Portal venous gas and thrombosis in a Chinese patient with fulminant Crohn's colitis: a case report with literature review

Abstract

Ever since its earliest reports, portal venous gas (PVG) has been associated with numerous intraabdominal catastrophes and has served as an indication for urgent surgical exploration. It is traditionally regarded to be an ominous finding of impending death, with highest mortality reported in patients with underlying bowel ischemia. Today, computed tomography has demonstrated a wider range of clinical conditions associated with PVG, some of which are "benign" and do not necessarily require surgery, unless when there are signs of intraabdominal catastrophe or systemic toxicity. One of these "benign" conditions is Crohn's disease. The present report describes a 19-year-old Chinese boy with Crohn's pancolitis who presented with septic shock associated with PVG and portal vein thrombosis, and was successfully managed surgically. To our knowledge, this is the first report of PVG and portal vein thrombosis associated with Crohn's disease in a Chinese patient. In addition, we have also reviewed the reports of another 18 Crohn's patients with PVG previously described in the English literature. Specific predisposing factors for PVG were identified in 8 patients, including barium enema, colonoscopy, blunt abdominal trauma, and enterovenous fistula. The patients who developed PVG following barium enema and blunt trauma were all asymptomatic and no specific treatment was necessary. Eleven patients (58%) who presented with signs of intraabdominal catastrophe or systemic toxicity required either immediate or eventual surgery. The overall mortality rate among the 19 patients was only 11%. The present literature review has shown that the finding of PVG associated with Crohn's disease does not always mandate surgical intervention. It is the clinical features and the related complications that ultimately determine the treatment approaches. The overall outcome of PVG associated with Crohn's disease has been favourable.

Figure 1

Computed tomography of the abdomen showing evidence of portal venous gas (long arrow), portal vein thrombosis, gross ascites, and pneumoperitoneum (short arrow).

Figure 2

Photograph of the total colectomy specimen showing the classical features of Crohn’s colitis: cobblestone mucosa with skipped lesions.

Figure 3

Computed tomography of the abdomen showing evidence of partial recanalization of the portal vein (long arrow) with increasing surrounding collaterals (short arrow).