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A, Computed tomographic scan showing a huge volume of hepatic portal venous gas throughout the whole liver, extending to below the hepatic capsule. B, Computed tomographic scan showing an important pneumatosis intestinalis and the presence of air in the mesenteric venous branches.

A, Computed tomographic scan showing a huge volume of hepatic portal venous gas throughout the whole liver, extending to below the hepatic capsule. B, Computed tomographic scan showing an important pneumatosis intestinalis and the presence of air in the mesenteric venous branches.

Table 1. 
Uncommon Pathologic Conditions Associated With Hepatic Portal Venous Gas
Uncommon Pathologic Conditions Associated With Hepatic Portal Venous Gas
Table 2. 
Outcome of Patients With Hepatic Portal Venous Gas
Outcome of Patients With Hepatic Portal Venous Gas
1.
Liebman  PRPatten  MTManny  JBenfield  JRHechtman  HB Hepatic portal venous gas in adults: etiology, pathophysiology, and clinical significance. Ann Surg. 1978;187281- 287PubMedArticle
2.
Haner  CInderbitzi  RBadulescu  MTeuscher  J Septische Pylephlebitis mit Nachweis von Gas in der Vena portae: seltene Komplikation der Sigmadivertikulitis. Schweiz Med Wochenschr. 1998;1281339- 1344PubMed
3.
Cambria  RPMargolies  MN Hepatic portal venous gas in diverticulitis: survival in a steroid-treated patient. Arch Surg. 1982;117834- 835PubMedArticle
4.
Graham  GABernstein  RBGronner  AT Gas in the portal and inferior mesenteric veins caused by diverticulitis of the sigmoid colon: report of a case with survival. Radiology. 1975;114601- 602PubMed
5.
Castillo  MMurphy  B Septic portal vein thrombophlebitis: computed tomography appearance: case report. Comput Radiol. 1986;10289- 292PubMedArticle
6.
Bodewes  HWPuylaert  JB Ultrasound in detection of portal venous gas in adults. Gastrointest Radiol. 1991;1635- 37PubMedArticle
7.
Lefleur  RSAmbos  MARothberg  MBenjamin  J Angiographic demonstration of gas and thrombus in the portal vein. AJR Am J Roentgenol. 1978;1301171- 1173PubMedArticle
8.
Graham  NG Gas in the portal vein in association with a pelvic abscess. BMJ. 1967;3288PubMedArticle
9.
Zielke  AHasse  CNies  CRothmund  M Hepatic-portal venous gas in acute colonic diverticulitis. Surg Endosc. 1998;12278- 280PubMedArticle
10.
Plemmons  RMDooley  DPLongfield  RN Septic thrombophlebitis of the portal vein (pylephlebitis): diagnosis and management in the modern era. Clin Infect Dis. 1995;211114- 1120PubMedArticle
11.
Haak  HRKooymans-Coutinho  MFvon  TMAdhin  SFalke  TH Portal venous gas in a patient with diverticulitis. Hepatogastroenterology. 1990;37528- 529PubMed
12.
Bach  MCAnderson  LGMartin  TAJMcAfee  RE Gas in the hepatic portal venous system: a diagnostic clue to an occult intra-abdominal abscess. Arch Intern Med. 1982;1421725- 1726PubMedArticle
13.
Tedesco  FJStanley  RJ Hepatic portal vein gas without bowel infarction or necrosis. Gastroenterology. 1975;69240- 243PubMed
14.
Burgard  GCuilleron  MCuilleret  J An unusual complication of perforated sigmoid diverticulitis: gas in the portal vein with miliary liver abscesses [in French]. J Chir (Paris). 1993;130237- 239PubMed
15.
Fataar  SCadogan  ESpruyt  O Ultrasonography of hepatic portal venous gas due to diverticulitis. Br J Radiol. 1986;59183- 185PubMedArticle
16.
Chang  SGLee  SCHong  DHChai  SE Portal and superior mesenteric venous gas with retroperitoneal abscess—CT diagnosis (case report). J Korean Med Sci. 1992;762- 65PubMed
17.
