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Wolfe  JNEvans  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) 486- 488PubMedGoogle Scholar
Susman  NSenturia  HR Gas embolization of the portal venous system.  Am J Roentgenol Radium Ther Nucl Med 1960;83847- 850PubMedGoogle Scholar
Wiot  JFFelson  B Gas in the portal venous system.  Am J Roentgenol Radium Ther Nucl Med 1961;86920- 929PubMedGoogle Scholar
Lazar  HP Survival following portal venous air embolization: report of a case.  Am J Dig Dis 1965;10259- 264PubMedGoogle ScholarCrossref
Liebman  PRPatten  MTManny  JBenfield  JRHechtman  HB Hepatic-portal venous gas in adults: etiology, pathophysiology and clinical significance.  Ann Surg 1978;187 (3) 281- 287PubMedGoogle ScholarCrossref
Kinoshita  HShinozaki  MTanimura  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) 1410- 1414PubMedGoogle ScholarCrossref
Faberman  RSMayo-Smith  WW Outcome of 17 patients with portal venous gas detected by CT.  AJR Am J Roentgenol 1997;169 (6) 1535- 1538PubMedGoogle ScholarCrossref
Schindera  STTriller  JVock  PHoppe  H Detection of hepatic portal venous gas: its clinical impact and outcome.  Emerg Radiol 2006;12 (4) 164- 170PubMedGoogle ScholarCrossref
Sebastià  CQuiroga  SEspin  EBoye  RAlvarez-Castells  AArmengol  M Portomesenteric vein gas: pathologic mechanisms, CT findings, and prognosis.  Radiographics 2000;20 (5) 1213- 1224, discussion 1224-1226PubMedGoogle ScholarCrossref
Sisk  PB Gas in the portal venous system.  Radiology 1961;77103- 106Google ScholarCrossref
Masannat  YMasannat  YShatnawei  A Gallstone ileus: a review.  Mt Sinai J Med 2006;73 (8) 1132- 1134PubMedGoogle Scholar
Kasznia-Brown  JCook  C Radiological signs of pneumoperitoneum: a pictorial review.  Br J Hosp Med (Lond) 2006;67 (12) 634- 639PubMedGoogle Scholar
Wiesner  WMortele  KJGlickman  JNJi  HRos  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) 1319- 1323PubMedGoogle ScholarCrossref
Arnon  RGFishbein  JF Portal venous gas in the pediatric age group: review of the literature and report of twelve new cases.  J Pediatr 1971;79 (2) 255- 259PubMedGoogle ScholarCrossref
See  CElliott  D Images in clinical medicine: pneumatosis intestinalis and portal venous gas.  N Engl J Med 2004;350 (4) e3PubMedGoogle ScholarCrossref
Berne  TVMeyers  HIDonovan  AJ Gas in the portal vein of adults with necrotizing enteropathy.  Am J Surg 1970;120 (2) 203- 209PubMedGoogle ScholarCrossref
Sibbald  WJSweeney  JPInwood  MJ Portal venous gas (PVG) as an indication for heparinization.  Am J Surg 1972;124 (5) 690- 693PubMedGoogle ScholarCrossref
Kriegshauser  JSReading  CCKing  BFWelch  TJ Combined systemic and portal venous gas: sonographic and CT detection in two cases.  AJR Am J Roentgenol 1990;154 (6) 1219- 1221PubMedGoogle ScholarCrossref
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;29 (1) 49- 51PubMedGoogle ScholarCrossref
Birnberg  FAGore  RMShragg  BMargulis  AR Hepatic portal venous gas: a benign finding in a patient with ulcerative colitis.  J Clin Gastroenterol 1983;5 (1) 89- 91PubMedGoogle ScholarCrossref
Haber  I Hepatic portal vein gas following colonoscopy in ulcerative colitis: report of a case.  Acta Gastroenterol Belg 1983;46 (1-2) 14- 17PubMedGoogle Scholar
Wiesner  WMortele  KJGlickman  JNJi  HRos  PR Portal-venous gas unrelated to mesenteric ischemia.  Eur Radiol 2002;12 (6) 1432- 1437PubMedGoogle ScholarCrossref
Celoria  GCoe  NP Does the presence of hepatic portal venous gas mandate an operation? A reassessment.  South Med J 1990;83 (5) 592- 594PubMedGoogle ScholarCrossref
Foster  SCSchneider  BSeaman  WB Gas-containing pyogenic intrahepatic abscesses.  Radiology 1970;94 (3) 613- 618PubMedGoogle ScholarCrossref
Yoshida  MMitsuo  MKutsumi  H  et al.  A successfully treated case of multiple liver abscesses accompanied by portal venous gas.  Am J Gastroenterol 1996;91 (11) 2423- 2425PubMedGoogle Scholar
Zielke  AHasse  CNies  CRothmund  M Hepatic-portal venous gas in acute colonic diverticulitis.  Surg Endosc 1998;12 (3) 278- 280PubMedGoogle ScholarCrossref
Tedesco  FJStanley  RJ Hepatic portal vein gas without bowel infarction or necrosis.  Gastroenterology 1975;69 (1) 240- 243PubMedGoogle Scholar
Nakao  AIwagaki  HIsozaki  H  et al.  Portal venous gas associated with splenic abscess secondary to colon cancer.  Anticancer Res 1999;19 (6C) 5641- 5644PubMedGoogle Scholar
