Massive Hepatic Parenchymal and Portal Venous Gas

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, https://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.

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

The authors declare no competing interests.