Hepatic portal venous gas: Physiopathology, etiology, prognosis and treatment

Online Submissions: wig. wjgnet comWorld gastroenterol 2009 August 73585-3590ig@wignet.comWorld Journal of Gastroenterology10079327doi:10.3748/wg153585c 2009 The wjG Press and Baishideng. AEDITORIALHepatic portal venous gas: Physiopathology, etiologyprognosis and treatmentBassam Abboud, Jad El Hachem, Thierry Yazbeck, Corinne DoumaBassam Abboud, Jad El Hachem, Thierry Yazbeck, CorinneDoumit, Department of General Surgery, Hotel-Dieu de france Abboud B, El Hachem J, Yazbeck T, Doumit C. Hepatic portalHospital, Boulevard Alfred Naccache, Beirut 16-6830. Lebanon venous gas: Physiopathology, etiology, prognosis and treatment.Author contributions: Abboud b designed the researchWorld J Gastroentero/ 2009; 15(29): 3585-3590 AvailableAbboudB,ElHachemJandDoumitCperformedtheresearchfromUrl:http://www.wjgnet.com/1007-9327/15/3585.aspAbboud B, El Hachem J and Yazbeck T wrote the paperDol:http://dx.doi.org/10.3748/wig.15.3585Correspondence to: Bassam Abboud, MD, Departmentof General Surgery, Hotel-Dieu de fra.ANaccache Street, Beirut 16-6830Lebanon. dbabboud(@yahoo. frTelephone:+961-1-615400Fax:+961-1-615295INTRODUCTIONReceived May 9, 2009 Revised: July 7, 2009Hepatic portal venous gas(HPVG), an ominous radio-Accepted: July 14, 2009logic sign, was first described by Wolfe and Evens inPublished online: August 7. 2009infants with necrotizing enterocolitis(NEC)2.HPVGis associated with numerous underlying abdominal dis-eases, ranging from benign causes to potentially lethaldiseases that require prompt surgical intervention/oAbstractThe mechanism for the appearance of gas in theHepatic portal venous gas(HPVG), an ominous ra- portal vein is not well understood. The proposed factorsdiologic sign, is associated in some cases with a se- predisposing the portal venous system to the accumula-vere underlying abdominal disease requiring urgent tion of gas include the following:(1)escape of gas pro-operative intervention. HPVG has been reported with duced by gas-forming organisms in the bowel lumen orincreasing frequency in medical literature and usually in an abscess which then circulate into the liver or(2)theaccompanies severe or lethal conditions. The diagnosis presence of gas-forming organisms in the portal venousof HPVG is usually made by plain abdominal radiogra- system with passage of gas into the circulation"phy, sonography, color Doppler flow imaging or computed tomography(CT) scan. Currently, the increasedThe diagnosis of HPVG is usually made by plainbdominal radiography, sonography, color Doppler flowallows early and highly sensitive detection of such se- imaging, or computed tomography (T) scan. The char-vere illnesses and also the recognition of an increasing acteristic finding on abdominal plain film is a branchingnumber of benign and non-life threatening causes of radiolucency extending to within 2 cm beneath the liverHPVG. HPVG is not by itself a surgical indication and capsule. This is because of the centrifugal flow of portalthe treatment depends mainly on the underlying dis- venous blood, which carries portal venous gas periphease. The prognosis is related to the pathology itself erally, in contrast to biliary gas, which tends to collectand is not influenced by the presence of HPVG. Based centrally as a result of the centripetal movement of bileon a review of the literature, we discuss in this paper Although HPVG may be diagnosed by conventionalthe pathophysiology, risk factors, radiographic findings, radiography, detection is difficult and it is easily overmanagement, and prognosis of pathologies associated looked. Sonography, color Doppler flow imaging, andwith HPVgCT scan have been reported to be superior to abdominaldigraphs in identifying HPVG Sonography coupledC 2009 The WJG Press and Baishideng All rights reservedto Doppler is very sensitive for HPVG detection ands follow-up, and