Quirke  TE Hepatic-portal venous gas associated with ileus.  Am Surg 1995;61 (12) 1084- 1086PubMedGoogle Scholar
Lee  CSKuo  YCPeng  SM  et al.  Sonographic detection of hepatic portal venous gas associated with suppurative cholangitis.  J Clin Ultrasound 1993;21 (5) 331- 334PubMedGoogle ScholarCrossref
Sonnenshein  MACone  LAAlexander  RM Diverticulitis with colovenous fistula and portal venous gas: report of two cases.  J Clin Gastroenterol 1986;8 (2) 195- 198PubMedGoogle ScholarCrossref
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;165 (2) 338- 339PubMedGoogle ScholarCrossref
Chen  KWShin  JSChi  CHCheng  L Seizure: a rare and transient cause of portal venous gas.  Am J Gastroenterol 1997;92 (2) 351- 352PubMedGoogle Scholar
Saksena  MHarisinghani  MGWittenberg  JMueller  PR Case report: hepatic portal venous gas. Transient radiographic finding associated with colchicine toxicity.  Br J Radiol 2003;76 (911) 835- 837PubMedGoogle ScholarCrossref
Delamarre  JCapron  JPDupas  JLDeschepper  BJouet-Gondry  CRudelli  A Spontaneous portal venous gas in a patient with Crohn's ileocolitis.  Gastrointest Radiol 1991;16 (1) 38- 40PubMedGoogle ScholarCrossref
Niki  MShimizu  IHorie  T  et al.  Hepatic portal venous gas disappearing within 24 hours.  Intern Med 2002;41 (11) 950- 952PubMedGoogle ScholarCrossref
Mognol  PChosidow  DMarmuse  JP Hepatic portal gas due to gastro-jejunal anastomotic leak after laparoscopic gastric bypass.  Obes Surg 2005;15 (2) 278- 281PubMedGoogle ScholarCrossref
Herman  JBLevine  MSLong  WB Portal venous gas as a complication of ERCP and endoscopic sphincterotomy.  Am J Gastroenterol 1995;90 (5) 828- 829PubMedGoogle Scholar
Barthet  MMembrini  PBernard  JPSahel  J Hepatic portal venous gas after endoscopic biliary sphincterotomy.  Gastrointest Endosc 1994;40 (2, pt 1) 261- 263PubMedGoogle ScholarCrossref
Blind  PJOberg  LHedberg  B Hepatic portal vein gas following endoscopic retrograde cholangiography with sphincterotomy: case report.  Eur J Surg 1991;157 (4) 299- 300PubMedGoogle Scholar
Simmons  TC Hepatic portal venous gas due to endoscopic sphincterotomy.  Am J Gastroenterol 1988;83 (3) 326- 328PubMedGoogle Scholar
Nguyen  HNPurucker  ERiehl  JMatern  S Hepatic portal venous gas following emergency endoscopic sclerotherapy of gastric varices.  Hepatogastroenterology 1998;45 (23) 1767- 1769PubMedGoogle Scholar
Pfaffenbach  BWegener  MBohmeke  T Hepatic portal venous gas after transgastric EUS-guided fine-needle aspiration of an accessory spleen.  Gastrointest Endosc 1996;43 (5) 515- 518PubMedGoogle ScholarCrossref
Benson  MD Adult survival with intrahepatic portal venous gas secondary to acute gastric dilatation, with a review of portal venous gas.  Clin Radiol 1985;36 (4) 441- 443PubMedGoogle ScholarCrossref
Hughes  DGBarker  CS Adult survival with portal venous gas secondary to acute gastric dilation.  Clin Radiol 1986;37 (6) 603PubMedGoogle ScholarCrossref
Radin  DRRosen  RSHalls  JM Acute gastric dilatation: a rare cause of portal venous gas.  AJR Am J Roentgenol 1987;148 (2) 279- 280PubMedGoogle ScholarCrossref
Chezmar  JLNelson  RCBernardino  ME Portal venous gas after hepatic transplantation: sonographic detection and clinical significance.  AJR Am J Roentgenol 1989;153 (6) 1203- 1205PubMedGoogle ScholarCrossref
Oei  TvanSonnenberg  EShankar  SMorrison  PRTuncali  KSilverman  SG Radiofrequency ablation of liver tumors: a new cause of benign portal venous gas.  Radiology 2005;237 (2) 709- 717PubMedGoogle ScholarCrossref
Schmidt  AG Portal vein gas due to administration of fluids via the umbilical vein.  Radiology 1967;88 (2) 293- 294PubMedGoogle ScholarCrossref
Bull  MJKaye  B Portal vein gas following double-contrast barium enema.  Br J Radiol 1985;58 (695) 1129- 1130PubMedGoogle ScholarCrossref
Kees  CJHester  CL  Jr Portal vein gas following barium enema examination.  Radiology 1972;102 (3) 525- 526PubMedGoogle ScholarCrossref
Stein  MGCrues  JV  IIIHamlin  JA Portal venous air associated with barium enema.  AJR Am J Roentgenol 1983;140 (6) 1171- 1172PubMedGoogle ScholarCrossref
Shaw  ACooperman  AFusco  J Gas embolism produced by hydrogen peroxide.  N Engl J Med 1967;277 (5) 238- 241PubMedGoogle ScholarCrossref
