Hepatic portal venous gas: acute deterioration in an elderly patient

Abstract

A 91-year-old female presented to the Emergency Department with a 10-day history of constipation and abdominal pain. Abdominal examination was normal and rectal examination showed faecal loading. A phosphate enema was given and the patient was admitted. Overnight, the patient's GCS dropped from 15/15 to 3/15 and an arterial blood gas showed a lactate of 8 mmol/L (1.5 on admission). Abdomen remained soft throughout. A CT scan showed a large amount of free air and free fluid within the abdomen and pelvis, highly suspicious for perforation. Hepatic portal venous gas (HPVG) was visible, with portal venous air fluid levels noted. The patient was treated palliatively and died shortly thereafter. HPVG is a recognized but rarely identified radiological sign, which is a poor prognostic indicator, with most cases subsequently proving terminal, often due to subsequent bowel necrosis.

Figure 1:

Coronal section of abdominal CT scan. A large amount of gas can be seen within the hepatic portal venous system.

Figure 2:

Axial section of abdominal CT scan. There is a significant quantity of free air and fluid within the abdomen, which can be seen adjacent to the liver, indicative of bowel perforation. Free air can also be seen in the portal venous system of the liver.