can be useful as an initial screeningKey words: Hepatic portal venous gas; Bowel ischemia/ examination 9, 10). However. use of ultrasound is limitednecrosis; Diverticulitis: Gastric pathologies; UlcerativeoDerator variability and lackcolitis; Abdominal computed tomography scan; Crohnsdisease; Liver transplantation; Chemotherapyof availability中国煤化工 sonographicfeatures of hCNMH Genic particles,poorly defined,on Medical School, 1 -1-5 Sendagi, Bunkyo-kuhighly echogenic patches within the hepatic parenchyma,which are most apparent in the non-dependent partwww.wignet.com3586 ISSN 1007-9327 CN 14-1219/R World J Gastroenterol August 7, 2009 Volume 15 Number 29Color Doppler flow imaging showwS hyperechogenic fociTable 1 Pathologies associated with hypoperfusion inmoving within the lumen of the portal vein, producingneonatessharp bidirectional spikes superimposed on the normalmonophasic portal vein wave pattern. The CT scan has Etiologies of hypoperfusion in preterm infantssensitivity for detection of HPVg and can detectthe underlying pathology 215. On scanographic images,HPVG is characteristically associated with peripheralPolycythemiaIn utero cocaine exposulucencies which branch out and are noted even withinPeri-or postnatal asphyxiathe last 2 cm beneath the liver capsule. This peripheralRespiratory distress syndromegas distribution is related to the direction of blood Aow Congenital heart diseaseUmbilical catheters use and exchange transfusioninto the liver. It is crucial to differentiate it from pneumobilia, which is centrally located because of the biliaryanatomy and the direction of bile flow4. 15. Also, a CT feeding and antibacterial use, result in mucosal and/orscan can disclose gas in the bowel wall (pneumatosis transmural necrosisstinalis)and in the extrahepatic portal vein or itsThe bacterial translocation and production of hydrsplanchnic vasculature.gen gas into the bowel wall cause pneumatosis intestinaThe underlying clinical events associated with HPVG lis"which can be seen radiographically as linear or circularmight be important factors contributing to patient sur- lucencies within the intestinal wall 2. As a consequence,vival and prognosis. Liebman et ak reported that HPVG the gas can embolize from the bowel wall through theis associated most commonly with bowel necrosis(72%), mesenteric veins to the portal venous system and the non-followed by ulcerative colitis(8%), intra-abdominal ab- dependent parts of the liver, particularly the left lobe andscess(6%), small bowel obstruction(3%)and gastric ul- anterior segment of the right lobecer(3%). This explains the high mortality rate (56%90%7Abdominal sonography is very specific and sensitivereported in association with HPVG lo, 1i. Another factor for early detection of portal and hepatic gas thus allow-affecting the outcome of these patients is the coexis- ing early diagnosis and efficacious treatment of NECtence of a long-term chronic disease, such as chronic The micro-bubbles of gas appear as highly echogenicarticles flowing within the pornd highly echodecreases immune functions and alters the intestinal mi-genic patches within the hepatic parenchyma. At a morecrobial foraadvanced stage, HPVG can be seen on abdominal radioHowever, currently, the increased use of Ct scargraphs. Furthermore, HPVG may only be a transitionalhighly sensitive detection of such severe illnessesio, 18-20g sign or can persist for longer than 2dHPVG alone is not an indication for surgery", sinceand recognition of an increasing number of benign and 47% of infants with NEC and HPVG survive withoutnon-life threatening causes of HPVG20, 21. The progno- operative procedure. Surgery is indicated when infantssis is related to the pathology itself and is not influenceddo not improve significantly despite medical treatmentby thefor several days, as well as when radiographs show perIn this paper, we discuss the pathophysiology, risk