Computed Tomographic Evidence of Hepatic Portal Venous Gas After Blunt Abdominal Trauma Does Not Necessitate Surgery

By Vercruysse, Gary A Adams, Sasha D; Feliciano, David V

Historically, hepatic portal venous gas (HPVG) seen on abdominal radiographic examination indicated serious intra-abdominal pathology requiring urgent operative intervention. The mortality attributed to HPVG is associated closely with its causative source rather than a direct effect of the presence of venous air and, therefore, the finding should be correlated with a careful clinical examination before any therapeutic endeavor. Fourteen cases of HPVG associated with blunt trauma have been reported over the past 20 years, and only half of these have resulted in surgery. We report the case of a 24-year-old woman who presented with no abdominal pathology other than HPVG after a severe motor vehicle crash. She was managed nonoperatively and made a successful recovery. FIRST DESCRIBED BY WOLFE and Evans in 1955 in six infants with necrotizing enterocolitis, hepatic portal venous gas (HPVG) has since been identified in many adult diseases involving mucosal damage by infectious or inflammatory processes or frank necrosis of the bowel wall.1 In the past, by plain radiograph, only large amounts of HPVG could be identified. In this situation, HPVG is noticed as a relatively late finding and is a sign of gangrene of the intestinal wall with the accompanying gas formed by anaerobic organisms. By the time HPVG is identified in these patients, they are quite ill, so it is not surprising that HPVG historically has been associated with an 85 per cent mortality rate.2,3

Today, as a direct result of the increased use of CT and ultrasound in the inpatient setting, cases of otherwise previously fatal HPVG are being detected at an earlier, more treatable stage. Also, more cases of benign and nonlife-threatening causes of HPVG are becoming evident (Table 1). HPVG seen in this subgroup of relatively benign situations also impacts the overall mortality rate. This has resulted in recent reports of mortality associated with HPVG as low as 29 per cent.4

Case Report

A 24-year-old black woman was transferred to our trauma center after being involved in a motor vehicle collision with prolonged extrication. Initially hypotensive, she responded to resuscitation with intravenous fluids. A focused assessment for the sonographic examination of the trauma patient (FAST) was negative; however, a CT scan of the abdomen revealed portal venous air within the liver without an associated visceral injury. She subsequently required a hemicraniectomy for a significant traumatic brain injury. Diagnostic peritoneal lavage approximately 6 hours posttrauma was negative. Because she was critically ill, and her abdominal examination and diagnostic peritoneal lavage were benign, she did not undergo laparotomy. Her abdominal examination remained benign and she was discharged 1 month later to a rehabilitation facility without further abdominal sequelae.

Discussion

Hepatic portal venous gas is diagnosed radiologically by lucencies branching horizontally away from the porta hepatis to the edge of the liver, as seen in Figure 1. Typically, venous gas collects within 2 cm of the liver capsule in comparison to biliary gas, which travels centrally to large ducts and collects near the hilum. The difference in these two patterns has been hypothesized to be the result of the different flow patterns of fluid in each system. The centrifugal direction of portal venous blood flow causes gas to collect in the periphery, whereas the centripetal flow of bile within the liver causes central accumulation of biliary gas.4

TABLE 1. Rare, Nonnecrotic Causes of Hepatic Portal Venous Gas

FIG. 1. Typical pattern of hepatic portal venous gas as seen in our patient.

The first report of HPVG in the trauma literature was in 1988 by Vauthey who discussed the incidental finding on an abdominal CT scan after blunt trauma, and the patient was managed conservatively.5

To date, including this report, there have been 14 reported cases of HPVG associated with trauma. Seven of these patients underwent operation secondary to abdominal pain or physician discomfort and the finding of intestinal pneumatosis.4,6-11 Of those patients, only four had significant intestinal findings requiring resection.4,6-8 The remaining seven patients, in the absence of associated visceral injury, were managed successfully without operation. In this subset, there were no delays in identification of intraabdominal injury (Table 2).5,12-15

TABLE 2. Management of All Known Cases of Traumatic Hepatic Portal Venous Gas

The proposed mechanism for HPVG in blunt trauma is the increased intraluminal pressure generated when gas-filled loops of intestine are compressed by external forces. This causes mucosal tears within the intestine, which allow gas to enter submucosal veins to travel to the mesenteric circulation and the hepatic portal system.4 Depending on the amount of damage done by this pressure, HPVG may be incidental or the result of significant trauma that will lead to intestinal necrosis and eventual rupture with peritonitis. We feel that there is a role for conservative management in HPVG after blunt trauma, but continued vigilance is warranted. Any progression of abdominal signs such as peritonitis with or without hypotension requires laparotomy.

REFERENCES

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GARY A. VERCRUYSSE, M.D.,* SASHA D. ADAMS, M.D.,[dagger] DAVID V. FELICIANO, M.D.*

From the * Department of Surgery, Emory University, Atlanta, Georgia; and the [dagger] University of Texas Medical School at Houston, Houston, Texas

Presented at the 58th annual meeting of the Southwestern Surgical Congress, Kauai, Hawaii, April 7, 2006.

Address correspondence and reprint requests to Gary A. Vercruysse, M.D., Emory University, Department of Surgery, 69 Jesse Hill Jr. Drive SE, Suite 312A, Atlanta, GA 30303. E-mail Gary.vercruysse@emory.org.

Copyright Southeastern Surgical Congress Apr 2008

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