcia-Planellaa
a Gastroenterology and Hepatology Unit. Hospital de la Santa Creu i Sant Pau (IIB Sant Pau), Barcelona, Catalonia, Spain
b Centro de Investigaciones Biomédicas en Red en Enfermedades Hepáticas y Digestivas (CIBEREHD), Instituto de Salud Carlos III, Madrid, Spain
c Radiology Department, Abdominal Section. Hospital de la Santa Creu i Sant Pau (IIB Sant Pau), Barcelona, Catalonia, Spain
d Service of Clinical Epidemiology and Public Health, Hospital de la Santa Creu i Sant Pau (IIB Sant Pau), Barcelona, Spain
Article information
Full Text
Bibliography
Download PDF
Statistics
Figures (1)
Tables (1)
Table 1. Cases of hepatic portal venous gas in ulcerative colitis.
Full Text

Hepatic portal venous gas (HPVG) has been defined as the presence of gas/air in the portal venous system. It has been traditionally associated with ischemic bowel processes, and has been considered as an ominous finding with a mortality rate up to 75%.1

HPVG has been described in patients with inflammatory bowel disease (IBD), mostly in Crohn's Disease (CD).2,3 We present a case of HPVG and a literature review of the reported cases of HPVG in ulcerative colitis (UC).

A 45-year-old-woman was diagnosed with left-sided UC 15 years ago. She started treatment with azathioprine after a steroid-dependent flare-up in 2010, adding infliximab in 2012 due to the persistence of UC activity.

In October 2014, the patient was admitted in our emergency care unit presenting acute severe abdominal pain referred to epigastrium, nausea, tachycardia and fever (39.3°C). She did not report evidence of clinical UC activity in recent months. In serial blood samples an increase in inflammatory markers (C-reactive protein [CRP], up to 63mg/L from normal values within the first 24h) was observed. Simple chest and abdominal X-rays showed no relevant findings. An abdominal computed tomography (CT) was performed, and HPVG was observed in the left lobe of the liver (Fig. 1). Other intra-abdominal complications were ruled out and inflammatory changes in the rectum and sigma were observed, suggesting active UC. Immediately afterwards, a rectosigmoidoscopy was performed in which continuous mucosal damage with moderate inflammation up to 40cm from the anal verge was identified.

Figure 1.

Computed tomography (CT)-scan images at diagnosis of HPVG. (a) Axial reconstruction. (b) Coronal reconstruction. Portal vein gas is predominantly located within the left hepatic lobe in both CT-scan images. Air bubbles appear to extend within 2cm of the liver capsule.

(0.05MB).

The patient was admitted in our department for conservative management. Endovenous antibiotics (metronidazole plus ceftriaxone) and steroids (metyl-prednisolone 1mg/kg daily) were initiated. Both azathioprine and infliximab treatment were discontinued.

The patient promptly reported feeling better and remained afebrile. Subsequent blood samples showed a progressive decrease of CRP (6.8mg/L at discharge). Urine and blood cultures, as well as stool samples studies, were negative. At the 7th day of admission, a control CT-scan was performed, with complete HPVG resolution. Thereafter, endovenous steroids were changed for oral steroids. The patient remained in our unit for a total of 10 days and at the time she was discharged, antibiotics were stopped.

Liebman1 reported 64 HPVG patients in which up to 72% cases were associated with bowel necrosis, with a global mortality rate of 75%, advocating for an aggressive management and urgent surgical exploration once this condition was diagnosed. More recently, an updated review of 182 patients with HPVG reported an overall mortality rate of 39%.2 Other apparently more benign conditions, such as gastric ulcer, complications of endoscopic procedures and IBD, were associated with HPVG.2 Some of these conditions reacted favorably to conservative management, suggesting that HPVG itself is not a predictor of poor outcome.1,2,4,5

Abdominal ultrasound and CT-scan are the radiological modalities used nowadays to diagnose HPVG.3,5 The classical appearance of this entity is that of branching lucencies within 2cm of the liver capsule, predominantly in the left lobe, which differs from biliary gas because the latter is associated with air within the central portion of the liver1–5 (Fig. 1).

The pathogenesis of HPVG could be explained as follows: (1) the passage of intraluminal air or gas-forming bacteria into the portomesenteric venous system due to mucosal disruption (2) increased bowel pressure that leads to bowel distension with mucosal disruption, described mainly in iatrogenic procedures such as colonoscopies and barium enemas; (3) the existence of abdominal infections.1,5

It seems that mucosal damage, as well as bowel distension secondary to increased bowel pressure in the setting of diagnostic studies, are the main factors that lead to the occurrence of HPVG in IBD patients.1,2,4,5

With the present case, only 18 cases of HPVG in patients with UC have been described in the English literature to date (Table 1).1,6,7–21 Sixty one percent of cases were found after a barium enema or a colonoscopy. The majority of cases (88%) were managed conservatively. The mortality rate was 5% (one out of 18 patients), although it seems that in this case the fatal outcome was due to a complications occurred after an emergency surgery in the setting of fulminant colitis.16

Table 1.