Speer  CSCarlson  DH Portal venous air with survival in ulcerative colitis: report of a case. Dis Colon Rectum. 1972;15453- 458PubMedArticle
18.
Moss  MLMazzeo  JT Pneumoperitoneum and portal venous air after barium enema. Va Med Q. Fall1991;118233- 235PubMed
19.
Maamary  Rde Toeuf  JPotvliege  R Hepatic portal venous gas (HPVG) following double-contrast barium enema in granulomatous colitis: a case report [in French]. J Belge Radiol. 1981;64175- 178PubMed
20.
Sadhu  VKBrennan  REMadan  V Portal vein gas following air-contrast barium enema in granulomatous colitis: report of a case. Gastrointest Radiol. 1979;4163- 164PubMedArticle
21.
Christensen  MALu  CH Gas in the portal vein after air-contrast barium enema in a patient with inflammatory colitis. South Med J. 1982;751291- 1292PubMedArticle
22.
Huycke  AMoeller  DD Hepatic portal venous gas after colonoscopy in granulomatous colitis. Am J Gastroenterol. 1985;80637- 638PubMed
23.
Birnberg  FAGore  RMShragg  BMargulis  AR Hepatic portal venous gas: a benign finding in a patient with ulcerative colitis. J Clin Gastroenterol. 1983;589- 91PubMedArticle
24.
Katz  BHSchwartz  SSVender  RJ Portal venous gas following a barium enema in a patient with Crohn's colitis: a benign finding. Dis Colon Rectum. 1986;2949- 51PubMedArticle
25.
Haber  I Hepatic portal vein gas following colonoscopy in ulcerative colitis: report of a case. Acta Gastroenterol Belg. 1983;4614- 17PubMed
26.
Pappas  DRomeu  JTarkin  NDave  PBMesser  J Portal vein gas in a patient with Crohn's colitis. Am J Gastroenterol. 1984;79728- 730PubMed
27.
Kees  CJHester  CLJ Portal vein gas following barium enema examination. Radiology. 1972;102525- 526PubMed
28.
Gosink  BB Intrahepatic gas: differential diagnosis. AJR Am J Roentgenol. 1981;137763- 767PubMedArticle
29.
Kirsch  MBozdech  JGardner  DA Hepatic portal venous gas: an unusual presentation of Crohn's disease. Am J Gastroenterol. 1990;851521- 1523PubMed
30.
Ajzen  SAGibney  RGCooperberg  PLScudamore  CHMiller  RR Enterovenous fistula: unusual complication of Crohn disease. Radiology. 1988;166745- 746PubMed
31.
Stein  MGCrues  JVHamlin  JA Portal venous air associated with barium enema. AJR Am J Roentgenol. 1983;1401171- 1172PubMedArticle
32.
Lee  CSKuo  YCPeng  SM  et al.  Sonographic detection of hepatic portal venous gas associated with suppurative cholangitis. J Clin Ultrasound. 1993;21331- 334PubMedArticle
33.
Dennis  MAPretorius  DManco-Johnson  MLBangert-Burroughs  K CT detection of portal venous gas associated with suppurative cholangitis and cholecystitis. AJR Am J Roentgenol. 1985;1451017- 1018PubMedArticle
34.
Edwards  AMMichalyshyn  BCostopoulos  LB Survival following gas in the portal venous system: a report of two cases. CMAJ. 1967;971029- 1031
35.
Munoz-Navas  MAJimenez-Perez  FJLecumberri  FJ Portal venous gas secondary to a penetrating foreign body of the stomach. Gastrointest Endosc. 1989;35573- 574PubMedArticle
36.
Benson  MD Adult survival with intrahepatic portal venous gas secondary to acute gastric dilatation, with a review of portal venous gas. Clin Radiol. 1985;36441- 443PubMedArticle
37.
Hughes  DGBarker  CS Adult survival with portal venous gas secondary to acute gastric dilation. Clin Radiol. 1986;37603PubMedArticle
38.
Radin  DRRosen  RSHalls  JM Acute gastric dilatation: a rare cause of portal venous gas. AJR Am J Roentgenol. 1987;148279- 280PubMedArticle
39.
Merine  DFishman  EK Uncomplicated portal venous gas associated with duodenal perforation following ERCP: CT features. J Comput Assist Tomogr. 1989;13138- 139PubMedArticle
40.
