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Original Article |

Clinical Features and Management of Hepatic Portal Venous Gas:  Four Case Reports and Cumulative Review of the Literature FREE

Hiroyuki Kinoshita, MD; Masahiro Shinozaki, MD; Hiroshi Tanimura, MD; Yoshiya Umemoto, MD; Satoshi Sakaguchi, MD; Katsunari Takifuji, MD; Sadao Kawasaki, MD; Hiroki Hayashi, MD; Hiroki Yamaue, MD
[+] Author Affiliations

From the Critical Care Medical Center (Drs Kinoshita, Shinozaki, Umemoto, Sakaguchi, Kawasaki, and Hayashi), and Second Department of Surgery, School of Medicine, Wakayama Medical University (Drs Kinoshita, Tanimura, Umemoto, Sakaguchi, Takifuji, and Yamaue), Wakayama, Japan.


Arch Surg. 2001;136(12):1410-1414. doi:10.1001/archsurg.136.12.1410.
Text Size: A A A
Published online

Hypothesis  Hepatic portal venous gas (HPVG) has been considered a rare entity associated with a grave prognosis. Since 1978, when Liebman et al reviewed 64 cases of HPVG and reported a mortality of 75%, the number of reported cases has been increasing.

Design  Case series.

Patients and Methods  We reviewed the literature on 182 cases of HPVG in adults, including 4 of our patients, (transplantation and abdominal trauma cases were excluded) and analyzed the cause, pathogenesis, and clinical features.

Results  In this series, the underlying clinical events associated with HPVG were bowel necrosis (43%), digestive tract dilatation (12%), intraperitoneal abscess (11%), ulcerative colitis (4%), gastric ulcer (4%), Crohn disease (4%), complications of endoscopic procedures (4%), intraperitoneal tumor (3%), and other (15%). The overall mortality was 39% but varied depending on the underlying disease.

Conclusions  Hepatic portal venous gas is a lethal or curable entity caused by various diseases. The underlying disease associated with HPVG determines the clinical features and prognosis of the patients. The treatment of patients with HPVG should be directed to the underlying disease.

Figures in this Article

HEPATIC PORTAL venous gas (HPVG) was first described by Wolf and Evans1 in 1955 in infants with necrotizing enterocolitis. In 1960, Susman and Senturia2 reported the first adult case, a patient critically ill with small bowel infarction. Thereafter, many authors have reported HPVG. Liebman et al3 reviewed 64 cases of HPVG in 1978 and reported a mortality of 75%. Since then, the number of reported cases has increased because of improvements in diagnostic methods, including computed tomography (CT) and ultrasonography, and the overall mortality rate has decreased because of adequate therapy. This study reviews the clinical data from 182 cases of this entity in adults from the literature, including 4 patients we treated, and discusses the management of HPVG relative to the underlying disease.

CASE 1

A 66-year-old man was referred to Wakayama Medical University Hospital, Wakayama, Japan, because of a fever spiking higher than 40°C and chills. He had a history of chronic hepatitis C, liver cirrhosis, and diabetes mellitus. The abdomen was soft and slightly distended without tenderness. Blood analysis showed a white blood cell count of 6.4 × 109/L, C-reactive protein value of 0.16 g/L, platelet count of 35 × 109/L, and prothrombin time of 12.7 seconds. Abdominal CT demonstrated splenomegaly, splenic abscess, and a tumor of the descending colon, which penetrated to the spleen. In addition, there were branching radiolucencies in the peripheries of the liver and no enhancement of the portal vein by intravenous administration of contrast medium (Figure 1).

Place holder to copy figure label and caption
Figure 1.

A, Air is present in the peripheral branches of the portal vein (arrows) in patient 1. B, Computed tomogram shows gas within the superior mesenteric vein (long arrow) and distal splenic vein (short arrow).

Graphic Jump Location

Emergency laparotomy was carried out under the diagnosis of cancer of the descending colon invaded to the spleen. Cancer of the splenic flexure with narrowing of the descending colon and infiltration into the spleen was found, and left hemicolectomy and splenectomy were performed, with construction of a stoma with transverse colon. Microscopically, the tumor exposed the serosa and penetrated to the spleen, with formation of abscess. The patient had liver abscess postoperatively, and percutaneous transhepatic abscess drainage was performed on the seventh day after the operation. The patient was treated for giant liver abscess at another hospital. Two months after the operation, he was discharged, and no recurrence has been noted.

