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January 2010

Careful Approach to the ABCs of the Management of Portal Venous Gas—Reply

Arch Surg. 2010;145(1):104. doi:10.1001/archsurg.2009.234

In reply

We thank Naguib and colleagues for their interest in our publication and the thorough analysis of our article and would like to respond to several comments. First, while plain radiography is clearly less sensitive than CT, one of our key observations is the correlation between the increased sensitivity of CT and the decreased mortality associated with HPVG. Indeed, we conclude that it is the sensitivity of CT that has resulted in the discovery of iatrogenic HPVG as well as other low-mortality conditions. By this mechanism, the introduction of CT has essentially reduced the specificity of HPVG for life-threatening conditions, necessitating guidelines for the management of those findings. The data from the 1950s and 1960s are clear: plain radiography HPVG is definitively associated with high mortality rates because the low sensitivity will detect only profound anatomic abnormalities. Furthermore, we agree completely with the authors' opinion, that “for borderline cases, further reviewing or investigations, eg, diagnostic laparoscopy, may help in deciding the proper management,” circumstances in which we advise caution in our ABC algorithm (B = be careful).

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