Vauthey  JMatthews  C Hepatic portal venous gas identified by computed tomography in a patient with blunt abdominal trauma: a case report. J Trauma. 1992;32120PubMed
41.
Friedman  DFlancbaum  LRitter  ETrooskin  SZ Hepatic portal venous gas identified by computed tomography in a patient with blunt abdominal trauma: a case report. J Trauma. 1991;31290- 292PubMedArticle
42.
Torriero  FMacori  FMisiti  AIacari  VAnaveri  G A case of gas occurrence in the venous hepato-portal area after blunt trauma of the abdomen [in Italian]. Radiol Med (Torino). 1998;96118- 120
43.
Quirke  TE Hepatic-portal venous gas associated with ileus. Am Surg. 1995;611084- 1086PubMed
44.
Chezmar  JLNelson  RCBernardino  ME Portal venous gas after hepatic transplantation: sonographic detection and clinical significance. AJR Am J Roentgenol. 1989;1531203- 1205PubMedArticle
45.
Ozgur  HTUnger  ECWright  WHJ Portal venous gas in a cardiac transplant patient [letter]. AJR Am J Roentgenol. 1996;166992- 993Article
46.
Waymack  JPPenn  IFirst  MRAlexander  JW Portal vein gas and sepsis after administration of OKT3 [letter]. Lancet. 1987;1984PubMedArticle
47.
Knechtle  SJDavidoff  AMRice  RP Pneumatosis intestinalis: surgical management and clinical outcome. Ann Surg. 1990;212160- 165PubMedArticle
48.
Pfaffenbach  BWegener  MBohmeke  T Hepatic portal venous gas after transgastric EUS-guided fine-needle aspiration of an accessory spleen. Gastrointest Endosc. 1996;43515- 518PubMedArticle
49.
Shaw  ACooperman  AFusco  J Gas embolism produced by hydrogen peroxide. N Engl J Med. 1967;277238- 241PubMedArticle
50.
Katzgraber  FGlenewinkel  FFischler  SRittner  C Mechanism of fatal air embolism after gastrointestinal endoscopy. Int J Legal Med. 1998;111154- 156PubMedArticle
51.
Ghani  AKasirajan  KSmith  J Portal pyelophlebitis identified by CT scan in a patient with ischemic bowel. Am Surg. 1995;611039- 1040PubMed
52.
Berne  TVMeyers  HIDonovan  AJ Gas in the portal vein of adults with necrotizing enteropathy. Am J Surg. 1970;120203- 209PubMedArticle
53.
Mallens  WMSchepers-Bok  RNicolai  JJJacobs  FAHeyerman  HG Portal and systemic venous gas in a patient with cystic fibrosis: CT findings. AJR Am J Roentgenol. 1995;165338- 339PubMedArticle
54.
Kriegshauser  JSReading  CCKing  BFWelch  TJ Combined systemic and portal venous gas: sonographic and CT detection in two cases. AJR Am J Roentgenol. 1990;1541219- 1221PubMedArticle
55.
Jones  B Massive gas embolism in E. coli septicemia. Gastrointest Radiol. 1981;6161- 163PubMedArticle
56.
Fisher  JK Computed tomography of colonic pneumatosis intestinalis with mesenteric and portal venous air. J Comput Assist Tomogr. 1984;8573- 574PubMedArticle
57.
Radin  DRRosen  RSHalls  JM Acute gastric dilatation: a rare cause of portal venous gas. AJR Am J Roentgenol. 1987;148279- 280PubMedArticle
58.
Laing  FCRego  JDJJeffrey  RB Ultrasonographic identification of portal vein gas. J Clin Ultrasound. 1984;12512- 514PubMedArticle
59.
Nachtegaele  PAfschrift  MVandendriessche  MVan  RRVoet  DVerdonk  G Sonographic diagnosis of gas embolism in the portal vein. Gastrointest Radiol. 1982;7375- 377PubMedArticle
60.
Pear  BL Pneumatosis intestinalis: a review. Radiology. 1998;20713- 19PubMed
61.
Boerner  RMFried  DBWarshauer  DMIsaacs  K Pneumatosis intestinalis: two case reports and a retrospective review of the literature from 1985 to 1995. Dig Dis Sci. 1996;412272- 2285PubMedArticle
62.
Scheidler  JStabler  AKleber  GNeidhardt  D Computed tomography in pneumatosis intestinalis: differential diagnosis and therapeutic consequences. Abdom Imaging. 1995;20523- 528PubMedArticle
Original Article
December 1, 2003

