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International Scholarly Research NetworkISRN Emergency MedicineVolume 2012, Article ID 480795, 7 pagesdoi:10.5402/2012/480795

Review Article

Self-Limited Pneumoporta in the Era of Computed Tomography:A Case Report and Review of the Literature

Yu-Tso Liao, Hong-Shee Lai, Rey-Heng Hu, Po-Huang Lee, and Cheng-Maw Ho

Department of Surgery, National Taiwan University Hospital, No. 7 Chung-Shan South Road, 10002 Taipei, Taiwan

Correspondence should be addressed to Cheng-Maw Ho, [email protected]

Received 25 October 2012; Accepted 18 November 2012

Academic Editors: A. K. Attri, R. Cirocchi, and A. Pazin-Filho

Copyright © 2012 Yu-Tso Liao et al. This is an open access article distributed under the Creative Commons Attribution License,which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Pneumoporta in patients with abdominal pain has been thought to be suggestive of fatal underlying conditions, such as mesentericinfarct, requiring emergency treatment. Widespread use of computed tomography (CT) has increased the frequency of detectionof pneumoporta in patients with diseases other than mesenteric infarct. The natural course of resolution of pneumoporta hasbeen rarely discussed in the literature and mainly focused on patients with iatrogenic diseases. Herein, we report the case of a64-year-old woman who presented at our emergency department with positive peritoneal signs and pneumoporta. A 10 cm longsegment of resolved ischemic bowel was detected on exploratory laparotomy, and bowel resection was not performed. Follow-upCT performed 62 hours later revealed complete resolution of pneumoporta. The patient was discharged uneventfully and wasadministered short-term prophylactic therapy with enoxaparin for thromboembolism. The epidemiology, etiology, and resolutionof pneumoporta are also reviewed.

1. Background

Pneumoporta has been thought to be an ominous radiolog-ical sign. However, the etiology is associated with variousdiseases ranging from severe fatal conditions requiring rapidsurgical intervention to medical diseases with a benigncourse. Treatment of pneumoporta should be based on theetiology of the condition. The natural course of resolutionof pneumoporta has rarely been discussed in the literature.Here, we report a case of a 64-year-old woman with sponta-neously resolved ischemic bowel and pneumoporta, and theepidemiology, etiology, and resolution of pneumoporta arereviewed.

2. Case Presentation

A 64-year-old woman presented at our emergency depart-ment with intermittent abdominal pain for 3 days withoutvomiting or dysentery. The patient was otherwise healthy,but had a history of spinal surgery and was a carrierof the hepatitis B virus. She did not have a history ofhydrogen peroxide ingestion. Upon arrival at the emergencydepartment, her vital signs were stable and consciousness

was clear. Physical examination revealed distended abdomenand diffuse peritoneal sign. Laboratory examination showedno leukocytosis, but a mild left shift. Lactic acid levelswere within the normal range. Abdominal CT scan showedthe presence of air in the portal venous tree in the lefthepatic lobe, patent superior mesenteric artery (SMA), andsuperior mesenteric vein, and bowel wall thickening anddistension of the ileum were noted (Figures 1 and 2). Thepatent SMA, as detected by the abdominal CT scan, wasalso observed. The patient underwent emergency exploratorylaparotomy. Intraoperative examination revealed a 10 cmlong segment of the resolved ischemic ileum with a thickenedwall and no transmural infarction. The liver surface wasnoncontributory. Follow-up abdominal CT performed 62hours after laparotomy revealed complete resolution ofhepatic portal venous gas (Figure 3). A series of workupsfor the thromboembolic event, including cardiac echographyand coagulation studies for autoantibodies, factor VIII,protein C, and protein S, yielded no abnormal data exceptelevated levels of D-D dimer and factor VIII. The patientwas discharged uneventfully and was administered short-term prophylactic therapy with enoxaparin for thromboem-bolism.

2 ISRN Emergency Medicine

Figure 1: Computed tomography (CT) scan showed the presenceof gas in the portal vein, mainly in the left hepatic lobe.

Figure 2: Thickening of the ileum wall (arrow).