CASE 2

A 57-year-old man was referred to our hospital with chief complaints of severe abdominal pain with involuntary guarding and rebound tenderness. The patient had had distal gastrectomy for a gastric peptic ulcer at age 47 years. Laboratory data revealed a white blood cell count of 14.7 × 109/L, prothrombin time of 14.6 seconds, glutamic oxaloacetic transaminase level of 361 U/L, lactate dehydrogenase level of 411 U/L, serum amylase level of 645 U/L, creatinine level of 2.7 mg/dL (239 µmol/L), and serum urea nitrogen level of 56 mg/dL (20.0 mmol/L). Arterial blood gas analysis on admission showed: pH, 7.26; PaCO2, 33 mm Hg; bicarbonate, 14.2 mmol/L; and base excess, −11.5 mmol/L. Abdominal CT revealed large amounts of gas in the superior mesenteric vein and multiple small tubular lucencies in the peripheries of the liver (Figure 2).

Place holder to copy figure label and caption
Figure 2.

A, Computed tomogram demonstrates several collections of gas (arrow) in the branches of the portal vein in patient 2. B, Air is seen inside the superior mesenteric vein (arrow).

Graphic Jump Location

Cyanotic bowel from the jejunum to the middle of the ascending colon was found at laparotomy. No pulsation of the superior mesenteric artery was detected. Resection of 350 cm of necrotic small intestine and ascending colon was performed, with construction of a jejunal stoma. The patient is alive 10 months after surgery, with short bowel syndrome with severe diarrhea and malnutrition.

CASE 3

A 51-year-old woman with progressive systemic sclerosis was referred to our hospital because of a continuous fever and abdominal distension. Nine days before admission, she had had a partial resection of the ileum for intestinal necrosis in another hospital. Her blood pressure was 139/75 mm Hg, pulse rate was 120/min, the abdomen was distended with decreased bowel sounds, and involuntary guarding was shown with rebounding tenderness. Laboratory data indicated a white blood cell count of 24.1 × 109/L, prothrombin time of 19.6 seconds, creatine kinase level of 211 U/L, lactate dehydrogenase level of 411 U/L, serum urea nitrogen level of 24 mg/dL (8.6 mmol/L), and C-reactive protein level of 0.12 g/L. Blood gas analysis at room temperature demonstrated: pH, 7.11; PaCO2, 85 mm Hg; PaO2, 22.2 mm Hg; bicarbonate, 6.7 mmol/L; and base excess, −21.3 mmol/L, which indicated metabolic acidosis.

Plain abdominal radiography and CT showed an abundance of free intraperitoneal air and multiple branching radiolucencies to the liver (Figure 3). An emergency operation was performed because of the diagnosis of peritonitis and portal venous gas because of bowel necrosis. At laparotomy, an extensive necrotic change was seen from the stomach to the sigmoid colon. Air bubbles were seen in all the mesenteric veins, and pulsation was absent in the celiac axis and superior mesenteric artery. The patient died 3 hours after the operation. No postmortem examination was performed.

Place holder to copy figure label and caption
Figure 3.

A, Branching lucencies of the biliary tract (arrow) on plain abdominal radiograph of patient 3. B, Abdominal computed tomogram shows that air filled the intrahepatic portal vein and intraperitoneal free space.

Graphic Jump Location
CASE 4

A 57-year-old man was admitted to our hospital with disturbed consciousness, hypotension at 60 mm Hg, and tachycardia at 141/min. The patient had a history of alcohol abuse, chronic hepatitis C, liver cirrhosis, esophageal varices, and diabetes mellitus. Physical examination revealed general jaundice, abdominal involuntary guarding, and an absence of bowel sounds. Laboratory data showed leukocytopenia, thrombocytopenia, and severe liver and kidney dysfunction. The arterial pH was 7.10; PaCO2, 50 mm Hg; bicarbonate, 12.9 mmol/L; and base excess, −13.3 mmol/L. Abdominal CT showed multiple small tubular lucencies in the periphery of the liver, in addition to intraperitoneal effusion and splenomegaly.

