Imaging and clinical features of heptic portal vein gas
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摘要:
目的 探讨肝脏门静脉积气（HPVG）的临床及影像学特征。 方法 回顾性分析10例HPVG患者的资料，结合文献对其临床特征、影像学特征、治疗及预后进行总结。 结果 10例患者中，以急性消化道症状起病7例，发热5例。存在肾功能不全、维持性血透等相关病史3例，高血压病8例，外科手术史6例。临床诊断中肠梗阻5例，重症感染、感染性休克6例。10例患者仅3例存活。采取手术治疗的2例患者均确诊为肠坏死。HPVG量无论多少均以门静脉左支分布为著；10例中脾静脉、肠系膜上静脉积气7例，肠壁下积气9例；局部肠壁水肿7例，肠梗阻5例，消化道穿孔3例。在5例增强扫描病例中，肠系膜上动脉血栓2例。 结论 HPVG病例中合并肠壁下积气的发生率较高，临床应重视HPVG及相关影像特征的识别，从而对患者进行及时干预。 Abstract:Objective To investigate the imaging and clinical features of hepatic portal vein gas (HPVG). Methods The data of 10 HPVG patients in the Second People's Hospital of Lianyungang, Zhongda Hospital Southeast University from June 2012 to April 2020 were analyzed retrospectively. The imaging and clinical features, treatment and prognosis were summarized. Results Acute gastrointestinal symptoms occurred in 7 cases and fever in 5 cases. Renal insufficiency and maintenance hemodialysis in 3 cases, 8 cases of hypertension, 6 cases of surgical history. In clinical diagnosis, 5 cases of intestinal obstruction, 6 cases of severe infection and septic shock. Only 3 of the 10 patients survived. Both patients treated with surgery were diagnosed with intestinal necrosis. The gas in portal vein was mainly distributed in the left branch of portal vein. There were 7 cases of pneumatosis of splenic vein, superior mesenteric vein and its tributaries, and 9 cases of pneumatosis of intestinal wall. There were 7 cases of local intestinal wall edema, 5 cases of intestinal obstruction and 3 cases of digestive tract perforation. Enhanced scan confirmed superior mesenteric artery thrombosis in 2 cases. Conclusion The incidence of pneumatosis cystoides intestinalis in HPVG cases is high. Clinical attention should be paid to the identification of HPVG and related imaging features, so as to intervene in patients in time. -
图 1 病例7的CT及病理切片图
Figure 1. CT image and pathological section of case 7
A-C: CT image on the day of admission. A: HPVG was mainly distributed in the distal left branch of the portal vein; B: Multiple small vesicles, strip-like gas accumulation (white arrow) under the intestinal wall; C: The distal part of superior mesenteric vein belongs to the branch with accumulated gas (white arrow). D-E: CT images reviewed. D: A large amount of free gas in the abdominal cavity (white arrow); E: The intestinal wall of the transverse colon near the splenic flexure is edematous, with exudation around it (white arrow); F: Transverse colon pathological section (HE staining, ×100), lesion area intestinal mucosal erosion with inflammatory exudative necrosis, inflammatory cell infiltration, and histiocytes aggregation.
图 2 病例1的CT及病理切片图
Figure 2. CT image and pathological section of case 1
A: A small amount of short linear gas shadow (white arrow) under the capsule of the left lobe and caudate lobe of the liver; B, C: CT reexamination of the next day showed that the wall of ascending colon had obvious thickening and uneven enhancement, and exudation and small lymph nodes were seen around it; D: Pathological section of ascending colon (HE staining, × 400), mucosal erosion, bleeding, submucosal edema, and small vessel hyperplasia.
图 3 病例4的CT表现
Figure 3. CT image of case 4
A: The localization image showed a "withered branch" gas shadow (white arrow) in the liver, and the intestinal tract was inflated and dilated; B: A large amount of gas shadows could be seen in the left and right branches and main trunk of the portal vein, with the left branch being the main one; C: Coronary MIP reconstruction showed that the portal vein had obvious air accumulation and appeared as a "withered branch", and the superior mesenteric vein and its branches had obvious air accumulation (white arrow); D: The intestines were inflated and dilated, with multiple flat air and liquid, multiple vesicular gas shadows under the intestinal wall (white arrow), and obvious gas accumulation in the branches of superior mesenteric vein (white arrow).
