Pneumatosis of portal vein: A report of 5 cases

Wang, Fangfei; Lyu, Shaocheng; He, Qiang

doi:10.1016/j.medcli.2021.06.008

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At present, CT is an important auxiliary examination for definite diagnosis. Now we report the general information and diagnosis and treatment of 5 patients with pneumatosis of portal vein in our hospital. Among them, 3 cases were seriously ill and could not tolerate operation. Finally, 5 patients received conservative treatment, 3 patients were cured and 2 patient died. The characteristics of the 5 patients were analyzed and the related literature was reviewed. The results showed that the patients with mild portal vein pneumatosis could be treated conservatively and the changes of the disease should be closely observed. If the condition could not be controlled or suspected of intestinal necrosis, intestinal perforation or severe infection, emergency surgery should be actively carried out (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).<elsevierMultimedia ident="fig0005"></elsevierMultimedia>The 5 patients above were 4 males and 1 female, aged 22–83 years, with acute abdomen caused by intestinal obstruction and cavity pressure rise. In addition, 3 patients also had severe abdominal infection symptoms (fever, elevated white blood cells, and signs of peritonitis). The other 2 patients only showed abdominal distension with slight abdominal pain after stopping exhaust and defecation, without fever and peritonitis. 5 patients with PVG were diagnosed by plain abdominal CT scan. In 3 patients with severe infection, the gas in portal vein extended to the secondary branch of portal vein. And in 2 patients with mild symptoms, the gas in portal vein only appeared in the third branch of portal vein.There are 2 treatment methods for PVG: surgical treatment and conservative treatment. The choice of different treatment methods mainly depends on the primary disease and the severity of the disease.<a class="elsevierStyleCrossRef" href="#bib0030">1</a> In the past, PVG was generally considered to be associated with intestinal necrosis, so it was considered as the surgical indication for abdominal exploration in acute abdomen. In 1978, Liebman<a class="elsevierStyleCrossRef" href="#bib0035">2</a> and others first reviewed and analyzed the literature about PVG. The incidence of intestinal necrosis in 64 patients with PVG was 72%, and the overall mortality rate was 75%. However, with the deepening of the understanding of PVG, it is considered that conservative treatment should be tried for patients with mild symptoms, stable vital signs or poor general conditions that are not suitable for surgery. The conservative treatment programs mainly include the fasting water, gastrointestinal decompression, intravenous nutrition support treatment, anti-inflammatory treatment, etc. In the conservative process, it was possible to closely observe the changes of the condition, and adopted surgical treatment when the condition could not be controlled.<a class="elsevierStyleCrossRef" href="#bib0040">3</a> However, patients who are highly suspected to have intestinal necrosis, intestinal perforation or severe infection at the beginning should be actively treated with emergency surgery.<a class="elsevierStyleCrossRef" href="#bib0045">4</a> Among the 5 patients, 2 elderly patients gave up surgical exploration due to the history of coronary heart disease and unstable angina pectoris. The young patient with severe infection was given conservative treatment first, however the disease progressed rapidly and deteriorated quickly. The 2 patients with mild symptoms were treated with conservative treatment including anti-inflammatory, gastrointestinal decompression and nutritional support. Finally, the young one elderly patient died during the observation period, and the remaining three patients were cured.It can be seen that PVG is not the indication of surgical exploration for acute abdomen.<a class="elsevierStyleCrossRef" href="#bib0050">5</a> Once found, it is necessary to carefully evaluate whether there is intestinal ischemia and necrosis in patients. Dynamic assessment should be made according to the etiology, vital signs and changes of auxiliary examination, so as to avoid improper selection of treatment plan and delay of treatment opportunity. For patients with mild symptoms, stable vital signs or poor general conditions, conservative treatment such as fasting water, gastrointestinal decompression, intravenous nutrition support, anti-inflammatory treatment can be tried first; for patients with intestinal necrosis, active surgical treatment should be taken.ContributorsHQ proposed the study. WFF and LSC performed the research and wrote the first draft. LSC and WFF had equal contribution to the study. All authors contributed to the design and interpretation of the study and to further drafts. HQ is the guarantor.Ethical approvalYes.FundingNo.Conflict of interestNo benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article." 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Koizumi" 1 => "N. Michihata" 2 => "H. Matsui" 3 => "K. Fushimi" 4 => "H. Yasunaga" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00268-017-4189-y" "Revista" => array:6 [ "tituloSerie" => "World J Surg" "fecha" => "2018" "volumen" => "42" "paginaInicial" => "816" "paginaFinal" => "822" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/28879575" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0035" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Hepatic-portal venous gas in adults: etiology, pathophysiology and clinical significance" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "P.R. Liebman" 1 => "M.T. Patten" 2 => "J. Manny" 3 => "J.R. Benfield" 4 => "H.B. 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Fisichella" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1089/lap.2016.0171" "Revista" => array:5 [ "tituloSerie" => "J Laparoendosc Adv Surg Tech A" "fecha" => "2016" "volumen" => "26" "paginaInicial" => "713" "paginaFinal" => "714" ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0045" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Hepatic portal venous gas: an III omen or a misleading sign" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "S. Mehta" 1 => "G.S. Desai" 2 => "S. Shah" 3 => "H. Mehta" 4 => "A. Phadke" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1055/s-0040-1702919" "Revista" => array:5 [ "tituloSerie" => "Surg J (N Y)" "fecha" => "2020" "volumen" => "6" "paginaInicial" => "37" "paginaFinal" => "41" ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0050" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Optimal treatment strategies for hepatic portal venous gas: a retrospective assessment" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "M. Gonda" 1 => "T. Osuga" 2 => "Y. Ikura" 3 => "H. Mehta" 4 => "A. Phadke" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.3748/wjg.v26.i14.1628" "Revista" => array:6 [ "tituloSerie" => "World J Gastroenterol" "fecha" => "2020" "volumen" => "26" "paginaInicial" => "1628" "paginaFinal" => "1637" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/32327911" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] "agradecimientos" => array:1 [ 0 => array:4 [ "identificador" => "xack591503" "titulo" => "Acknowledgements" "texto" => "We will thank the patients for their great help in this report. This paper is supported by Dr. HQ." 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