The patient was moved to the intensive care unit to improve his general condition. Nevertheless, he died 4 hours after admission. An autopsy confirmed diffuse bowel necrosis, including the stomach to the sigmoid colon, secondary to obstruction of the superior mesenteric artery.

The clinical features of these 4 cases are summarized in Table 1. Three patients who had bowel necrosis presented with severe metabolic acidosis, and 2 of them died after their operation or during treatment. The patient with HPVG associated with colon cancer underwent an appropriate operation immediately and survived. Analysis of our surviving cases indicated that an appropriate operation was required if HPVG was caused by bowel necrosis, abscess, or massive damage to the mucosa of the alimentary canal.

Table Graphic Jump LocationTable 1. Summary of the Clinical Features of 4 Case Reports
CUMULATIVE REVIEW OF THE LITERATURE

We summarized the clinical data from 182 cases of HPVG, including the present cases, in Table 2. The mean age of patients with this entity was 55 years, and 16 patients manifested signs of shock on admission.4 Patient management included an operation in 83 cases (46%) and conservative therapy in 79 (43%). The management of the other 20 cases were unclear. The overall mortality was 39%. Hepatic portal venous gas occurred in different clinical scenarios (Table 3), including bowel necrosis (43%), digestive tract dilatation (12%), intraperitoneal abscess (11%), ulcerative colitis (4%), gastric ulcer (4%), Crohn disease (4%), complications of endoscopic procedures (4%), intraperitoneal tumor (3%), and other (15%).

Table Graphic Jump LocationTable 2. Clinical Characteristics of 182 Cases*
Table Graphic Jump LocationTable 3. Underlying Disease and Mortality Rate

The mortality rate varied based on the underlying disease. The mortality was high in cases of HPVG associated with bowel necrosis (75%), and there was a tendency for the degree of bowel necrosis to affect mortality (Table 4). On the other hand, there were no lethal cases of HPVG associated with ulcerative colitis, intraperitoneal tumor, Crohn disease, cholangitis, pancreatitis, or complications of endoscopic procedures.

Table Graphic Jump LocationTable 4. Correlation Between the Degree of Bowel Necrosis and Mortality in 44 Cases of Hepatic Portal Venous Gas Caused by Bowel Necrosis*

Hepatic portal venous gas was first described in 1955 by Wolf and Evans.1 The pathogenesis of HPVG is not fully understood. Two sources of its origin have been proposed: (1) an escape of gas from increased pressure in the bowel lumen or in an abscess and then circulation into the liver or (2) the presence of gas-forming bacteria in the portal venous system and passage of gas into the circulation. Both findings were seen in many cases of HPVG.3,5,6

Hepatic portal venous gas is recognized not as a specific disease entity but as a diagnostic clue in patients with acute abdominal pathology. The diagnosis of HPVG is usually made by plain abdominal radiography, CT, or ultrasonography. It is diagnosed by the appearance of branching lucencies within 2 cm of the liver capsule on plain abdominal radiography or CT,7,8 whereas biliary gas usually is found within the central portion of the liver more than 2 cm from the liver capsule. Gas in the portal venous system is likely transported to the small peripheral branches in the liver by the centrifugal flow of portal venous blood, whereas gas in the biliary tree is prevented from migrating peripherally by the centripetal flow of bile.

Computed tomography has a higher sensitivity for the detection of HPVG than plain radiography.9,10 The number of cases of HPVG diagnosed in the United States has been steadily increasing.1114 The ultrasonographic features of HPVG have been reported as (1) echogenic particles flowing within the portal vein or (2) poorly defined, echogenic patches within the hepatic parenchyma, especially in the nondependent part.15 Schulze et al9 reported that color Doppler sonograms showed bright spots moving with the bloodstream.

Most cases of HPVG are caused by mesenteric vascular occlusion and subsequent bowel necrosis. However, HPVG has occurred with various conditions, some of which were cured with conservative management alone, including digestive tract dilatation,7,1620 gastric ulcer,9,11,21,22 ulcerative colitis,23 Crohn disease,2428 and complications of endoscopic procedures.2934 However, other cases were potentially lethal, and an emergency operation has been recommended in conditions such as abscess9,3541 and tumors.8,21,42,43 All 4 of our patients required an emergency operation. From our surviving cases, it appeared that survival in potentially lethal cases is dependent on adequate treatment of the underlying disease associated with HPVG. Statistical analysis did not show a correlation between age, heart rate, or base excess on admission and survival rate. However, relative to the high mortality rate of HPVG associated with bowel necrosis, the underlying disease might be an important factor contributing to patient survival. There was a tendency toward association of degree of bowel necrosis with mortality.

