1320 Out of Gas: A Rare Case of Spontaneous Hepatic Portal Venous Gas

Abstract

INTRODUCTION: Hepatic Portal Venous Gas (HPVG) was first described between 1955-1960 and is identified by the presence of tubular, branching translucencies in the non-dependent part of the liver, distributed within 2 cm of the periphery owing to centrifugal blood flow. The exact mechanism for the formation of gas in the portomesenteric venous system is still unclear. Bowel ischemia is the primary etiology of HPVG (70% cases), and when together they are related to transmural necrosis in 91% and mortality in 85%. Thus HPVG is an indication for surgery in the presence of mesenteric ischemia. CASE DESCRIPTION/METHODS: A 69-year-old male with a history of atrial fibrillation and congestive heart failure presented to the ER complaining of weakness, palpitations and dark stools. On physical exam, he was found to have BRBPR and tachycardia with an irregularly irregular rhythm. Days in to the admission, the patient was found to be hypotensive with sinus bradycardia and acutely altered. He was intubated and paced. CT scans showed portal venous gas within the superior mesenteric vein and right common iliac vein, causing hepatic portal vein gas, suggestive of ischemic disease, which led to a recommendation for surgery. A repeat showed thickened loops of ascending, transverse and proximal descending colon in the distribution of the superior mesenteric artery along with free air in the abdomen anteriorly. A colonoscopy showed an extended area of colitis in the ascending colon, transverse colon, splenic flexure, and descending colon with erythema and ulceration concerning for ischemic colitis. Multiple biopsies showed inflammatory related ulceration. Based on the clinical improvement of the patient, medical management was recommended. A repeat CT of the abdomen revealed spontaneous resolution of the hepatic and biliary pneumatosis. Upon recovery, the patient denied previous history of sphincterotomy or any hepatic or biliary manipulation. DISCUSSION: HPVG can be a diagnostic sign, indicating serious intra-abdominal pathology requiring emergent surgical intervention in patients. As CT scans and ultrasound modalities increase, we have the capability to detect severe disease earlier, thus allowing immediate treatment and reducing mortality rates. As with this case, the need for surgical intervention is becoming questionable, even in the presence of ischemia. As clinicians we must be abreast of all information and treatment options. Medical management may allow for less complications and shorter recovery times.