Portal Venous Gas SUNY Downstate Medical Center Department of Surgery. Jacob Eisdorfer, DO 6/9/2011

Transcription

1 SUNY Downstate Medical Center Department of Surgery Jacob Eisdorfer, DO 6/9/2011

2 Case 56 y/o M presented to ER c/o severe Abd Pain, N/V x 4days PMHx: HIV, HTNHep C, COPD, renal insufficiency VS: 98.7; 86/60; 96; 16; 99% Lethargic, but arousable Abdomen distended and tender Labs:

3 Imaging Case

4 Case Imaging

5 Case Imaging

6 Case Imaging

7 Case Imaging

8 Case Resuscitation in ER & OR Ex-Lap Significant amount of small bowel found to be gangrenous and was resected 20cm of jejunum, and 120cm of distal Ileum left, some dusky patches Good Doppler signal throughout mesentery, no sign of venous congestion Left OR on Levophed, Vasopressin, & Epinephrine drips Skin closed, fascia left open with plan to come back to OR for second look laparotomy

9 Case POD 0-1 Aggressively resuscitated overnight in PACU By 6am all pressors off Labs: 2am: -6am:

10 Case Second Look All remaining small and large bowel appeared viable and well perfused Small bowel to small bowel anastomosis created Abdomen Closed

11 Case Hospital course POD 1-2, intubated in MICU, resuscitation continued POD 3 Extubated POD 5 continued to pass flatus and had BM liquid diet started & slowly advanced to regular POD 8: Discharged home

12 Nelson AL, Millington TM, Sahani D, Chung RT, Bauer C, Hertl M, Warshaw AL, Conrad C. Hepatic portal venous gas: the ABCs of management. Arch Surg Jun; 144(6): (Tufts)

13 Rare Radiologic Finding Only 182 cases documented in the literature by Reviews of CT scans in academic medical centers: 17 / 14,000 scans 11 / 19,000 scans Kinoshita H, Shinozaki M, Tanimura H, et al. Clinical features and management of hepatic portal venous gas: four case reports and cumulative review of the literature. Arch Surg. 2001;136(12): (Japan) Faberman RS, Mayo-Smith WW. Outcome of 17 patients with portal venous gas detected by CT. AJR Am J Roentgenol. 1997;169(6): (R.I. Hosp., Brown Univ. Med School) Schindera ST, Triller J, Vock P, Hoppe H. Detection of hepatic portal venous gas: its clinical impact and outcome. Emerg Radiol. 2006;12(4): (Switzerland)

14 Described 1955 by Wolfe and Evans abdominal plain radiographs 6 Neonates who died secondary to necrotic bowel Followed by a report in 1960 of Hepatic Portal venous gas in 5 adults who died Wolfe JN, Evans WA. Gas in the portal veins of the liver in infants: a roentgenographic demonstration with postmortem anatomical correlation. Am J Roentgenol Radium Ther Nucl Med. 1955;74(3): Susman N, Senturia HR. Gas embolization of the portal venous system. Am J Roentgenol Radium Ther Nucl Med. 1960;83:

15 First reported survivor: 1965 Liebman & colleagues analyzed all reported cases by 1978 Mortality 75% Concluded that the finding of portal venous gas demands emergent laparotomy Lazar HP. Survival following portal venous air embolization: report of a case. Am J Dig Dis. 1965;10: Liebman PR, Patten MT, Manny J, Benfield JR, Hechtman HB. Hepatic-portal venous gas in adults: etiology, pathophysiology and clinical significance. Ann Surg. 1978;187(3):

16 Defined by Sisk as tubular areas of decreased attenuation in the liver periphery Injected contrast into portal vein & detected it within 2cm of the capsule. Distinguished from aerobilia which is centrally located air in the biliary tree Sebastià C, Quiroga S, Espin E, Boye R, Alvarez-Castells A, Armengol M. Portomesenteric vein gas: pathologic mechanisms, CT findings, and prognosis. Radiographics. 2000;20(5): , discussion (Spain) Masannat Y, Masannat Y, Shatnawei A. Gallstone ileus: a review. Mt Sinai JMed. 2006;73(8): (UK)

17

18 Experimentally Air injected into submucosa or mesenteric veins of dog intestines was found in the portal venous system. Occlusion of mesenteric arteries in dogs resulting in infarction also results in portal venous air Berne TV, Meyers HI, Donovan AJ. Gas in the portal vein of adults with necrotizing enteropathy. Am J Surg. 1970;120(2): Marston A. Causes of death in mesenteric arterial occlusion, I: local and general effects of devascularization of the bowel. Ann Surg. 1963;158:

