EDUCATION Charles D. Collard, M.D., Editor Alan Jay Schwartz, M.D., M.S. Ed., Associate Editor
Images in Anesthesiology: Massive Hepatic Parenchymal and Portal Venous Gas David W. Barbara, M.D., Stephen M. Broski, M.D., Benjamin C. Smith, M.D., Thomas B. Comfere, M.D.
H
EPATIC portal venous gas (HPVG) may result from a variety of etiologies including mesenteric ischemia (43%), intraabdominal infection or malignancy (16%), inflammatory bowel disease (8%), gastroenteric ulcers (4%), necrotizing pancreatitis (2%), benign pneumatosis intestinalis, and following procedures or operations.1,2 HPVG has an overall mortality of 39%, but this varies by cause, ranging from 0% for postprocedural origins to 75% when associated with necrotic bowel.2 Computerized tomography (CT), ultrasound, and conventional radiography may be used to diagnose HPVG.3 On CT, HPVG presents as a branching area of low attenuation extending to within 2 cm of the liver capsule (fig. A), in contrast to pneumobilia, which is typically more central.3 Rarely, confluent hepatic parenchymal gas may occur in severe cases of HPVG (fig. B, arrows indicate HPVG) and portends a high mortality if present. Treatment for HPVG is based on underlying etiology and includes operative management in 51% of cases.2 It follows that anesthesiologists may care for patients with HPVG in providing anesthesia for urgent/emergent surgeries or outside the operating room under nonoperative circumstances. This patient presented very late with widely metastatic adenocarcinoma and bowel ischemia resulting in a lactate of more than 40 mmol/l (normal, 0.6 to 2.3 mmol/l), HPVG, and hepatic parenchymal gas as demonstrated on the axial contrast-enhanced CT images in the figure and in the video (Supplemental Digital Content 1, http://links.lww.com/ALN/ B173). Although HPVG may be benign, its presence in this patient’s clinical context carries a very high mortality. Recognition of the often grave prognosis associated with these imaging findings may allow for initiation of end-of-life discussions with patients and families and facilitates transition to comfort care, as was elected in this case after review of the imaging.
Acknowledgments Support was provided solely from institutional and/or departmental sources.
Competing Interests The authors declare no competing interests.
Correspondence Address correspondence to Dr. Barbara: [email protected]
References 1. Alqahtani S, Coffin CS, Burak K, Chen F, MacGregor J, Beck P: Hepatic portal venous gas: A report of two cases and a review of the epidemiology, pathogenesis, diagnosis and approach to management. Can J Gastroenterol 2007; 21:309–13 2. Kinoshita H, Shinozaki M, Tanimura H, Umemoto Y, Sakaguchi S, Takifuji K, Kawasaki S, Hayashi H, Yamaue H: Clinical features and management of hepatic portal venous gas: Four case reports and cumulative review of the literature. Arch Surg 2001; 136:1410–4 3. Sebastià C, Quiroga S, Espin E, Boyé R, Alvarez-Castells A, Armengol M: Portomesenteric vein gas: Pathologic mechanisms, CT findings, and prognosis. Radiographics 2000; 20:1213–24; discussion 1224–6 Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are available in both the HTML and PDF versions of this article. Links to the digital files are provided in the HTML text of this article on the Journal’s Web site (www.anesthesiology.org). From the Departments of Anesthesiology (D.W.B., T.B.C.) and Radiology (S.M.B., B.C.S.), Mayo Clinic College of Medicine, Rochester, Minnesota. Copyright © 2015, the American Society of Anesthesiologists, Inc. Wolters Kluwer Health, Inc. All Rights Reserved. Anesthesiology 2016; 124:184
Anesthesiology, V 124 • No 1 184
January 2016
Copyright © 2015, the American Society of Anesthesiologists, Inc. Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
Images in Anesthesiology: Massive Hepatic Parenchymal and Portal Venous Gas David W. Barbara, M.D., Stephen M. Broski, M.D., Benjamin C. Smith, M.D., Thomas B. Comfere, M.D.
H
EPATIC portal venous gas (HPVG) may result from a variety of etiologies including mesenteric ischemia (43%), intraabdominal infection or malignancy (16%), inflammatory bowel disease (8%), gastroenteric ulcers (4%), necrotizing pancreatitis (2%), benign pneumatosis intestinalis, and following procedures or operations.1,2 HPVG has an overall mortality of 39%, but this varies by cause, ranging from 0% for postprocedural origins to 75% when associated with necrotic bowel.2 Computerized tomography (CT), ultrasound, and conventional radiography may be used to diagnose HPVG.3 On CT, HPVG presents as a branching area of low attenuation extending to within 2 cm of the liver capsule (fig. A), in contrast to pneumobilia, which is typically more central.3 Rarely, confluent hepatic parenchymal gas may occur in severe cases of HPVG (fig. B, arrows indicate HPVG) and portends a high mortality if present. Treatment for HPVG is based on underlying etiology and includes operative management in 51% of cases.2 It follows that anesthesiologists may care for patients with HPVG in providing anesthesia for urgent/emergent surgeries or outside the operating room under nonoperative circumstances. This patient presented very late with widely metastatic adenocarcinoma and bowel ischemia resulting in a lactate of more than 40 mmol/l (normal, 0.6 to 2.3 mmol/l), HPVG, and hepatic parenchymal gas as demonstrated on the axial contrast-enhanced CT images in the figure and in the video (Supplemental Digital Content 1, http://links.lww.com/ALN/ B173). Although HPVG may be benign, its presence in this patient’s clinical context carries a very high mortality. Recognition of the often grave prognosis associated with these imaging findings may allow for initiation of end-of-life discussions with patients and families and facilitates transition to comfort care, as was elected in this case after review of the imaging.
Acknowledgments Support was provided solely from institutional and/or departmental sources.
Competing Interests The authors declare no competing interests.
Correspondence Address correspondence to Dr. Barbara: [email protected]
References 1. Alqahtani S, Coffin CS, Burak K, Chen F, MacGregor J, Beck P: Hepatic portal venous gas: A report of two cases and a review of the epidemiology, pathogenesis, diagnosis and approach to management. Can J Gastroenterol 2007; 21:309–13 2. Kinoshita H, Shinozaki M, Tanimura H, Umemoto Y, Sakaguchi S, Takifuji K, Kawasaki S, Hayashi H, Yamaue H: Clinical features and management of hepatic portal venous gas: Four case reports and cumulative review of the literature. Arch Surg 2001; 136:1410–4 3. Sebastià C, Quiroga S, Espin E, Boyé R, Alvarez-Castells A, Armengol M: Portomesenteric vein gas: Pathologic mechanisms, CT findings, and prognosis. Radiographics 2000; 20:1213–24; discussion 1224–6 Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are available in both the HTML and PDF versions of this article. Links to the digital files are provided in the HTML text of this article on the Journal’s Web site (www.anesthesiology.org). From the Departments of Anesthesiology (D.W.B., T.B.C.) and Radiology (S.M.B., B.C.S.), Mayo Clinic College of Medicine, Rochester, Minnesota. Copyright © 2015, the American Society of Anesthesiologists, Inc. Wolters Kluwer Health, Inc. All Rights Reserved. Anesthesiology 2016; 124:184
Anesthesiology, V 124 • No 1 184
January 2016
Copyright © 2015, the American Society of Anesthesiologists, Inc. Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
