Abstract

Supplemental Digital Content is available in the text.

Hepatic portal venous gas (HPVG) may result from a variety of etiologies including mesenteric ischemia (43%), intraabdominal infection or malignancy (16%), inflammatory bowel disease (8%), gastroenteric ulcers (4%), necrotizing pancreatitis (2%), benign pneumatosis intestinalis, and following procedures or operations.1,2  HPVG has an overall mortality of 39%, but this varies by cause, ranging from 0% for postprocedural origins to 75% when associated with necrotic bowel.2  Computerized tomography (CT), ultrasound, and conventional radiography may be used to diagnose HPVG.3  On CT, HPVG presents as a branching area of low attenuation extending to within 2 cm of the liver capsule (fig. A), in contrast to pneumobilia, which is typically more central.3  Rarely, confluent hepatic parenchymal gas may occur in severe cases of HPVG (fig. B, arrows indicate HPVG) and portends a high mortality if present.

Treatment for HPVG is based on underlying etiology and includes operative management in 51% of cases.2  It follows that anesthesiologists may care for patients with HPVG in providing anesthesia for urgent/emergent surgeries or outside the operating room under nonoperative circumstances. This patient presented very late with widely metastatic adenocarcinoma and bowel ischemia resulting in a lactate of more than 40 mmol/l (normal, 0.6 to 2.3 mmol/l), HPVG, and hepatic parenchymal gas as demonstrated on the axial contrast-enhanced CT images in the figure and in the video (Supplemental Digital Content 1, http://links.lww.com/ALN/B173). Although HPVG may be benign, its presence in this patient’s clinical context carries a very high mortality. Recognition of the often grave prognosis associated with these imaging findings may allow for initiation of end-of-life discussions with patients and families and facilitates transition to comfort care, as was elected in this case after review of the imaging.

Acknowledgments

Support was provided solely from institutional and/or departmental sources.

Competing Interests

The authors declare no competing interests.

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discussion 1224–6