19 Pathophysiology (Hypothesis) Microbe-derived gas production Absorbed Intraluminal air through disrupted mucosa No actual experimental evidence Jones B. Massive gas embolism in E. coli septicemia. Gastrointest Radiol. 1981; 6(2):

20 Portal venous gas has also been reported in many nonfatal conditions Crohn s Disease Ulcerative Colitis Gastric Ulcer Graft-vs-Host Disease Uncomplicated Bowel Obstruction Pseudo-obstruction Bacterial Abscesses Diverticulitis Paralytic Ileus Suppurative Cholangitis Colovenous Fistulae Cystic Fibrosis Seizures Colchicine Toxicity Iatrogenic: Laparoscopy Endoscopy ERCP Gastric Dilitation Liver Transplant RFA Arterial Cath Nelson AL, Millington TM, Sahani D, Chung RT, Bauer C, Hertl M, Warshaw AL, Conrad C. Hepatic portal venous gas: the ABCs of management. Arch Surg Jun; 144(6):

21 Newer data reports the mortality associated to be 39% Decrease thought to be due to change in diagnostic imaging CT scanning More sensitive for portal venous gas and also diagnostic for non fatal etiologies A direct correlation is also made with the frequency of bowel ischemia as an etiology 72% in % in 2001 When Bowel ischemia is the cause mortality remains high (~75%) Kinoshita H, Shinozaki M, Tanimura H, et al. Clinical features and management of hepatic portal venous gas: four case reports and cumulative review of the literature. Arch Surg. 2001;136(12): (Japan)

22 Nelson AL, Millington TM, Sahani D, Chung RT, Bauer C, Hertl M, Warshaw AL, Conrad C. Hepatic portal venous gas: the ABCs of management. Arch Surg Jun; 144(6): (Tufts)

23 References Nelson AL, Millington TM, Sahani D, Chung RT, Bauer C, Hertl M, Warshaw AL, Conrad C. Hepatic portal venous gas: the ABCs of management. Arch Surg Jun; 144(6): Wolfe JN, Evans WA. Gas in the portal veins of the liver in infants: a roentgenographic demonstration with postmortem anatomical correlation. Am J Roentgenol Radium Ther Nucl Med. 1955;74(3): Susman N, Senturia HR. Gas embolization of the portal venous system. Am J Roentgenol Radium Ther Nucl Med. 1960;83: Lazar HP. Survival following portal venous air embolization: report of a case. Am J Dig Dis. 1965;10: Liebman PR, Patten MT, Manny J, Benfield JR, Hechtman HB. Hepatic-portal venous gas in adults: etiology, pathophysiology and clinical significance. Ann Surg. 1978;187(3): Kinoshita H, Shinozaki M, Tanimura H, et al. Clinical features and management of hepatic portal venous gas: four case reports and cumulative review of the literature. Arch Surg. 2001;136(12): Faberman RS, Mayo-Smith WW. Outcome of 17 patients with portal venous gas detected by CT. AJR Am J Roentgenol. 1997;169(6): Schindera ST, Triller J, Vock P, Hoppe H. Detection of hepatic portal venous gas: its clinical impact and outcome. Emerg Radiol. 2006;12(4): Wiesner W, Mortele KJ, Glickman JN, Ji H, Ros PR. Pneumatosis intestinalis and portomesenteric venous gas in intestinal ischemia: correlation of CT findings with severity of ischemia and clinical outcome. AJR Am J Roentgenol. 2001;177 (6): (Brigham, Boston) Wolfe JN, Evans WA. Gas in the portal veins of the liver in infants: a roentgenographic demonstration with postmortem anatomical correlation. Am J Roentgenol Radium Ther Nucl Med. 1955;74(3): Berne TV, Meyers HI, Donovan AJ. Gas in the portal vein of adults with necrotizing enteropathy. Am J Surg. 1970;120(2): Marston A. Causes of death in mesenteric arterial occlusion, I: local and general effects of devascularization of the bowel. Ann Surg. 1963;158: Jones B. Massive gas embolism in E. coli septicemia. Gastrointest Radiol. 1981; 6(2): Kinoshita H, Shinozaki M, Tanimura H, et al. Clinical features and management of hepatic portal venous gas: four case reports and cumulative review of the literature. Arch Surg. 2001;136(12):