Hepatic Portal Gas in AdultsReview of the Literature and Presentation of a Consecutive Series of 11 Cases

Author Affiliations

From the Departments of Surgery (Drs Peloponissios, Halkic, Nordback, and Gillet), Radiology (Dr Pugnale), and Gastroenterology (Dr Jornod), Centre Hospitalier et Universitaire Vaudois, Lausanne, Switzerland; and the Department of Surgery, District Hospital of Morges, Morges, Switzerland (Dr Meyer).

Arch Surg. 2003;138(12):1367-1370. doi:10.1001/archsurg.138.12.1367
Abstract

Background  Hepatic portal venous gas (HPVG) in adults is a rare entity. The underlying pathologic condition is usually an intestinal ischemia, but it has been reported in association with a variety of conditions.

Hypothesis  Miscomprehension of the underlying pathologic conditions has led to some confusion in the literature concerning its etiology, diagnostic methods, and clinical consequences.

Setting  Centre Hospitalier et Universitaire Vaudois, Lausanne, Switzerland, and District Hospital of Morges, Morges, Switzerland.

Method  Between February 1, 1995, and May 30, 2000, eleven cases of HPVG were treated. These cases were retrospectively reviewed, together with a review of the literature to define the clinical significance of HPVG, the role of the computed tomographic scan, and the necessity of performing systematic emergency exploratory surgery.

Results  Two groups have to be distinguished—those who have HPVG with associated pneumatosis intestinalis and those who have HPVG without associated pneumatosis intestinalis. When associated with pneumatosis intestinalis, the cause is usually an intestinal ischemia and in a symptomatic patient it justifies systematic exploratory surgery. An abdominal computed tomographic scan including lung window settings to better identify air in the bowel wall will distinguish between these 2 groups. Pneumatosis intestinalis and HPVG due to bowel ischemia do not allow prediction of the severity of bowel wall damage.

Conclusions  The cause of HPVG without pneumatosis intestinalis is variable. Good knowledge of the possible causes combined with the clinical picture and the abdominal computed tomographic scan is required to correctly identify the underlying cause of HPVG and to avoid unnecessary surgery.

HEPATIC PORTAL venous gas (HPVG) was first reported in neonates in 1955 by Wolfe and Nevins as cited by Liebman et al.1(p281) In adults, it has since been described in association with a variety of pathologic conditions (Table 1) that include intestinal ischemia and necrosis (75% of the cases), ulcerative colitis (8% of the cases), and intra-abdominal abcess (6% of the cases).1,47 Patients with hepatic portal venous gas have a global survival rate of less than 25%1,2 owing to the severity of the underlying pathologic condition that most commonly is intestinal necrosis.1 This is a review of the literature and a retrospective study of 11 reported cases of HPVG that presented between February 1, 1995, and May 30, 2000, at either the Centre Hospitalier et Universitaire Vaudois, Lausanne, Switzerland, or the District Hospital of Morges, Morges, Switzerland. The aim of the study was to clarify the significance and treatment of HPVG, emphasizing the role of performing early exploratory surgery.

METHODS

Our case series included 6 men and 5 women whose mean age was 66 years (age range, 40-84 years). In 6 of the 11 patients the diagnosis of the underlying disease was confirmed by either surgery or autopsy (extensive intestinal ischemia, 3 patients; segmental bowel ischemia, 2 patients; and giant gastric ulcer, 1 patient). One case of pylephlebitis following diverticulitis was confirmed on computed tomographic (CT) scan. In 4 patients intestinal ischemia was suspected but was never confirmed. The diagnosis of HPVG in 10 patients was confirmed by CT scans, although the diagnosis was already suggested after ultrasonography or standard abdominal radiographs in 6 patients. In 9 cases of HPVG, CT scans revealed an associated pneumatosis intestinalis (PI). The 2 other cases of HPVG were not associated with PI and neither of these cases was related to intestinal ischemia. Eight of 11 patients died within 48 hours after presentation. Of the 5 patients who underwent surgery, 2 (40%) survived. These results are summarized in Table 2.