Hepatic portal venous gas has been considered an ominous sign, with an overall mortality higher than 75%.3,44 Because of poor clinical outcomes, exploratory laparotomy is recommended. In reviewing the cases in the literature, the overall mortality was 39%, but this was mitigated by a large number of patients with HPVG with underlying diseases other than bowel necrosis, which was associated with a 75% mortality. Operations were not performed in patients with HPVG associated with digestive tract dilatation, gastric ulcer, ulcerative colitis, Crohn disease, or complications of endoscopic procedures, because these conditions are curable with conservative management alone. The mortality was 38% in operated cases and 39% in nonoperated cases. There was no statistical difference in mortality rates between the operated and nonoperated cases in the cumulative review.

In conclusion, HPVG is not a specific disease entity but rather a diagnostic clue in patients with acute abdominal pathologic conditions. The treatment of patients with HPVG should be directed to the underlying disease, and the indications for an emergency operation should be based on the primary disease, with consideration of the high mortality rate of HPVG associated with bowel necrosis.

Corresponding author and reprints: Hiroki Yamaue, MD, Second Department of Surgery, School of Medicine, Wakayama Medical University, 811-1, Kimiidera, Wakayama 641-8510, Japan (e-mail: yamaue-h@wakayama-med.ac.jp).

Wolf  JNEvans  WA Gas in the portal veins of the liver in infants: a roentgenographic demonstration with postmortem anatomical correlation. AJR Am J Roentgenol. 1955;74486- 489
Susman  NSenturia  HR Gas embolization of the portal venous system. AJR Am J Roentgenol. 1960;83847- 850
Liebman  PRPatten  MTManny  J  et al.  Hepatic-portal venous gas in adults: etiology, pathophysiology and clinical significance. Ann Surg. 1978;187281- 287
Link to Article
Committee on Trauma, Shock. Advanced Trauma Life Support Program for Doctors6th ed. Chicago, Ill American College of Surgeons1997;87- 107
Kennedy  JHolt  CLRicketts  RR The significance of portal vein gas in necrotizing enterocolitis. Am Surg. 1987;53231- 234
Quirke  TE Hepatic-portal venous gas associated with ileus. Am Surg. 1995;611084- 1086
Nielsen  STOlsen  A Gas in the portal venous system. ROFO Fortschr Geb Rontgenstr Nuklearmed. 1985;142702- 703
Link to Article
Faberman  RSMayo-Smith  WW Outcome of 17 patients with portal venous gas detected by CT. AJR Am J Roentgenol. 1997;1691535- 1538
Link to Article
Schulze  CGBlum  UHaag  K Hepatic portal venous gas: imaging modalities and clinical significance. Acta Radiol. 1995;36377- 380
Chang  SGLee  SCHong  DH  et al.  Portal and superior mesenteric venous gas with retroperitoneal abscess. J Korean Med Sci. 1992;762- 65
Chang  YSWang  HPHuang  GT  et al.  Sonographic "gastric corona sign": diagnosis of gastric pneumatosis caused by a penetrating gastric ulcer. J Clin Ultrasound. 1999;27409- 412
Link to Article
Brown  MAHauschildt  JPCasola  GGosink  BBHoyt  DB Intravascular gas as an incidental finding at US after blunt abdominal trauma. Radiology. 1999;210405- 408
Link to Article
Chen  KWShin  JSChi  CHCheng  L  et al.  Seizure: a rare and transient cause of portal venous gas. Am J Gastroenterol. 1997;92351- 352
Lee  CSKuo  YCPeng  SM  et al.  Sonographic detection of hepatic portal venous gas associated with suppurative cholangitis. J Clin Ultrasound. 1993;21331- 334
Link to Article
Merritt  CRGoldsmith  JPSharp  MJ Sonographic detection of portal venous gas in infants with necrotizing enterocolitis. AJR Am J Roentgenol. 1984;1431059- 1062
Link to Article
Radin  DRRosen  RSHalls  JM Acute gastric dilatation: a rare cause of portal venous gas. AJR Am J Roentgenol. 1987;148279- 280
Link to Article
Hughes  DGBarker  CS Adult survival with portal venous gas secondary to acute gastric dilation [letter]. Clin Radiol. 1986;37603
Link to Article
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- 443
Link to Article