3. Discussion

Pneumoporta has been considered to be an ominous radi-ological sign. However, pneumoporta may be associatedwith conditions ranging from severe fatal diseases requiringurgent surgical intervention to medical diseases that follow abenign course, such as gastroenteritis, which can be managedwith only conservative treatment [1, 2]. A mortality rateas high as 75–90% has been reported, mainly owing tothe occurrence of mesenteric infarction [3–5]. Nowadays,the widespread utilization of CT scan has increased thefrequency of detection of pneumoporta in the clinicalscenario [6, 7]. Indeed, mesenteric infarctions are the mainetiological factors that lead to potentially fatal outcomes andshould always be considered when diagnosing the cause ofpneumoporta [8, 9]. In addition, because of the increasedfrequency of occurrence of benign diseases [2, 6], promptclinical evaluation and surgical decision are paramount incases of pneumoporta.

CT scan enables early detection due to high sensitivityfor pneumoporta and is superior to other radiologicalmodalities, including ultrasound and abdominal plain film,

Figure 3: CT performed 62 hours after laparotomy showed com-plete resolution of hepatic portal vein gas.

in diagnosis of underlying abdominal diseases [7]. Sincethe 1970s, the introduction of the CT scan has graduallyadvanced the ability of physicians to accurately diagnosepneumoporta, and pneumoporta can now be detected atless advantaged stages [7]. More than half of the etiolo-gies of pneumoporta were mesenteric infarct, reported toaccount for 61–75% of cases [3, 8, 10]. Other etiologiesinclude gastrointestinal dysmotility, infectious/inflammatoryprocesses, toxicity-related conditions, and iatrogenic lesions[11, 12]. Notably, the appearance of pneumoporta in relationto iatrogenic causes increase in frequency over recent decades[8].

The correlation of outcomes and the presence ofpneumoporta, as well as the duration of pneumoporta,have not been clearly elucidated [3, 9]. The appearanceof pneumoporta is associated with poor outcomes inpatients experiencing cardiac arrest outside of the hospital[13]. Nevertheless, the notoriously high mortality generallyencountered in patients with pneumoporta has decreasedto 25–29% in recent reports, mainly due to early detectionand incidental findings during the diagnosis of other diseases[9, 14, 15]. Furthermore, the resolution of pneumoporta hasbeen shown to be associated with the improvement of theunderlying diseases.

In order to investigate the clinical characteristics ofpneumoporta resolution in the era of CT scan, we reviewedthe English literature by searching for the keyword “portalvenous gas” or “hepatic portal venous gas” in PubMed. Theage, sex, etiology, diagnostic modality (including conven-tional roentgenography, ultrasound, and CT scan), durationof pneumoporta, and patient outcomes were reviewed.Patients who were diagnosed as pneumoporta on CT scanwere included in the study. The exclusion criteria werelisted as following: the patients died of fulminant mesentericinfarct without CT followup, the unclear recording aboutresolution of pneumoporta, or the detection of pneumoportaby the radiological modalities other than CT scan. A totalof 61 cases were eligible and are listed according to theetiology (Table 1). Several classifications have been proposedin literature, and the system we used here was based on

ISRN Emergency Medicine 3

Ta

ble

1:C

linic

alch

arac

teri

stic

san

dou

tcom

esof

pneu

mop

orta

reso

luti

onin

repo

rted

case

sin

the

liter

atu

re.

Cau

seA

ge(y

ears

)Se

xD

etec

ted

mod

alit

yD

ura

tion

ofpn

eum

opor

taFo

llow

-up

mod

alit

ySu

rger

yO

utc

ome

Non

iatr

ogen

ic

Bow

elis

chem

ia/n

ecro

sis

[19–

22]

73F

CT

3da

ysC

TY

Exp

ired

82F

CT

24h

ours

CT

NU

nev

entf

ul

51F

CT

2m

onth

sC

TY

Un

even

tfu

l

86M

CT

6da

ysC

TY

Un

even

tfu

l

Isch

emic

colit

is[2

3]61

MC

T20

days

CT

NU

nev

entf

ul

Dys

mot

ility

Smal

lbow

elob

stru

ctio

n[2

4,25

]64

FX

R7

days

CT

YU

nev

entf

ul

61M

CT

3h

CT

NU

nev

entf

ul

Supe

rior

mes

ente

ric

arte

rysy

ndr

ome

[26]