COMMENT

Hepatic portal venous gas can be due to gas under pressure in the bowel lumen or to an alteration of the mucosa, allowing the gas to enter the portal system through the mesenteric veins.1 These 2 mechanisms were demonstrated by Shaw et al49 in 1967 using a dog model. Based on these observations, we can hypothesize that any pathologic changes in the mucosa, for example, Crohn disease, may lead to alteration of vessel walls and the surrounding tissue, preventing them from collapsing. Thus, it allows an easier entry for air, as already hypothesized by Katzgraber et al50 in a gastric ulcer. A third mechanism is gas-forming bacteria in an intra-abdominal abscess1,3,4,43 with or without a related pylephlebitis35,51 as observed in our patient 4.

Hepatic portal venous gas can occur alone or in association with PI (Figure 1). When associated with PI, the origin seems to be intestinal ischemia, as observed in our case series. Hepatic portal venous gas is not predictive of its severity when caused by intestinal ischemia1 and has even been observed with reversible ischemia.1,52,53 In this series, 2 cases of HPVG and PI were observed with segmentary bowel ischemia (patients 9 and 10).

Associated portal and inferior or superior vena cava gas has already been described5355 and also has been observed in patient 1 of our case series. In 1 of the 3 reported cases described, air could clearly be observed in the superior and inferior mesenteric, hemorrhoidal, internal iliac, and left colic veins and inferior vena cava. Mallens et al53 hypothesized that the important quantity of gas caused temporary obstruction of the portal sinusoids with portosystemic shunting. In 1 of the cases described by Kriegshauser et al,54 the gas was observed with real-time sonography passing through the liver from the portal veins to the systemic circulation. In the third case the association between HPVG and air in the vena cava was observed in a fulminant sepsis and was attributed to a gas-forming organism causing portal and systemic venous gas.55

Transient cases of HPVG without clinical consequence have been observed in numerous cases (inflammatory bowel disease, acute gastric dilatation, blunt abdominal trauma, jejunostomy catheter insertion, and other isolated cases).45,47,53 Benign HPVG has even been observed, but exceptionally, in association with colonic intramural air.56

Abdominal radiographs can detect large quantities of HPVG or intestinal intramural gas, but its accuracy in demonstrating them is inferior to ultrasonographic or CT scans, both of which allow an earlier detection of small quantities of gas in the portal tract.6,44,57 The finding of HPVG on standard radiographs is suggestive of a poor prognosis and is commonly associated with bowel infarction (patients 7 and 11).6 A radiograph is more revealing in cases of HPVG when taken with the patient lying on his or her left side.1

At echography HPVG appears as numerous small hyperechogenic images with inconstant acoustic shadows.6,58,59 Gas in the portal venous system is carried by the centrifugal flow of blood in the periphery of the liver, appearing to extend to within 2 cm of the hepatic capsule. Inversely, gas in the biliary tract moves with the centripetal flow of bile, thus appearing more centrally in the liver. Ultrasonography gives additional real-time information, allowing the observation of the hepatofugal or hepatopetal gas displacement.59 With concomitant portal hypertension, gas bubbles may be slower to reach the liver periphery, making the diagnosis difficult.7 A history of biliodigestive anastomosis, endoscopic papillotomy, biliary endoprosthesis, or choledocointestinal fistula are certainly of importance in the differential diagnosis.28

With its excellent spatial and contrast resolution, a CT scan provides a conclusive diagnosis in most cases. Furthermore, associated necrotic bowel signs are more specific on CT scan than with ultrasonography. In necrosis, the gas generally produces a bubbly image whereas with innocuous causes, it can be linear or clusterlike, larger and more spherical.60 However, these signs are not specific and do not allow a clear-cut diagnosis. The standard window setting for an abdominal CT scan may overlook even extensive gas, particularly when using restricted windows. Thus, the use of complementary lung window settings is necessary when PI is suspected.61,62 Nevertheless, in all of our cases, PI was clearly observed with standard window settings.