Fisher  JK Computed tomography of colonic pneumatosis intestinalis with mesenteric and portal venous air. J Comput Assist Tomogr. 1984;8573- 574
Link to Article
Haswell  DMCarsky  EW Hepatic portal venous gas and gastric emphysema with survival. AJR Am J Roentgenol. 1979;1331183- 1185
Link to Article
Scheidler  JStabler  AKleber  G  et al.  Computed tomography in pneumatosis intestinalis: differential diagnosis and therapeutic consequences. Abdom Imaging. 1995;20523- 528
Link to Article
Bodewes  HWPuylaert  JB Ultrasound in detection of portal venous gas in adults. Gastrointest Radiol. 1991;1635- 37
Link to Article
Birnberg  FAGore  RMShragg  B  et al.  Hepatic portal venous gas: a benign finding in a patient with ulcerative colitis. J Clin Gastroenterol. 1983;589- 91
Link to Article
Al-Jahdali  HPon  CThompson  WG  et al.  Non-fatal portal pyaemia complicating Crohn's disease of the terminal ileum. Gut. 1994;35560- 561
Link to Article
Delamarre  JCapron  JPDupas  JL  et al.  Spontaneous portal venous gas in a patient with Crohn's ileocolitis. Gastrointest Radiol. 1991;1638- 40
Link to Article
Kirsch  MBozdech  JGardner  DA Hepatic portal venous gas: an unusual presentation of Crohn's disease. Am J Gastroenterol. 1990;851521- 1523
Venugopal  CColley  DP Portal venous gas in a patient with Crohn's disease. J Clin Gastroenterol. 1990;12595- 597
Link to Article
Gosink  BB Intrahepatic gas: differential diagnosis. AJR Am J Roentgenol. 1981;137763- 767
Link to Article
Nguyen  HNPurucker  ERiehl  J  et al.  Hepatic portal venous gas following emergency endoscopic sclerotherapy of gastric varices. Hepatogastroenterology. 1998;451767- 1769
Pfaffenbach  BWegener  MBohmeke  T Hepatic portal venous gas after transgastric EUS-guided fine-needle aspiration of an accessory spleen. Gastrointest Endosc. 1996;43515- 518
Link to Article
Herman  JBLevine  MSLong  WB Portal venous gas as a complication of ERCP and endoscopic sphincterotomy. Am J Gastroenterol. 1995;90828- 829
Barthet  MMembrini  PBernard  JP  et al.  Hepatic portal venous gas after endoscopic biliary sphincterotomy. Gastrointest Endosc. 1994;40261- 263
Link to Article
Blind  PJOberg  LHedberg  B Hepatic portal vein gas following endoscopic retrograde cholangiography with sphincterotomy: case report. Eur J Surg. 1991;157299- 300
Simmons  TC Hepatic portal venous gas due to endoscopic sphincterotomy. Am J Gastroenterol. 1988;83326- 328
Haak  HRKooymans-Coutinho  MFTeeffelen  ME  et al.  Portal venous gas in a patient with diverticulitis. Hepatogastroenterology. 1990;37528- 529
Tanisi  CFHiette  P Gas in the portal venous system after percutaneous abscess drainage. AJR Am J Roentgenol. 1989;1531314- 1315
Link to Article
Sisley  JFMiller  DMNesbit  RR  Jr Computerized axial tomography (CT) as an aid in the diagnosis of hepatic portal venous gas: a case report. Surgery. 1987;101376- 379
Sonnenshein  MACone  LAAlexander  RM Diverticulitis with colovenous fistula and portal venous gas: report of two cases. J Clin Gastroenterol. 1986;8195- 198
Link to Article
Pearse  BSauerbrei  ELeddin  D The ultrasonic and computerized tomographic diagnosis of gas in the mesenteric-portal venous system. J Can Assoc Radiol. 1982;33269- 272
Bach  MCAnderson  LGMartin  TA  JrMcAfee  RE Gas in the hepatic portal venous system: a diagnostic clue to an occult intra-abdominal abscess. Arch Intern Med. 1982;1421725- 1726
Link to Article
Cambria  RPMargolies  MN Hepatic portal venous gas in diverticulitis: survival in a steroid-treated patient. Arch Surg. 1982;117834- 835
Link to Article
Nakao  AIwagaki  HIsozaki  H  et al.  Portal venous gas associated with splenic abscess secondary to colon cancer. Anticancer Res. 1999;195641- 5644
Kriegshauser  JSReading  CCKing  BF  et al.  Combined systemic and portal venous gas: sonographic and CT detection in two cases. AJR Am J Roentgenol. 1990;1541219- 1221
Link to Article
Graham  GABernstein  RBGronner  AT Gas in the portal and inferior mesenteric veins caused by diverticulitis of the sigmoid colon: report of a case survival. Radiology. 1975;114601- 602