sistent fixed dilated bowel loops or pneumoperitoneumfactors, management, and prognosis of pathologies as- which are, respectively, signs of bowel necrosis and pesociated with HPVgforation. In infants with a birth weight >1500 g. laparot-omy and resection of the necrotic intestine is generallyNECthe preferred approach. In very low birth weight infants<1500 g, and unstable neonates, surgery is associatedNEC is a disease of premature neonates, with 90% of with a high rate of mortality and morbidity. In thiscases occurrng in infants born before 36 wk gestational case, peritoneal drainage can be indicated as a definitiveage. In 10% of cases it occurs in full-term infants whoprocedure or as part of the resuscitation phase prior tohave comorbidities predisposing them to decreased mes- definitive laparotomyenteric perfusion. This pathognomonic radiographicHPVG has been associated in some studies. with asign can be missed in extremely low birth weight (less poorer survival rate. In their prospective study, Sharmathan 1000 g)the gravity of the illness, et al24 found that infants with HPVG were 1.4 timesbecause of absence of enteral feedingmore likely to have severe NEC, but mortality rates didNEC is a multifactorial disease process resulting not differ from those of infants without HPVOfrom the association of a hypoxic ischemic injury ofHPVG is associated with severe lesions of thethe immature gastrointestinal tract and alterations in bowel wall and intra-mural gas that leads to muscularthe microbiological intestinal flora. Hypoperfusiondisruption anticture formationpreterm infants has many etiologies(Table 1). It induces 20% of all pati中国煤化工blood to shunt away from the bowels towards critical or-CNMHGgans which may cause alterations in the mucosal barrier. BOWEL ISCHEMIAThese alterations, in combination with pathogenic microbiological intestinal flora proliferation exaggerated by Bowel ischemia and/or infarction is a common andwww.wignet.comAbboud B et al. Hepatic portal venous gas3587Table 2 Etiologies of bowel ischemiaCurrently, the multidetector row CT angiographyMDCT) has become the first choice for HPVG detec-Etiologiestion and determination of the underlying processThromboembolism AtherosclerosisMDCT sensitivity has been markedly increasing overArterial dissectiontime from a low of 39%o to a current high of 82%0, andAortic surgeit has reached a similarly high sensitivity in diagnosingsculitisProducing occlusion of large, medium andacute bowel ischemia as that of angiographysmall arteriesHPVG is often associated with pneumatosis intestiemmentalharacterized by a non inflammatoryalis, posing a grave prognosis, especially in the ischemicarteriopathy causing lysis of adultintestine 27-31. The CT scan alone cannot predict whichvisceral arteriesBowel obstruction Distension of proximal bowel loops resultingpatients are experiencing true intestinal ischemia andin venous congestionwhich simply have benign pneumatosis. The presence ofangulation of mesenteric vesselsHPVG does not provide any information concerning theAbdominal trauextent of bowel necrosis In all cases, CT findings shouldstenosis with late chronic presentation' enetrating trauma with direct injury tobe correlated with the clinical signs and with laboratorythe major mesenteric vesselsparameters to reach a high sensitivity and specificity levelNeoplasmsInvasion of the major mesenteric vesselsfor intestinal necrosis. When HPVg associated withthe tumorischemic bowel disease is encountered, coexisting otherOver distension and fecal material stagnabdominal conditions should be considered pre-andabove an obstacleAbdominalMesenteric, portal and splenic vein thrombosisintraoperatively. Intestinal resection is performed wheninflammatorybowel necrosis is found on laparotomy. Nowadays, withconditionsthe development of highly advanced imaging techniques,Chemotherapy,Vasoconstrictionpotentially severe pathologies, such as bowel ischemia,Thromboembolismare diagnosed at much earlier stages, allowing promptLiquefaction necrosis(Alkalis)treatment and significantly reducing mortality ratesRadiationObliteration of small arterioles producinga progressive occlusive vasculitisDIVERTICULITISHepatic portal venous gas is a rare complication ofdiverticulitis[16, 32). However. Sellner et aAll found thatdangerous abdominal condition, especially in elderly complicated diverticulitis is the second most frequentlyPatients. 