CONCLUSIONS

The recognition of HPVG in adults indicates, in most cases, a life-threatening, acute abdominal process. Hepatic portal venous gas as well as PI are radiological clues and not diagnoses. Two groups have to be distinguished–those who have HPVG with associated PI and those who have HPVG without associated PI. When associated with PI, the cause of HPVG is usually an intestinal ischemia and in a symptomatic patient it justifies performing systematic exploratory surgery. An abdominal CT scan, including lung window settings to better identify air in the bowel wall, will distinguish between these 2 groups. Pneumatosis intestinalis and HPVG due to bowel ischemia do not allow prediction of the severity of bowel wall damage. The finding of HPVG on standard radiographs is suggestive of a poor prognosis and is commonly associated with bowel infarction. The cause of HPVG without PI can vary between innocuous and life-threatening causes. Both the patient's history and the clinical findings have to be considered to exclude a benign cause of HPVG and, thus, avoid unnecessary laparotomy. In doubtful cases, a prompt laparoscopic exploratory procedure is mandatory to exclude a surgically treatable disease.

Corresponding author and reprints: Nicolas Peloponissios, MD, Department of Surgery, Centre Hospitalier et Universitaire Vaudois, Rue du Bugnon 46, 1011 Lausanne, Switzerland (e-mail: nicolas.peloponissios@hospvd.ch).

Accepted for publication May 24, 2003.