Figures

Place holder to copy figure label and caption
Figure 1.

A, Air is present in the peripheral branches of the portal vein (arrows) in patient 1. B, Computed tomogram shows gas within the superior mesenteric vein (long arrow) and distal splenic vein (short arrow).

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.

A, Computed tomogram demonstrates several collections of gas (arrow) in the branches of the portal vein in patient 2. B, Air is seen inside the superior mesenteric vein (arrow).

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3.

A, Branching lucencies of the biliary tract (arrow) on plain abdominal radiograph of patient 3. B, Abdominal computed tomogram shows that air filled the intrahepatic portal vein and intraperitoneal free space.

Graphic Jump Location

Tables

Table Graphic Jump LocationTable 1. Summary of the Clinical Features of 4 Case Reports
Table Graphic Jump LocationTable 2. Clinical Characteristics of 182 Cases*
Table Graphic Jump LocationTable 3. Underlying Disease and Mortality Rate
Table Graphic Jump LocationTable 4. Correlation Between the Degree of Bowel Necrosis and Mortality in 44 Cases of Hepatic Portal Venous Gas Caused by Bowel Necrosis*

References

Wolf  JNEvans  WA Gas in the portal veins of the liver in infants: a roentgenographic demonstration with postmortem anatomical correlation. AJR Am J Roentgenol. 1955;74486- 489
Susman  NSenturia  HR Gas embolization of the portal venous system. AJR Am J Roentgenol. 1960;83847- 850
Liebman  PRPatten  MTManny  J  et al.  Hepatic-portal venous gas in adults: etiology, pathophysiology and clinical significance. Ann Surg. 1978;187281- 287
Link to Article
Committee on Trauma, Shock. Advanced Trauma Life Support Program for Doctors6th ed. Chicago, Ill American College of Surgeons1997;87- 107
Kennedy  JHolt  CLRicketts  RR The significance of portal vein gas in necrotizing enterocolitis. Am Surg. 1987;53231- 234
Quirke  TE Hepatic-portal venous gas associated with ileus. Am Surg. 1995;611084- 1086
Nielsen  STOlsen  A Gas in the portal venous system. ROFO Fortschr Geb Rontgenstr Nuklearmed. 1985;142702- 703
Link to Article
Faberman  RSMayo-Smith  WW Outcome of 17 patients with portal venous gas detected by CT. AJR Am J Roentgenol. 1997;1691535- 1538
Link to Article
Schulze  CGBlum  UHaag  K Hepatic portal venous gas: imaging modalities and clinical significance. Acta Radiol. 1995;36377- 380
Chang  SGLee  SCHong  DH  et al.  Portal and superior mesenteric venous gas with retroperitoneal abscess. J Korean Med Sci. 1992;762- 65
Chang  YSWang  HPHuang  GT  et al.  Sonographic "gastric corona sign": diagnosis of gastric pneumatosis caused by a penetrating gastric ulcer. J Clin Ultrasound. 1999;27409- 412
Link to Article
Brown  MAHauschildt  JPCasola  GGosink  BBHoyt  DB Intravascular gas as an incidental finding at US after blunt abdominal trauma. Radiology. 1999;210405- 408
Link to Article
Chen  KWShin  JSChi  CHCheng  L  et al.  Seizure: a rare and transient cause of portal venous gas. Am J Gastroenterol. 1997;92351- 352
Lee  CSKuo  YCPeng  SM  et al.  Sonographic detection of hepatic portal venous gas associated with suppurative cholangitis. J Clin Ultrasound. 1993;21331- 334
Link to Article
Merritt  CRGoldsmith  JPSharp  MJ Sonographic detection of portal venous gas in infants with necrotizing enterocolitis. AJR Am J Roentgenol. 1984;1431059- 1062
Link to Article