26). It is associated with a high mortality rate reported cause of HPVG, which can be due to twothat ranges from 75% to 90% of casesmechanisms: The first is a septic thrombophlebitis ofBowel ischemia is produced by insufficient blood flow the inferior mesenteric vein complicated by gas-formingto or from the intestines. It may have an acute or chronicetting depending on the underlying disorder(Table 2)pathogens. The second is a direct communication between the intestinal lumen and the portomesenteric veinThe extent of bowel ischemia in the bowel wall is dividedsystem. This is caused by intramesocolic intestinal perfo-into three stages :stage I: the ischemic lesions are ration, dissecting between the peritoneal leaflets of theconfined to the mucosa and are reversible(known asreversible ischemic enteritis); Stage I: characterized bymesocolon and creating access to mesocolicnecrosis of the mucosal and submucosal tissues. whichPatients with mesocolic abscess have better prognosimay lead to fibrotic stricture development; Stage I: the than patients with septic pylephlebitis 6lentire wall is affected by ischemia. It is associated with aDiverticulitis associated with HPVg necessitates ahigh mortality rate.elective surgical approach after adequate reanimationIntestinal ischemia results in damage to the mucosal with intravenous fluids and antibiotics. However,barrier which, in association with over-distension of Nobili et al) suggested that if medical conservativethe bowel loops and gas-forming bacterial proliferation, therapy is effective and the clinical status improves, theleads to gas moving from the intestinal lumen to the surgery could be delayedmesenteric veins and flowing through it to the portalIn one case, Negro et a/ l reported a patient withsystem and hepatic parenchymasigmoid diverticulitis who developed aBowel ischemia is the primary etiology of HPvoof the intra-and extra-hepatic portal systems due to an(70% of cases)and when associated, they are related enterovascular fistula, and who was treated with fistulato transmural necrosis in 91% of cases and to a high embolization and subsequent sigmoidectomy.mortality rate(85% of patients). These facts signifythat HPVG is an absolute indication for surgery in theGASTRICcontext of mesenteric ischemia中国煤化工so Abdominal radiographs are not sensitive for early HPVG has beC NMH GIth either gasge bowel ischemia detection, but they predict bowel tric dilatationThe treatmentinfarction and a poor prognosis when intramural gas is conservative or surgical depending on the underlyingand hpvg are seenprocess.www.wignet.com3588 ISSN 1007-9327 CN 14-1219/R World J Gastroenterol August 7, 2009 Volume 15 Number 29Gastroparesis is a frequent complication after a poly- reported In the first case, Kung et a/described HPVGtraumatic event, leading to gastric emphysema and sub- to be secondary to pneumatosis intestinalis in a patientsequent HPVG. In these cases, gastric decompression who received irinotecan and cisplatin. On laparotomy,with a naso-gastric tube, nil by mouth and observation is the colon and the small bowel were normal, and thesufficient treatmentpatient was managed supportively with success. GastroinFurthermore, HPVG has been described in a patient testinal toxicity is a common side effect of irinotecan 5Iwith hypertrophic pyloric stenosis, and in a patient which may be exacerbated by the adjunction of cisplatinwith peptic