Griffiths  DMGough  MH Gas in the hepatic portal veins.  Br J Surg 1986;73 (3) 172- 176PubMedGoogle ScholarCrossref
Paran  HEpstein  TGutman  MShapiro Feinberg  MZissin  R Mesenteric and portal vein gas: computerized tomography findings and clinical significance.  Dig Surg 2003;20 (2) 127- 132PubMedGoogle ScholarCrossref
Peloponissios  NHalkic  NPugnale  M  et al.  Hepatic portal gas in adults: review of the literature and presentation of a consecutive series of 11 cases.  Arch Surg 2003;138 (12) 1367- 1370PubMedGoogle ScholarCrossref
Kennedy  JHolt  CLRicketts  RR The significance of portal vein gas in necrotizing enterocolitis.  Am Surg 1987;53 (4) 231- 234PubMedGoogle Scholar
Marston  A Causes of death in mesenteric arterial occlusion, I: local and general effects of devascularization of the bowel.  Ann Surg 1963;158952- 959PubMedGoogle ScholarCrossref
Lai  CFChang  WTLiang  PCLien  WCWang  HPChen  WJ Pneumatosis intestinalis and hepatic portal venous gas after CPR.  Am J Emerg Med 2005;23 (2) 177- 181PubMedGoogle ScholarCrossref
Shiotani  SKohno  MOhashi  NYamazaki  KNakayama  HWatanabe  K Postmortem computed tomographic (PMCT) demonstration of the relation between gastrointestinal (GI) distension and hepatic portal venous gas (HPVG).  Radiat Med 2004;22 (1) 25- 29PubMedGoogle Scholar
Barsan  WGLevy  RCWeir  H Lidocaine levels during CPR: differences after peripheral venous, central venous, and intracardiac injections.  Ann Emerg Med 1981;10 (2) 73- 78PubMedGoogle ScholarCrossref
Earls  JPDachman  AHColon  EGarrett  MGMolloy  M Prevalence and duration of postoperative pneumoperitoneum: sensitivity of CT vs left lateral decubitus radiography.  AJR Am J Roentgenol 1993;161 (4) 781- 785PubMedGoogle ScholarCrossref
Schulze  CGBlum  UHaag  K Hepatic portal venous gas: imaging modalities and clinical significance.  Acta Radiol 1995;36 (4) 377- 380PubMedGoogle Scholar
Brenner  DJHall  EJ Computed tomography—an increasing source of radiation exposure.  N Engl J Med 2007;357 (22) 2277- 2284PubMedGoogle ScholarCrossref
Jones  B Massive gas embolism in E. coli septicemia.  Gastrointest Radiol 1981;6 (2) 161- 163PubMedGoogle ScholarCrossref
Chau  TNLoke  TKLeung  VKLaw  STLai  MHHo  YW Hepatic portal venous gas complicating septic thrombophlebitis of the superior mesenteric vein.  Hong Kong Med J 2007;13 (1) 69- 72PubMedGoogle Scholar
Yale  CEBalish  EWu  JP The bacterial etiology of pneumatosis cystoides intestinalis.  Arch Surg 1974;109 (1) 89- 94PubMedGoogle ScholarCrossref
Christensen  MALu  CH Gas in the portal vein after air-contrast barium enema in a patient with inflammatory colitis.  South Med J 1982;75 (10) 1291- 1292PubMedGoogle ScholarCrossref
Sadhu  VKBrennan  REMadan  V Portal vein gas following air-contrast barium enema in granulomatous colitis: report of a case.  Gastrointest Radiol 1979;4 (2) 163- 164PubMedGoogle ScholarCrossref
Huycke  AMoeller  DD Hepatic portal venous gas after colonoscopy in granulomatous colitis.  Am J Gastroenterol 1985;80 (8) 637- 638PubMedGoogle Scholar
Bilger  M Pneumatosis cystoides intestinalis in children; report of a case complicated with fatal pneumoperitoneum.  J Pediatr 1956;49 (4) 445- 449PubMedGoogle ScholarCrossref
Karaosmanoğlu  DOktar  SOArac  MErbas  G Case report: portal and systemic venous gas in a patient after lumbar puncture.  Br J Radiol 2005;78 (932) 767- 769PubMedGoogle ScholarCrossref
Negro  UVerdecchia  MPaci  E  et al.  Hepatic portal venous gas in a patient with enterovascular fistula.  Abdom Imaging 2006;31 (6) 706- 709PubMedGoogle ScholarCrossref
Oktar  SOKaraosmanoglu  DYucel  C  et al.  Portomesenteric venous gas: imaging findings with an emphasis on sonography.  J Ultrasound Med 2006;25 (8) 1051- 1058PubMedGoogle Scholar
Ruíz  DSde Perrot  TMajno  PE A case of portal venous gas secondary to acute appendicitis detected on gray scale sonography but not computed tomography.  J Ultrasound Med 2005;24 (3) 383- 386PubMedGoogle Scholar
Patriquin  LKassarjian  ABarish  M  et al.  Postmortem whole-body magnetic resonance imaging as an adjunct to autopsy: preliminary clinical experience.  J Magn Reson Imaging 2001;13 (2) 277- 287PubMedGoogle ScholarCrossref
Huurman  VAVisser  LGSteens  SCTerpstra  OTSchaapherder  AF Persistent portal venous gas.  J Gastrointest Surg 2006;10 (5) 783- 785PubMedGoogle ScholarCrossref
June 15, 2009