10F

CT

48h

CT

NU

nev

entf

ul

Infe

ctio

n/i

nfl

amm

atio

n

Gas

troe

nte

riti

s[1

]58

MC

T4

days

CT

NU

nev

entf

ul

Pye

lon

eph

riti

s[2

7]56

MC

T1

mon

thC

TY

Un

even

tfu

lSe

ptic

thro

mbo

phle

biti

s[2

8]52

MC

T2

mon

ths

CT

NU

nev

entf

ul

Term

inal

ileit

is[2

9]64

FC

T18

hou

rsC

TN

Un

even

tfu

l

Cro

hn’

sdi

seas

e[3

0–32

]40

FC

T7

days

CT

NU

nev

entf

ul

70M

CT

2da

ysC

TN

Un

even

tfu

l26

FC

T9

hou

rsC

TN

Un

even

tfu

lR

etro

per

iton

eala

bsce

ss[3

3,34

]31

MC

T10

days

CT

YU

nev

entf

ul

64M

CT

3da

ysC

TY

—

Med

icat

ion

/tox

icit

y-re

late

dco

ndi

tion

s

Acc

iden

tali

nge

stio

nof

hydr

ogen

per

oxid

e[3

5–37

]67

MC

T24

hou

rsC

TN

Un

even

tfu

l31

FC

T3

days

CT

NU

nev

entf

ul

Cau

stic

inge

stio

n[3

8]55

FC

T24

hou

rsC

TN

Un

even

tfu

lC

olch

icin

e[3

9]57

MC

T4

days

CT

NU

nev

entf

ul

Oth

ers

Gra

ft-v

ersu

s-h

ost

dise

ase

[15,

40]

29M

CT

2w

eeks

CT

NU

nev

entf

ul

52M

CT

3w

eeks

CT

NE

xpir

ed(d

ied

due

tou

nde

rlyi

ng

dise

ase)

Pn

eum

atos

iscy

stoi

des

inte

stin

alis

[41]

94F

CT

11da

ysC

TY

Un

even

tfu

lIa

trog

enic

Rad

iofr

equ

ency

abla

tion

[42]

—∗

—∗

CT

20m

ins

CT

NU

nev

entf

ul

Cry

oth

erap

y[4

3]50

MC

T24

hou

rsC

TN

Exp

ired

(por

talv

ein

thro

mbo

sis

and

seps

is)

En

dosc

opy

orre

late

dpr

oced

ure

[40,

44]

26F

CT

24h

ours

XR

NU

nev

entf

ul

76M

CT

2da

ysC

TN

Un

even

tfu

l

En

dosc

opic

ballo

ondi

lata

tion

[45]

31M

CT

5da

ysC

TN

Un

even

tfu

lE

soph

agea

lvar

icea

lban

dlig

atio

nor

endo

scop

icsc

lero

ther

apy

[46]

77F

CT

3da

ysC

TN

Un

even

tfu

l


Ta

ble

1:C

onti

nu

ed.

Cau

seA

ge(y

ears

)Se

xD

etec

ted

mod

alit

yD

ura

tion

ofpn

eum

opor

taFo

llow

-up

mod

alit

ySu

rger

yO

utc

ome

Lin

ton

prob

ein

sert

ion

[47]

54M

CT

24h

ours

CT

NU

nev

entf

ul

Bar

ium

enem

a[4

8]86

MC

T3

days

CT

NU

nev

entf

ul

Oxy

gen

per

oxid

een

ema

[36]

31M

CT

48h

ours

CT

NU

nev

entf

ul

Lum

bar

pun

ctu

re[4

9]19

FU

ltra

sou

nd

4da

ysC

TN

Un

even

tfu

l

Intr

a-ao

rtic

ballo

onpu

lsat

ion

[50]

49—

CT

2da

ysU

ltra

sou

nd

NU

nev

entf

ul

Pan

crea

tico

duod

enec

tom

y[5

1]63

MC

TC

T:1

8da

ys;u

ltra

sou

nd:

22da

ysC

T,u

ltra

sou

nd

NU

nev

entf

ul

Res

usc

itat

ion

[52]

25M

CT

24h

ours

CT

NU

nev

entf

ul

CT

:com

pute

dto

mog

raph

y;E

US:

endo

scop

icu

ltra

sou

nd.

—:n

otm

enti

oned

inth

elit

erat

ure

.∗ 2

5ca

ses

wer

ere

port

ed.


whether the causes were iatrogenic or not because theclassification conveyed clinical usefulness and prognosticprediction [12, 16].