ulcer. A gastric volvulus in a diaphragmatic leading to mucosal ulceration, bowel distension andhernia,without necrosis, was also reported in one pa- gas-forming anaerobic bacterial proliferationtient". These observations prove that raised intra-lumiIn the second case, Zalinski et a/b2 reported localnal pressure results in gastric pneumatosis and HPVG in ized HPVG in the right liver after complete colorectalthe absence of bowel ischemia and gas-forming organism proliferationcancer liver metastasis necrosis in a patient receiving achronic toluene inhalation,G ve been described afterSeveral cases of hpⅤGhtreatment of oxaliplatin and cetuximab. Infection of theaccidental ingestion of caustics, hydrogen peroxide and necrotized metastasis was promoted by the tumor whichchich lead to mucosalbsequently turned into a liver abscess, and fistulized toulcerations and acute gastric distension by oxygen pro-he right portal veinduction. Generally, the patient will be stable and can bemanaged by symptomatic treatment. In cases of massivetion therapy for an advanced esophageal cancer y radia-One case of HPVG was reported after chemoradiagas embolization to the portal venous system, and thepresence of cardiac and neurological symptoms, hyperOTHER CONDITIONSbaric oxygen should be used and can be a successfulreadmeHPVG has been reported in association with acutepancreatitis., obstructive pyelonephritis after extraINFLAMMATORY BOWEL DISEASEScorporeal shock wave lithotripsy), acute appendici-gastro-jejunal anastomotic leak afterKinoshita et a/ reported that in 182 cases of HPVOlaparoscopic gastric bypass 5 ), uterine gangrene,and4% were associated with ulcerative colitis, and 4% with percutaneous endoscopic gastrostomy tube placementCrohn's diseaseHPVG has also been seen in the presence of a jejunalHPVG, in patients presenting inflammatory bowel feeding tube, following esophageal variceal band ligadisease, can be caused by mucosal damage alone or in tion", gastrointestinal perforation with amyloidosiscombination with bowel distension, sepsis, invasion by with severe hyperglycemic shock and in superior mes-gas-producing bacteria", or after colonoscopy, upper enteric artery syndromegastrointestinal barium examination, barium enemaThese conditions may lead to bowel hypoperfusionor blunt abdominal trauma". Therefore, a finding and subsequent intestinal ischemia, or may induce anof HPVG associated with Crohn's disease does not ileus and intestinal distention with mucosal damage andmandate surgical intervention especially in the absence bacterial proliferation producing pneumatosis intestinalisof peritoneal signs or free intraperitoneal gasand HPVG. In these cases, surgical treatment afteradequate medical resuscitation is indicated depending onLIVER TRANSPLANTATIONthe underlying processOccasionally, in cases of abdominal blunt traumaHepatic portal venous gas is a common finding on Dopthe increased intra-luminal pressure causes mucosal tearspler sonography in the early postoperative period ante within the intestine, which allows gas to enter submucosalliver transplantation. Chezmar et al concluded in theveins and flow to the hepatic portal vein".Howeverstudy that HPVG alone, in the absence of bowel necro- a severe blunt abdominal trauma may lead to intestinalntra-abdominal abscess, small-bowel obstruction of necrosis and eventual bowel rupture with peritonitissepsis, is a transient finding without clinical significance. Thus, when HPVG after abdominal trauma is associatedFurthermore there was no correlation between the finding of portal venous air and transplant rejection, the with free intra-abdominal gas, pneumatosis intestinalis andneed for retransplantation, the cause of hepatic failure, signs or peritonits, surgical intervention is mandatorthe type of biliary anastomosis, ventilator dependence,or subsequent deathCONCLUSIONIn pediatric liver transplant recipients, Wallot etA radiologic finding of HPVg does not necessarily iniggested that the detection of HPVG beyond the early dicate a severe underlying pathology. It can be seen inpostoperative period may be a sign of intra-abdominalpost-transplant lymphoproliferative disease, leading tong endoscopicthe loss of bowel wall integrity.