Cases of hepatic portal venous gas in ulcerative colitis.

Author  Gender  Age  UC extent  Years of UC  Prior procedure  Clinical features  Clinical UC activity  Diagnostic modality  Mucosal damage  Treatment  Outcome 
Lazar et al.6  Male  48  Extensive  UK (1–3)  BE  Abdominal painFeverEmesis  Flare  X-ray (plus perforation)  Yes  ATBsSulfathalidinePrednisone  Recovery 
Weinstein et al.11  Male  35  UK  BE  MalaiseChills FeverTenderness  Remission  X-ray  Yes  ATBs  Recovery 
Speer et al.12  Male  79  Left-sideda  10  None  Abdominal painLow fever  Remission  X-ray  Yes  ATBs (as an outpatient)  Recovery 
Kees et al.9  Female  44  Extensive  1-BE2-BE  Low feverMild TC  1-Flare2-Remission  X-ray  1-Yes2-Yes  Sulfasalazine, ATBs  1-Recovery2-Recovery 
Liebman et al.1  Male  23  UK  UK  BE  LightheadedShaking chill  Remission  X-ray  Yes  ATBs  Recovery 
Christensen et al.8  Male  71  Left-sideda  BE  Mild stomach ache  Remission  X-ray  No  None  Recovery 
Haber13  Female  45  Left-sided  RSC  Fever  Flare  X-ray  Yes  ATBsNG aspiration  Recovery 
Birnberg et al.14  Female  24  UK  BE  Low fever  Remission  X-ray  Yes  ATBs  Recovery 
Moss et al.15  Male  39  Extensive  <1  BE  Tenderness  Flare  X-Ray (plus perforation)  Yes  ATBsSurgery (subtotal colectomy)  Recovery 
See et al.16  Female  53  UK  UK  Total colectomy due to fulminant colitis  Multiple organ failure  –  CT-scan  –  ATBs  Death 
Bull et al.7  Female  60  Extensive  BE  None  Flare  X-ray  Yes  None  Recoveryb 
Paran et al.10  Male  51  UK  UK  None  Abdominal painBloodless diarrhea  Flare  CT-scan  Yes  Parenteral NutritionATBs  Recovery 
Shah et al.17  Male  22  Extensive  UK  Total colectomy due to refractory UC  Abdominal painTachycardiaHypotension  –  CT-scan  Parenteral NutritionATBs  Recovery 
Shinagawa et al.18  Male  18  Extensive  <1  Colonoscopy  Fever  Flare  CT-scan  Yes  ATBs  Recovery 
Bamba et al.19  Male  54  Extensive  2.5  Colonoscopy  None  Flare  X-ray  Yes  Food deprivation  Recovery 
Tanaka et al.20  Female  87  UK  22  None  DiarrheaAbdomnial painVomiting  Flare  CT-scan  Yes  ATBs  Recovery 
Fukita et al.21  Male  40  UK  None  HematocheziaAbdominal painFeber  Flare  CT-scan  Yes  ATBs  Recovery 
Present case  Female  45  Left-sided  15  None  Abdominal pain Fever  Remission  CT-scan  Yes  ATBsPrednisolone  Recovery 

ATBs, Antibiotics; BE, Barium Enema; CT-scan, Computer Tomography-scan; NG, Naso-gastric; RSC, Rectoscopy; TC, Tachycardia; UC, Ulcerative Colitis; UK, Unknown, X-ray: plain film abdominal radiography.

a

Minimum known extension.

b

Panproctocolectomy due to UC flare nine days after admission.

Therefore, it seems that the management and treatment of HPVG has to be addressed to the underlying disease, which will determine the prognosis of the patients.

Author contributions

Murzi M, Oblitas E, Garcia-Planella E and Gordillo J designed the case report; Posso M provided advice on performing the systematic review and searched in the databases; Murzi M and Gordillo J screened the articles and selected the full texts; Murzi M wrote the paper; Soriano G, Gordillo J, Pernas JC and Garcia-Planella E provided clinical advice; Soriano G, Gordillo J and Garcia-Planella E revised the paper. All authors contributed and approved the last version of the manuscript.

Funding

No funding was provided for this manuscript.

Conflict of interest

The authors declare that they have no conflict of interest.

Acknowledgments

The authors would like to thanks German Soriano and David Bridgewater for the help with the translation of the present manuscript.

