Conservative treatment of hepatic portal vein gas after transarterial chemoembolization treatment for liver metastasis of postoperative esophageal cancer: a case report

Abstract

Background: Hepatic portal vein gas (HPVG), which is a rare clinical manifestation, is usually considered a sign of critical illness. If the treatment is not timely, it will lead to intestinal ischemia, intestinal necrosis, and even death. There is still no consensus on whether to adopt surgical or conservative treatment for HPVG. Herein, we report a rare case of conservative treatment of HPVG after transarterial chemoembolization (TACE) treatment in a patient with liver metastasis of postoperative esophageal cancer, who received long-term enteral nutrition (EN).

Case description: A 69-year-old male patient, who had undergone surgery for esophageal cancer, needed long-term use of jejunal feeding tube implantation for enteral nutritional support due to postoperative complications. About 9 months after the operation, multiple metastases of the liver were detected. To control the progress of the disease, TACE was conducted. EN was restored on the second day after TACE, and the patient was discharged on the fifth day. On the night of discharge, the patient suddenly experienced abdominal pain, nausea, and vomiting. Abdominal computed tomography (CT) showed that the abdominal intestinal lumen was obviously dilated, liquid and gas plane shadowing was visible, and gas was visible in the portal vein and its branches. The physical examination showed that peritoneal irritation was present, and bowel sounds were active. Blood routine examination showed an increase in neutrophil and neutrophil. Symptomatic treatment, including gastrointestinal decompression, anti-infection, and parenteral nutritional support, was provided. On the third day after the presentation of HPVG, abdominal CT reexamination showed that HPVG had disappeared and the intestinal obstruction was relieved. Repeated blood routine shows a decrease in neutrophil and neutrophil.

Conclusions: Elderly patients who require long-term EN support should avoid early EN support after TACE, as this can prevent intestinal obstruction and HPVG. If the patient suddenly experiences abdominal pain after TACE, CT scan should be performed in a timely manner to determine whether there is intestinal obstruction and HPVG. If the above type of patient experiences HPVG, conservative treatments such as early gastrointestinal decompression, fasting, and anti-infection treatment can be provided first without high-risk factors.

Keywords: Hepatic portal vein gas (HPVG); case report; enteral nutrition; liver metastasis; transarterial chemoembolization (TACE).

Figure 1

The abdominal CT findings before TACE treatment. (A-F) The abdominal CT showing multiple round masses in the liver, with borderline enhancement, leading to the diagnosis of liver metastasis. (E,F) The abdominal CT showing gas accumulation in the small intestine and intestinal dilation, no imaging finding of intestinal obstruction (arrows). CT, computed tomography; TACE, transarterial chemoembolization.

Figure 2

Abdominal CT findings during HPVG. (A-C) The abdominal CT showing the gas accumulation in the portal vein and its branches (red arrows). (D) The abdominal CT showing that the abdominal intestinal lumen was significantly expanded, and revealing the liquid-gas plane shadow (white arrow). CT, computed tomography; HPVG, hepatic portal venous gas.

Figure 3

Abdominal CT findings after 2 days of conservative treatment. (A-D) After the conservative treatment, a repeat abdominal CT showing that the gas accumulation in the portal vein disappeared and the intestinal obstruction was relieved. CT, computed tomography.

Figure 4

Abdominal CT findings after 12 days of conservative treatment. (A-D) Abdominal CT showing no gas accumulation in the hepatic portal vein or its branches, the perihepatic effusion has disappeared, and the abdominal intestinal lumen is not expanded. CT, computed tomography.

Figure 5

The timeline of this case. CT, computed tomography; TACE, transarterial chemoembolization; HPVG, hepatic portal vein gas.