中国煤化工 nly necessitateconservativeCNMHGVG was conCHEMOTHERAPYsidered as being an indicator of bad prognosis and asbeing associated with a particularly high mortality rateTwo cases of HPVG after chemotherapy have been Nowadays, with the development of highly advancedwww.wignet.comAbboud B et al. Hepatic portal venous gas3589imaging techniques, potentially severe pathologies, suchblunt abdominal trauma does not necessitate surgery. Ambowel ischemia, are diagnosed at much earlier stagesSrg2008;74:335337allowing prompt treatment and significantly reducing19 Saba L, Mallarini G, Computed tomographic imagingmortality rates. HPVG is not by itselffindings of bowel ischemia. Comput Assist Tomogr 2008; 32329-340tion and the treatment depends mainly on the underly- 20 Hou SK, Chern CH, How CK, Chen D, Wang LM, Lee CHing disease. The prognosis is related to the pathologyHepatic portal venous gas: clinical significance of computeditself and is not influenced by the presence of HPvgtomography findings. Am/Emerg Med 2004; 22: 214-21821 Gorospe EC Benign hepatic portal venous gas in a criticallyill patient ScientificworldJournal 2008; 8: 951-952REFERENCES22 Hunter C], Chokshi N, Ford HR. Evidence vs experiencein the surgical management of necrotizing enterocolitis1 Thompson AM, Bizzarro M]. Necrotizing enterocolitis inand focal intestinal perforation. Perinatol 2008; 28 Suppl 1newborns: pathogenesis, prevention and managementDrgs200868:1227-123823 Morris MS, Gee AC, Cho SD, Limbaugh K, Underwood2 Merritt CR, Goldsmith JP, Sharp M]. Sonographic detectionS, Ham B, Schreiber MA Management and outcome ofof portal venous gas in infants with necrotizing enterocolitispneumatosis intestinalis. Am/ Surg 2008; 195: 679-682;AJR Am J Roentgeno! 1984; 143: 1059-1062discussion 682-6833 Kinoshita H, Shinozaki M, Tanimura H, Umemoto Y, 24 Sharma R, Tepas JJ 3rd, Hudak ML, Wludyka PS, MollittSakaguchi S, Takifuji K, Kawasaki S, Hayashi H, YamaueDL, Garrison RD, Bradshaw JA, Sharma M. PortalH. Clinical features and management of hepatic portavenous gas and surgical outcome of neonatal necrotizingvenous gas: four case reports and cumulative review of theenterocolitis. Pediatr Surg 2005: 40: 371-376literature. Arch Surg 2001; 136: 1410-1414Lai WH, Hwang TL, Chen HW. Portomesenteric venous gasHussain A, Mahmood H, El-Hasani S Portal vein gas inin acute bowel ischemia: report of a case. Surg Today 2008,emergency surgery. World J Emerg Surg 2008; 3: 2138:656-665 Salyers w] Jr, Hanrahan JK Hepatic portal venous gas:6 Wiesner w, Khurana B, Ji H, Ros PR. CT of acute bowelIntern Med/2007, 37: 730ischemia. Radiology 2003: 226: 635-6506 Alqahtani S, Coffin CS, Burak K, Chen F, MacGregor J, 27 Wu JM, Liang JT. Pneumatosis intestinalis and hepatico-Beck P. Hepatic portal venous gas: a report of two casesand a review of the epidemiology, pathogenesis, diagnosisand approach to management. Can/ Gastroenterol 2007, 21: 28 Heemskerk J, de Hingh IH. Pneumatosis intestinalis,mesenteric venous gas and portal venous gas. Dig Surg7 Liebman PR, Patten MT, Manny J, Benfield JR, Hechtman008;25:85-86HB. Hepatic--portal venous gas in adults: etiology, 29 Shen CH, Chu HC, Chang WK, Chao YC, Hsieh TY Hepaticathophysiology and clinical significance. Ann Surg 1978,ortal venous gas in a patient with pneumatosis intestinalis187:281-287NAMed j2007;120:U26108 Gosink BB Intrahepatic gas: differential diagnosis. A/R Am 30 Ito M, Horiguchi A, Miyakawa S Pneumatosis intestinalisJ Roentgeno! 