A case with hepatic portal vein gas who required delayed elective surgery

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Executive Summary

Hepatic portal venous gas (HPVG) was historically viewed as a definitive indicator of severe abdominal pathology, often requiring emergent surgery and carrying a mortality rate as high as 75%. However, advances in modern abdominal computed tomography (CT) have led to increased detection of HPVG in more benign conditions, reducing the overall mortality rate to approximately 39% and necessitating a more nuanced decision-making process between surgical intervention and conservative management.

This briefing document analyzes a specific clinical case of an 84-year-old male who initially underwent successful conservative treatment for HPVG but subsequently required delayed elective surgery for ischemic intestinal stenosis. Key prognostic indicators identified include the Acute Physiology and Chronic Health Evaluation (APACHE) II score and the persistence of HPVG on follow-up imaging. While an APACHE II score of 15 typically correlates with successful conservative treatment and a score of 23±5 correlates with the need for emergent surgery, an intermediate score (such as 17 in this case) may signal the risk of late-stage complications requiring elective surgical intervention.

Clinical Case Profile: Delayed Elective Surgery Requirement

Initial Presentation and Diagnosis

An 84-year-old male with a history of cerebral infarction, atrial fibrillation, inguinal hernia repair, and appendectomy presented with sudden abdominal pain.

  • Physical Findings: Slight distension and tenderness in the lower abdomen; stable vital signs (BP 130/84 mmHg, HR 71/min, Temp 36.9°C).

  • Laboratory Data:

    • WBC: 13,300/µl

    • CRP: 37 mg/dl

    • Lactate dehydrogenase (LDH): 474 U/l

    • Alanine aminotransferase (ALT): 123 U/l

  • Imaging: Contrast-enhanced CT revealed HPVG throughout the whole liver and intestinal pneumatosis (gas within the bowel wall) at the ileum.

  • Initial Assessment: The patient’s APACHE II score was 17.

Treatment and Late Complication

  • Conservative Phase: The patient was treated with heparinization. On the second day, a follow-up CT showed that while intestinal pneumatosis had resolved, small amounts of HPVG remained in the lateral segment of the liver, and ascites had increased. Despite this, symptoms improved, feeding began on day 5, and the patient was discharged on day 9.

  • Secondary Presentation: On day 23, the patient returned with right lower abdominal pain and vomiting. Imaging revealed thickness of the intestinal wall and fluid collection.

  • Surgical Outcome: A laparotomy confirmed a bowel obstruction caused by ischemic intestinal stenosis. Surgeons performed a partial resection of 40 cm of the ileum, which contained segmental stenosis at three distinct portions.

Comparative Analysis of HPVG Management (2014–2017)

Data from 18 cases treated at Yamanashi Prefectural Central Hospital provides a framework for categorizing HPVG severity and predicting outcomes.

Patient Categorization and Prognosis

Group

Case Count

Management Strategy

Prognostic Outcome

Emergent Surgery

6 (33%)

Immediate resection/adhesiolysis

2 deaths; 4 survivors

Conservative

11 (61%)

No surgical intervention

All survived

Delayed Elective

1 (6%)

Initial conservative; late surgery

Survived (the presented case)

Etiology of HPVG

While intestinal ischemia is the most frequent cause, HPVG can develop from various non-ischemic conditions, including:

  • Ulcerative colitis and Crohn’s disease

  • Enteritis and cholangitis

  • Gastric ulcers

  • Neobladder obstruction

Critical Prognostic Indicators

The decision-making process for HPVG relies on two primary diagnostic pillars: physiological scoring and longitudinal imaging.

1. APACHE II Score Utility

The APACHE II score, which assesses the patient's overall physiological condition, is a significant predictor of whether emergent surgery is necessary.

  • Successful Conservative Treatment: Average score of 15.

  • Requirement for Emergent Surgery: Average score of 23 ± 5 (p < 0.05).

  • The "Intermediate" Risk: The presented case had a score of 17, placing it between the conservative and emergent thresholds. This slightly elevated score may serve as a warning for potential late-stage complications like stenosis.

2. Follow-Up CT Findings

The temporal progression of HPVG on imaging is a vital clinical clue. In a review of six cases where follow-up CT was performed within 1–3 days:

  • Standard Resolution: In 5 out of 6 cases, HPVG and mesenteric vein gas disappeared quickly once the underlying condition was stabilized.

  • Persistence Indicator: The presented case was the only one where HPVG remained on the follow-up CT (Day 2). This persistence, combined with increased ascites, suggests that even if symptoms improve initially, the underlying vascular or tissue damage may necessitate future surgery.

Clinical Conclusions and Guidance

  1. Shift in Paradigm: HPVG is no longer an absolute indication for emergent surgery. Conservative management is viable in over 60% of cases if physical findings are not severe.

  2. Importance of APACHE II: This score should be calculated at admission to help triage patients into surgical or conservative paths.

  3. Mandatory Follow-Up Imaging: A follow-up CT after a few days is highly recommended. The failure of HPVG to resolve within 72 hours should be viewed as a high-risk indicator for complications such as ischemic intestinal stenosis.

  4. Monitoring for Stenosis: Physicians must remain alert for signs of bowel obstruction in the weeks following a conservative recovery from HPVG, as segmental stenosis can develop even after the initial gas has cleared.