References
1.
Liebman  PRPatten  MTManny  JBenfield  JRHechtman  HB Hepatic portal venous gas in adults: etiology, pathophysiology, and clinical significance. Ann Surg. 1978;187281- 287PubMedArticle
2.
Haner  CInderbitzi  RBadulescu  MTeuscher  J Septische Pylephlebitis mit Nachweis von Gas in der Vena portae: seltene Komplikation der Sigmadivertikulitis. Schweiz Med Wochenschr. 1998;1281339- 1344PubMed
3.
Cambria  RPMargolies  MN Hepatic portal venous gas in diverticulitis: survival in a steroid-treated patient. Arch Surg. 1982;117834- 835PubMedArticle
4.
Graham  GABernstein  RBGronner  AT Gas in the portal and inferior mesenteric veins caused by diverticulitis of the sigmoid colon: report of a case with survival. Radiology. 1975;114601- 602PubMed
5.
Castillo  MMurphy  B Septic portal vein thrombophlebitis: computed tomography appearance: case report. Comput Radiol. 1986;10289- 292PubMedArticle
6.
Bodewes  HWPuylaert  JB Ultrasound in detection of portal venous gas in adults. Gastrointest Radiol. 1991;1635- 37PubMedArticle
7.
Lefleur  RSAmbos  MARothberg  MBenjamin  J Angiographic demonstration of gas and thrombus in the portal vein. AJR Am J Roentgenol. 1978;1301171- 1173PubMedArticle
8.
Graham  NG Gas in the portal vein in association with a pelvic abscess. BMJ. 1967;3288PubMedArticle
9.
Zielke  AHasse  CNies  CRothmund  M Hepatic-portal venous gas in acute colonic diverticulitis. Surg Endosc. 1998;12278- 280PubMedArticle
10.
Plemmons  RMDooley  DPLongfield  RN Septic thrombophlebitis of the portal vein (pylephlebitis): diagnosis and management in the modern era. Clin Infect Dis. 1995;211114- 1120PubMedArticle
11.
Haak  HRKooymans-Coutinho  MFvon  TMAdhin  SFalke  TH Portal venous gas in a patient with diverticulitis. Hepatogastroenterology. 1990;37528- 529PubMed
12.
Bach  MCAnderson  LGMartin  TAJMcAfee  RE Gas in the hepatic portal venous system: a diagnostic clue to an occult intra-abdominal abscess. Arch Intern Med. 1982;1421725- 1726PubMedArticle
13.
Tedesco  FJStanley  RJ Hepatic portal vein gas without bowel infarction or necrosis. Gastroenterology. 1975;69240- 243PubMed
14.
Burgard  GCuilleron  MCuilleret  J An unusual complication of perforated sigmoid diverticulitis: gas in the portal vein with miliary liver abscesses [in French]. J Chir (Paris). 1993;130237- 239PubMed
15.
Fataar  SCadogan  ESpruyt  O Ultrasonography of hepatic portal venous gas due to diverticulitis. Br J Radiol. 1986;59183- 185PubMedArticle
16.
Chang  SGLee  SCHong  DHChai  SE Portal and superior mesenteric venous gas with retroperitoneal abscess—CT diagnosis (case report). J Korean Med Sci. 1992;762- 65PubMed
17.
Speer  CSCarlson  DH Portal venous air with survival in ulcerative colitis: report of a case. Dis Colon Rectum. 1972;15453- 458PubMedArticle
18.
Moss  MLMazzeo  JT Pneumoperitoneum and portal venous air after barium enema. Va Med Q. Fall1991;118233- 235PubMed
19.
Maamary  Rde Toeuf  JPotvliege  R Hepatic portal venous gas (HPVG) following double-contrast barium enema in granulomatous colitis: a case report [in French]. J Belge Radiol. 1981;64175- 178PubMed
20.
Sadhu  VKBrennan  REMadan  V Portal vein gas following air-contrast barium enema in granulomatous colitis: report of a case. Gastrointest Radiol. 1979;4163- 164PubMedArticle
21.
Christensen  MALu  CH Gas in the portal vein after air-contrast barium enema in a patient with inflammatory colitis. South Med J. 1982;751291- 1292PubMedArticle
22.
Huycke  AMoeller  DD Hepatic portal venous gas after colonoscopy in granulomatous colitis. Am J Gastroenterol. 1985;80637- 638PubMed
23.
Birnberg  FAGore  RMShragg  BMargulis  AR Hepatic portal venous gas: a benign finding in a patient with ulcerative colitis. J Clin Gastroenterol. 1983;589- 91PubMedArticle
24.
Katz  BHSchwartz  SSVender  RJ Portal venous gas following a barium enema in a patient with Crohn's colitis: a benign finding. Dis Colon Rectum. 1986;2949- 51PubMedArticle
25.
Haber  I Hepatic portal vein gas following colonoscopy in ulcerative colitis: report of a case. Acta Gastroenterol Belg. 1983;4614- 17PubMed
26.
Pappas  DRomeu  JTarkin  NDave  PBMesser  J Portal vein gas in a patient with Crohn's colitis. Am J Gastroenterol. 1984;79728- 730PubMed
27.
Kees  CJHester  CLJ Portal vein gas following barium enema examination. Radiology. 1972;102525- 526PubMed
28.
Gosink  BB Intrahepatic gas: differential diagnosis. AJR Am J Roentgenol. 1981;137763- 767PubMedArticle
29.
Kirsch  MBozdech  JGardner  DA Hepatic portal venous gas: an unusual presentation of Crohn's disease. Am J Gastroenterol. 1990;851521- 1523PubMed
30.
Ajzen  SAGibney  RGCooperberg  PLScudamore  CHMiller  RR Enterovenous fistula: unusual complication of Crohn disease. Radiology. 1988;166745- 746PubMed
31.
Stein  MGCrues  JVHamlin  JA Portal venous air associated with barium enema. AJR Am J Roentgenol. 1983;1401171- 1172PubMedArticle
32.
Lee  CSKuo  YCPeng  SM  et al.  Sonographic detection of hepatic portal venous gas associated with suppurative cholangitis. J Clin Ultrasound. 1993;21331- 334PubMedArticle
33.
Dennis  MAPretorius  DManco-Johnson  MLBangert-Burroughs  K CT detection of portal venous gas associated with suppurative cholangitis and cholecystitis. AJR Am J Roentgenol. 1985;1451017- 1018PubMedArticle
34.
Edwards  AMMichalyshyn  BCostopoulos  LB Survival following gas in the portal venous system: a report of two cases. CMAJ. 1967;971029- 1031
35.
Munoz-Navas  MAJimenez-Perez  FJLecumberri  FJ Portal venous gas secondary to a penetrating foreign body of the stomach. Gastrointest Endosc. 1989;35573- 574PubMedArticle
36.
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