1981; 137: 763-767and hepatic portal venous gas. Hepat9 Chezmar JL, Nelson RC, Bernardino ME, Portal venous2008;15:334-337gas after hepatic transplantation: sonographic detection 31 Kunin N, Verbrackel L, Morin-Chouarbi V, Cressy G. [Theand clinical significance. A R Am/ Roentgeno 1989: 153association of Pneumatosis intestinalis and portal venot1203-1205gas] Presse med2003:32:1892-189310 Lee CS, Kuo YC, Peng SM, Lin DY, Sheen IS, Lin SM, Chuah 32 Sen M, Akpinar A, Inan A, Sisman M, Dener C, Akin KSonographic detection of hepatic portalExtensive hepatic-portal and mesenteric venous gas due tovenous gas associated with suppurative cholangitis )Clirsigmoid diverticulitis, World Gastroenterol 2009; 15: 879-881utrasound1993;21:331-33433JensenJA, Tsang D, Minnis JF,11 Pan HB, Huang JS, Yang TL, Liang HL. Hepatic portalPneumopylephlebitis and intramesocolic diverticularvenous gas in ultrasonogram-benign or noxious, ultrasounderforation. Am Surg 1985; 150: 284-287Med biol2007;:33:1179118334 Zielke A, Hasse C, Nies C, Rothmund M. Hepatic-portal12 Monneuse O, pilleul f, barth x gruner l, allaouchichevenous gas in acute colonic diverticulitis. Surg Endosc 1998,B, Valette PJ, Tissot E Portal venous gas detected on12:278-280computed tomography in emergency situations: surgery is 35 Nobili C, Uggeri F, Romano F, Degrate L, Caprotti R, Peregostill necessary. World )Surg 2007: 31: 1065-1071P, Franciosi C, Uggeri F. Pylephlebitis and mesenteric13 Chan SC, Wan YL, Cheung YC, Ng SH, Wong AM, Ng KK.thrombophlebitis in sigmoid diverticulitis: medicalComputed tomography findings in fatal cases of enormousapproach, delayed surgery. Dig Liver Dis 2007: 39: 1088-1090hepatic portal venous gas. World Gastroenterol 2005; 1136 Negro U, Verdecchia M, Paci E, Antico E, Valeri G, Risaliti A2953-2955Vecchi A, Svegliati-Baroni G, Giovagnoni A. Hepatic portal14 Yarze JC, Markowitz DM. Distinguishing between hepaticvenous gas in a patient with enterovascular fistula. Abdomportal vein gas and pneumo(aero)bilia, Liver Transp! 2007:naging2006;31:706-70913: 1476; author reply 147737 Bani-Hani KE, Heis HA latrogenic gastric dilatation: a rare15 Chirica M, Scatton O [Air in the portal venous systemd transient cause of hepatic-portal venous gas. Yonsei Medradiologic differential diagnosis and etiology-specific2008;49:669-671treatment)/Chir(Paris)2006; 143: 141-14238 Al-Jundi w, Shebl A. Emphysematous gastritis: case report16 Sellner F, Sobhian B, Baur M, Sellner S, Horvath B, Mostegeland literature review. Int/ Surg 2008: 6: e63-e66M, Karner J, Staettner S Intermittent hepatic portal vein 39 Bhargava P, Parisi M. Gastric pneumatosis and portalas complicating diverticulitis--a case report and literaturevenous gatrophic pyloricreview. Int/ Colorectal Dis 2007; 22: 1395-1399中国煤化工17 Muscari F, Suc B, Lagarrigue J. [Hepatic portal venous gas: 40 Sarti J, Keis it always a sign of severity and surgical emergency?CNMHGnnypertroppyloric stenChirurgie 1999: 124: 69-7241 Dominguez Jimenez JL, Puente Gutierrez JJ, Marin Moreno18 Vercruysse GA, Adams SD, Feliciano DV ComputedMA, Bernal Blanco E, Gallardo Camacho JL, Uceda vano Atomographic evidence of hepatic portal venous gas after[Gastric pneumatosis and gas in the portal venous systemwww.wignet.com3590 ISSN 1007-9327 CN 14-1219/R World J Gastroenterol August 7, 2009 Volume 15 Number 29secondary to peptic ulcer] Gastroenterol Hepatol 2008; 31: 54 Park HC, Lee WS, Joo SY, Park SY, Joo YE, Kim HS, Choi494496SK, Rew JS. [Hepatic portal venous gas associated with42 Haswell DM, Carsky EW. Hepatic portal venous gas andacute pancreatitis: reports of two cases and review ofgastric emphysema with survival. A/R Am/ Roentgenol 1979:literature] Korean gastroenterol 2007: 50: 131-135133:1183-118543 Lewin M, Pocard M, Caplin S, Blain A, Tubiana JM, Parc56 pancreatitis. Dig Surg 2009: 26 119-120 gas in necrotizingBenign hepatic portal venous gas following caustic 56 Rana AA, Sylla P, Woodland DC, Feingold DL. A caseingestion. Eur Radiol 2002; 12 Suppl 3: $59-S61rtal venous gas after extracorporeal