Hepatic Portal Venous Gas: The ABCs of Management

Author Affiliations

Author Affiliations: Tufts University School of Medicine (Dr Nelson) and Departments of Surgery (Drs Millington, Hertl, Warshaw, and Conrad), Radiology (Dr Sahani), and Medicine, Gastrointestinal Unit (Dr Chung), Massachusetts General Hospital, Boston, and Section of Gastroenterology, Medizinische Klinik Innenstadt, University of Munich, Munich, Germany (Dr Bauer).

Arch Surg. 2009;144(6):575-581. doi:10.1001/archsurg.2009.88

Objective  To review the use of computed tomography (CT) and radiography in managing hepatic portal venous gas (HPVG) at a university-affiliated tertiary care center and in the literature. Hepatic portal venous gas is frequently associated with acute mesenteric ischemia, accounting for most of the HPVG-associated mortality. While early studies were necessarily dependent on plain abdominal radiography, modern high-resolution CT has revealed a host of benign conditions in which HPVG has been reported that do not require emergent surgery.

Data Sources  Patient records from our institution over the last 10 years and relevant studies from BioMed Central, CENTRAL, PubMed, and PubMed Central. In addition, references cited in selected works were also used as source data.

Study Selection  Patient records were selected if the CT or radiograph findings matched the term hepatic portal venous gas. Studies were selected based on the search terms hepatic portal venous gas or portal venous gas.

Data Extraction  Quantitative and qualitative data were quoted directly from cited work.

Data Synthesis  Early studies of HPVG were based on plain abdominal radiography and a literature survey in 1978 found an associated mortality rate of 75%, primarily due to ischemic bowel disease. Modern abdominal CT has resulted in the detection of HPVG in more benign conditions, and a second literature survey in 2001 found a total mortality of only 39%. While the pathophysiology of HPVG is, as yet, unclear, changing abdominal imaging technology has altered the significance of this radiologic finding. Hepatic portal venous gas therefore predicts high risk of mortality (>50%) if detected by plain radiography or by CT in a patient with additional evidence of necrotic bowel. If detected by CT in patients after surgical or endoscopic manipulation, the clinician is advised that there is no evidence of increased risk. If HPVG is detected by CT in patients with active peptic ulcer disease, intestinal obstruction and/or dilatation, or mucosal diseases such as Crohn disease or ulcerative colitis, caution is warranted, as risk of death may approach 20% to 30%.

Conclusion  The finding of HPVG alone cannot be an indication for emergency exploration, and we have developed an evidence-based algorithm to guide the clinician in management of patients with HPVG.