References
[1]
P.R. Liebman, M.T. Patten, J. Manny, J.R. Benfield, H.B. Hechtman.
Hepatic – portal venous gas in adults: etiology, pathophysiology and clinical significance.
Ann Surg, 187 (1978), pp. 281-287
[2]
H. Kinoshita, M. Shinozaki, H. Tanimura, Y. Umemoto, S. Sakaguchi, K. Takifuji, et al.
Clinical features and management of hepatic portal venous gas: four case reports and cumulative review of the literature.
Arch Surg, 136 (2001), pp. 1410-1414
[3]
A.L. Nelson, T.M. Millington, D. Sahani, R.T. Chung, C. Bauer, M. Hertl, et al.
Hepatic portal venous gas: the ABCs of management.
Arch Surg, 144 (2009), pp. 575-581
[4]
S.S.M. Ng, R.Y.C. Yiu, J.F.Y. Lee, J.C.M. Li, K.L. Leung.
Portal venous gas and thrombosis in a Chinese patient with fulminant Crohn's colitis: a case report with literature review.
World J Gastroenterol, 12 (2006), pp. 5582-5586
[5]
S. Alqahtani, C.S. Coffin, K. Burak, F. Chen, J. MacGregor, P. Beck.
Hepatic portal venous gas: a report of two cases and a review of the epidemiology, pathogenesis, diagnosis and approach to management.
Can J Gastroenterol, 21 (2007), pp. 309-313
[6]
H.P. Lazar.
Survival following portal venous air embolization: report of a case.
Am J Dig Dis, 10 (1965), pp. 259-264
[7]
M.J. Bull, B. Kaye.
Portal vein gas following double-contrast barium enema.
Br J Radiol, 58 (1985), pp. 1129-1130
[8]
M.A. Christensen, C.H. Lu.
Gas in the portal vein after air-contrast barium enema in a patient with inflammatory colitis.
South Med J, 75 (1982), pp. 1291-1292
[9]
C.J. Kees, C.L. Hester Jr..
Portal vein gas following barium enema examination.
Radiology, 102 (1972), pp. 525-526
[10]
H. Paran, T. Epstein, M. Gutman, M. Shapiro Feinberg, R. Zissin.
Mesenteric and portal vein gas: computerized tomography findings and clinical significance.
Dig Surg, 20 (2003), pp. 127-132
[11]
G.E. Weinstein, M. Weiner, M. Schwartz.
Portal vein gas.
Am J Gastroenterol, 49 (1968), pp. 425-429
[12]
C.S. Speer, D.H. Carlson.
Portal venous air with survival in ulcerative colitis: report of a case.
Dis Colon Rectum, 15 (1972), pp. 453-458
[13]
I. Haber.
Hepatic portal vein gas following colonoscopy in ulcerative colitis: report of a case.
Acta Gastroenterol Belg, 46 (1983), pp. 14-17
[14]
F.A. Birnberg, R.M. Gore, B. Shragg, A.R. Margulis.
Hepatic portal venous gas: a benign finding in a patient with ulcerative colitis.
J Clin Gastroenterol, 5 (1983), pp. 89-91
[15]
M.L. Moss, J.T. Mazzeo.
Pneumoperitoneum and portal venous air after barium enema.
Va Med Q, 118 (1991), pp. 233-235
[16]
C. See, D. Elliott.
Images in clinical medicine. Pneumatosis intestinalis and portal venous gas.
N Engl J Med, 350 (2004),
[17]
A. Shah, H.A. Furajii, R.A. Cahill.
Symptomatic pneumatosis intestinalis (including portal venous gas) after laparoscopic total colectomy.
World J Gastrointest Endosc, 6 (2014), pp. 564-567
[18]
T. Shinagawa, K. Hata, T. Watanabe.
Hepatic portal venous gas after colonoscopy for ulcerative colitis: a case report.
J Crohns Colitis, 9 (2015), pp. 1058-1059
[19]
S. Bamba, T. Tsujikawa, T. Saotome, T. Okuno, Y. Saito, M. Sasaki, et al.
Pneumatosis coli with ulcerative colitis as a rare complication of colonoscopy.
Clin J Gastroenterol, 3 (2010), pp. 233-236
[20]
H. Tanaka, T. Watanabe, T. Nagai, K. Minaga, K. Kamata, Y. Komeda, et al.
Hepatic portal venous gas associated with Klebsiella oxytoca infection in the absence of preceding antibiotic treatment.
Clin J Gastroenterol, (2019 Feb 9),
[21]
Y. Fukita, H. Ishibashi, M. Toyomizu, S. Adachi, T. Asaki, T. Takeda, et al.
A case of Staphylococcus aureus colitis presenting with hepatic portal venous gas and pneumatosis cystoides intestinalis at onset.
Gastroenterol Endosc, 58 (2016), pp. 2182-2190
Copyright © 2019. Elsevier España, S.L.U.. All rights reserved
Article options
Tools
es en pt

¿Es usted profesional sanitario apto para prescribir o dispensar medicamentos?

Are you a health professional able to prescribe or dispense drugs?

Você é um profissional de saúde habilitado a prescrever ou dispensar medicamentos