For demography available in the literature, themale/female ratio was 1.5, with a mean age of 53.4years (range, 10 to 94 years). Iatrogenic etiologies werethe main causes of pneumoporta (61%). The resolutionof pneumoporta was associated with the improvementof underlying diseases, and the reported duration ofpneumoporta ranged from 20 min to 2 months.

The correlation between lethal potentiality and pneumo-porta is unclear. The risk of hepatic flow compromise byair accumulating in the portal systems may be taken intoconsideration. However, pneumoporta itself rarely affectedhepatic flow in both animal and human studies. Theobservation might be explained by the anatomy of the dualblood supply of liver [17, 18]. Accordingly, researchers haveassumed that the pathophysiological mechanism responsiblefor the onset of pneumoporta is the cause of death, notthe air bubbles themselves [17]. The detailed mechanismnecessitated further study.

4. Noniatrogenic Causes

For noniatrogenic causes, improvement of pneumoportain patients with mesenteric infarct was rarely reported,possibly because of the fulminant course of these underlyingconditions. The appearance of pneumoporta in mesentericinfarct is associated with high mortality and morbidity[53]. Other diseases in which pneumoporta has been notedinclude gastrointestinal dysmotility, infection/inflammation,and medication/toxicity-related conditions. The outcomesin these situations were satisfactory following prompt sur-gical intervention. Notably, various medical diseases arepredisposing factors for pneumoporta and do not mandatesurgical intervention. In these cases, pneumoporta is usuallynoticed incidentally, and the course is usually self-limited.Transient ischemic enteritis has been reported to be a causeof pneumoporta and can also be successfully managedconservatively [54].

5. Iatrogenic Causes

The course of pneumoporta after iatrogenic events is gen-erally benign and transient, lasting no more than 1 day inthe majority of cases. Incidental discovery of pneumoportausually urges clinicians to repeat the imaging examinationand followup with the patients closely, as shown in theliterature. The appropriate treatment for iatrogenic casesseems to “wait and see,” except in one patient who died ofportal vein thrombosis and sepsis after cryotherapy [43].

Diffuse peritoneal signs and wall thickening of thesmall bowel revealed by physical examination and CT scan,respectively, in the presence of pneumoporta is a conditionthat requires urgent surgical intervention [6]. The conditionmay be suggestive of an underlying clinical condition, such asmesenteric ischemia/infarction. However, in our case, onlyone segment of the thickened small bowel, which seemed

to be the resolved ischemic bowel, was observed during theintraoperative examination. This patient is alive, and bowelresection was not required.

The natural course of pneumoporta is rarely discussedsystemically in the literature and is only sporadically reportedin patients with iatrogenic diseases [24, 29, 44]. In our case,sequential CT scan performed 62 hours after laparotomyrevealed complete resolution of pneumoporta. This observa-tion implies that pneumoporta may be a paraphenomenonthat disappears when the underlying pathology is improved.

There were some limitations in our review. First, theduration of pneumoporta was ambiguous, lacking a cleardefinition and strict control. Actually the duration recordedin the paper indicated a potential period that the pneumo-porta may exist. Second, the appearance of pneumoportawas regarded as a paraphenomenon in benign diseases;therefore, the follow-up modalities depended on clinicians’judgment in the absence of standard protocol. Third,the real incidence of self-limited pneumoporta might beunderestimated because the “benign” pneumoporta woulddisappear spontaneously. We believed the occurrence ofpneumoporta would outnumber the cases recorded in theliterature. In despite of the above-mentioned limitations, weare convinced that our study offers a general description ofcurrent self-limited pneumoporta reported in the Englishliterature. The overall survey pointed out some undiscoveredissues concerning the pathophysiology and clinical outcomesof pneumoporta.

6. Conclusion

Mesenteric infarct should always be considered when diag-nosing the cause of pneumoporta accompanied by positiveperitoneal signs. The diagnosis of pneumoporta merelybased on radiological findings is an intriguing possibility,and the management of pneumoporta should be based onetiological findings. In our case, spontaneous resolution ofpneumoporta was observed.

Abbreviations

CT: Computed tomographySMA: Superior mesenteric artery.

Conflict of Interests

The authors declare that there is no conflict of interests.

Authors’ Contribution

C.-M. Ho and Y.-T. Liao participated in the patient’s care,including the operative procedures. Y.-T. Liao drafted thepaper. H.-S. Lai, R.-H. Hu, and P.-H. Lee supervised anddirected the review of the literature.


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