Radin  DRRosen  RSHalls  JM Acute gastric dilatation: a rare cause of portal venous gas. AJR Am J Roentgenol. 1987;148279- 280
Link to Article
Hughes  DGBarker  CS Adult survival with portal venous gas secondary to acute gastric dilation [letter]. Clin Radiol. 1986;37603
Link to Article
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- 443
Link to Article
Fisher  JK Computed tomography of colonic pneumatosis intestinalis with mesenteric and portal venous air. J Comput Assist Tomogr. 1984;8573- 574
Link to Article
Haswell  DMCarsky  EW Hepatic portal venous gas and gastric emphysema with survival. AJR Am J Roentgenol. 1979;1331183- 1185
Link to Article
Scheidler  JStabler  AKleber  G  et al.  Computed tomography in pneumatosis intestinalis: differential diagnosis and therapeutic consequences. Abdom Imaging. 1995;20523- 528
Link to Article
Bodewes  HWPuylaert  JB Ultrasound in detection of portal venous gas in adults. Gastrointest Radiol. 1991;1635- 37
Link to Article
Birnberg  FAGore  RMShragg  B  et al.  Hepatic portal venous gas: a benign finding in a patient with ulcerative colitis. J Clin Gastroenterol. 1983;589- 91
Link to Article
Al-Jahdali  HPon  CThompson  WG  et al.  Non-fatal portal pyaemia complicating Crohn's disease of the terminal ileum. Gut. 1994;35560- 561
Link to Article
Delamarre  JCapron  JPDupas  JL  et al.  Spontaneous portal venous gas in a patient with Crohn's ileocolitis. Gastrointest Radiol. 1991;1638- 40
Link to Article
Kirsch  MBozdech  JGardner  DA Hepatic portal venous gas: an unusual presentation of Crohn's disease. Am J Gastroenterol. 1990;851521- 1523
Venugopal  CColley  DP Portal venous gas in a patient with Crohn's disease. J Clin Gastroenterol. 1990;12595- 597
Link to Article
Gosink  BB Intrahepatic gas: differential diagnosis. AJR Am J Roentgenol. 1981;137763- 767
Link to Article
Nguyen  HNPurucker  ERiehl  J  et al.  Hepatic portal venous gas following emergency endoscopic sclerotherapy of gastric varices. Hepatogastroenterology. 1998;451767- 1769
Pfaffenbach  BWegener  MBohmeke  T Hepatic portal venous gas after transgastric EUS-guided fine-needle aspiration of an accessory spleen. Gastrointest Endosc. 1996;43515- 518
Link to Article
Herman  JBLevine  MSLong  WB Portal venous gas as a complication of ERCP and endoscopic sphincterotomy. Am J Gastroenterol. 1995;90828- 829
Barthet  MMembrini  PBernard  JP  et al.  Hepatic portal venous gas after endoscopic biliary sphincterotomy. Gastrointest Endosc. 1994;40261- 263
Link to Article
Blind  PJOberg  LHedberg  B Hepatic portal vein gas following endoscopic retrograde cholangiography with sphincterotomy: case report. Eur J Surg. 1991;157299- 300
Simmons  TC Hepatic portal venous gas due to endoscopic sphincterotomy. Am J Gastroenterol. 1988;83326- 328
Haak  HRKooymans-Coutinho  MFTeeffelen  ME  et al.  Portal venous gas in a patient with diverticulitis. Hepatogastroenterology. 1990;37528- 529
Tanisi  CFHiette  P Gas in the portal venous system after percutaneous abscess drainage. AJR Am J Roentgenol. 1989;1531314- 1315
Link to Article
Sisley  JFMiller  DMNesbit  RR  Jr Computerized axial tomography (CT) as an aid in the diagnosis of hepatic portal venous gas: a case report. Surgery. 1987;101376- 379
Sonnenshein  MACone  LAAlexander  RM Diverticulitis with colovenous fistula and portal venous gas: report of two cases. J Clin Gastroenterol. 1986;8195- 198
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