Hepatic portal venous gas: a report of two cases and a review of the epidemiology, pathogenesis, diagnosis and approach to management

Abstract

Background: Hepatic portal venous gas (HPVG) is a rare condition that occurs when intraluminal gas and/or gas produced by intestinal bacteria enters the portal venous circulation. The most common precipitating factors include ischemia, intra-abdominal abscesses and inflammatory bowel disease. However, HPVG has recently been recognized as a rare complication of endoscopic and radiological procedures. Earlier studies advised immediate surgical intervention, but according to current recommendations, in some settings, HPVG can be managed conservatively. The present study reports two cases of HPVG; one that occurred following colonoscopy in a patient with severe Crohn's disease and one in a patient with graft-versus-host disease.

Methods: The epidemiology, pathogenesis, diagnosis and management of HPVG are reviewed. Two case reports are presented, followed by the development of a management algorithm.

Results: Of the two patients that developed HPVG, one was an outpatient undergoing a colonoscopy for assessment of Crohn's disease activity and the other was an inpatient with graft-versus-host disease. Once the diagnosis of HPVG was made, both patients were managed conservatively with antibiotic therapy and management of their underlying disease.

Conclusions: HPVG can occur in the setting of severe gastrointestinal disease states and following endoscopic procedures. It is critical that gastroenterologists are aware of the differential diagnosis, pathogenesis, diagnostic approach and management of HPVG.

Figure 1)

Chest radiograph of patient 1 showing tubular branching lucencies projecting over the liver (arrow). Enlarged upright abdominal x-ray (inset) showing tubular branching lucencies (arrows)

Figure 2)

Computed tomography scan of patient 1 with hepatic portal venous gas, confirming the presence of gas in the portal veins. Note the branching pattern with a peripheral distribution extending to within 2 cm of the liver capsule, involving predominantly the left liver lobe. Hepatic portal venous gas can be differentiated from pneumobilia, because in pneumobilia, the central air lucencies do not extend to within 2 cm of the liver capsule

Figure 3

Algorithm for the management of hepatic portal venous gas (HPVG). CT Computed tomography; GVHD Graft-versus-host disease; IBD Inflammatory bowel disease; IV Intravenous; NPO Nothing by mouth; XR X-ray