shockwave44 Mullins ME, Beltran JT, Acute cerebral gas embolism fromlithotripsy and obstructive pyelonephritis Urology 2008; 71hydrogen peroxide ingestion successfully treated with546e5-546,e7yperbaric oxygen / Toxicol Clin Toxicol 1998; 36: 253-25657 Tuite DJ, Byrne A, Colhoun E, Torreggiani Wo45 Salyers W] Jr, Mansour A, Portal venous gas followingPneumatosis intestinalis and portal-venous gas: an unusualcolonoscopy and small bowel follow-through in a patientpresentation of acute appendicitis. Australas radiol 2007; 5with Crohn's disseasedoscopy 2007: 39 Suppl 1: E130Spec No. B137-B13946 Cerezo Ruiz A, Gomez Camacho F, Garcia Sanchez V, 58 Mognol P, Chosidow D, Marmuse JP. Hepatic portal gasIglesias Flores E, Gallardo Valverde JM, DE Dios Vega JFdue to gastro-jejunal anastomotic leak after laparoscopic[A young woman with Crohn's disease and portal gasgastric bypass. Obes Surg 2005: 15: 278-281Gastroenterol Hepatol 2008; 31: 550-55159 Bobba RK, Arsura EL Hepatic portal and mesent47 Ng SS, Yiu RY, Lee JF, Li jC, Leung KL. Portal venousgas as a late complication of percutaneous engas and thrombosis in a Chinese patient with fulminantgastrostomy tube placement in an elderly patientCrohns colitis: a case report with literature review. World JSci2005;50:411-414Gastroenterol 2006: 12: 5582-558660 Lebiedz P, Ullerich H, Seelig M, Domschke W, Kucharzik48 Ha NR, Lee HL, Lee OY, Yoon BC, Choi HS, Hahm JS, LeeT. Jejunal feeding tube causing intestinal pneumatosis andDH, Lee MH. [A case of Crohn's disease presenting withfulminant portal venous gas embolism. Endoscopy 2005; 37free perforation and portal venous gas] Korean/ Gastroenterol2007:50:31932361 Ahmed K, Atiq M, Richer E, Neff G, Kemmer N, Safdar K.49 Wallot MA, Klepper J, Clapuyt P, Dirsch O, Malago MCareful observation of hepatic portal venous gas followingReding R, Otte JB, Sokal EM. Repeated detection of gas inesophageal variceal band ligation. Endoscopy 2008; 40 Supplthe portal vein after liver transplantation: A sign of EBV.2:E103associated post-transplant lymphoproliferation? Pediatr 62 Yamamoto A, Kawahito Y, Niimi M, Kadoya M, HamaguchiTransplant 2002; 6: 332-336M, Ishino H, Wada M, Kohno M, Tsubouchi Y, Yoshikawa50 Kung D, Ruan DT, Chan RK, Ericsson ML, Saund MsT. Pneumatosis intestinalis and hepatic portal venous gasPneumatosis intestinalis and portal venous gas withoutcaused by gastrointestinal perforation with amyloidosis. Jbowel ischemia in a patient treated with irinotecan andClin Gastroenterol 2008: 42: 758-759cisplatin Dig Dis Sci 2008: 53: 217-21963 Nishikawa K, Higuchi M, Kimura S, Shimodate Y, Namik51 Alimonti A, Gelibter A, Pavese I, Satta F, Cognetti F, FerrettiA Severe hyperglycemic shock associated with hepaticG, Rasio D, Vecchione A, Di Palma M. New approaches toIs gas ) Anesth 2008; 22: 74-76prevent intestinal toxicity of irinotecan-based regimens. 64 Lim JE, Duke GL, Eachempati SR Superior mesentericCancer treat rev 2004: 30: 555-562artery syndrome presenting with acute massive gastric52 Zalinski S, Scatton O, Jacqmin S, Tacher V, Brezault Cdilatation, gastric wall pneumatosis, and portal venous gasSoubrane o, portalI venous gas following chemotheraSurgery2003:134:840-843colorectal cancer liver metastasis. Eur Surg Oncol 2009; 35: 65 Tsai CL, Chen M), Tan CK, Chan KS, Cheng KC. Superiormesenteric artery syndrome with hepatic portal venous gas53 Matsutani T, Sasajima Maruyama H, Miyamoto MMed j Aust 2007; 186 48Yokoyama T, Suzuki S, Yanagi K, Kashiwabara M, Matsuda 66 Sakamoto Y, Mashiko K, Matsumoto H, Hara Y, KutsukataA, Tajiri T. [A case of hepatic portal venous gas causedN, Yamamoto Y, Gastric pneumatosis and portal venousby chemo-radiation therapy for an advanced esophagealgas in superior mesenteric artery syndrome. Indiancer] Nippon Shokakibyo Gakkai Zasshi 2008: 105: 1504-1508astroenterol 2006: 25: 265-266S- Editor Tian LL- Editor Logan s E- Editor Zheng xm中国煤化工CNMHGwww.wignet.com