表 1 10例HPVG患者临床资料
Table 1. Clinical data of 10 patients with HPVG
Case Gender/Age (years) Medical history Underlying disease Main diagnosis Main treatments Prognosis 1 Male/59 Abdominal pain with diarrhea and vomiting after eating Chronic renal insufficiency, postrenal transplantation, maintenance hemodialysis; postoperative aortic coarctation (Standford type B), hypertension; post-operative spinal fracture Ischemic intestinal necrosis Surgical operations Survival 2 Male/87 Diarrhea for 4 d, abdominal pain for more than 1 d, with vomiting Hypertension Ischemic intestinal necrosis Symptomatic support Survival 3 Male/79 1 week after total gastrectomy, vomiting, abdominal pain, and fever for 1 d Hypertension Duodenal stump fistula and abdominal infection after total gastrectomy for cardiac cancer Symptomatic support Survival 4 Male/52 Vomiting (vomiting blood) with confusion after alcohol abuse Alcoholism, high blood pressure Upper gastrointestinal bleeding with hemorrhagic shock, multiple organ failure Symptomatic support Death 5 Male/63 Abdominal pain with nausea for 12 h Chronic renal insufficiency, maintenance hemodialysis; hypertension, gout, rheumatoid arthritis; postoperative right femoral neck fracture Severe infection with septic shock, gastrointestinal perforation Symptomatic support, refused surgery Death 6 Male/76 Fatigue, anorexia for more than 5 years, fever for 12 d, accompanied by diarrhea and vomiting. Chronic renal insufficiency, maintenance hemodialysis; hypertension, diabetes, cerebral infarction; postcholecystectomy Severe infection with septic shock, upper gastrointestinal bleeding, metabolic acidosis Symptomatic support Death 7 Male/48 Fever for 2 d, chest tightness for 1 d Hypertension, asthma, postoperative right knee fracture Severe myocarditis with cardiogenic shock, severe pneumonia with ARDS (moderate), sepsis, septic shock Surgical operations Death 8 Female/30 Postpartum hemorrhage, hysterectomy, 3 d after cardiopulmonary resuscitation No Postpartum massive bleeding, after hysterectomy; Ischemic hypoxic encephalopathy after cardiopulmonary resuscitation surgery; Abdominal infection and septic shock; Multiple organ failure; DIC Symptomatic support Death 9 Male/88 After severe craniocerebral trauma, disturbance of consciousness for 10 d, fever for 8 d. Cardiac dysfunction, paroxysmal atrial fibrillation; postoperative inguinal hernia Severe craniocerebral trauma, pulmonary infection, respiratory failure, septic shock Symptomatic support Death 10 Male/43 Abdominal pain and fever for 3 d, diarrhea and vomiting for 1 d. Hypertension Abdominal infection, septic shock Symptomatic support Death HPVG: Hepatic portal vein gas. 
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表 2 10例HPVG患者影像学特征
Table 2. Imaging features of 10 patients with HPVG
Case Distribution of HPVG Gas accumulation in SMV and splenic vein PCI SMA thrombosis Edema of intestinal wall Intestinal obstruction Gastrointestinal perforation 1 A small amount in left branch distal and caudate lobe No No Yes Yes No No 2 A small amount in left branch distal Yes Yes Yes Yes No No 3 A small amount in left branch distal No Yes No enhanced scan No No No 4 A large amount in left and right branch, the left branch is obvious Yes Yes No enhanced scan None Yes No 5 A small amount in left branch distal Yes Yes No Yes No Yes 6 Left branch distal Yes Yes No Yes Yes No 7 Left branch, a small amount in distal right branch Yes Yes No Yes Yes Yes 8 A small amount in left branch distal No Yes No enhanced scan Yes Yes No 9 A large amount in left and right branch Yes Yes No enhanced scan No No Yes 10 Left branch distal Yes Yes No enhanced scan Yes Yes No SMA: Superior mesenteric artery; SMV: Superior mesenteric vein; PCI: Pneumatosis cystoides intestinalis.
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