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Arch Surg. 2008;143(8):804.

Answer: Benign Portal Venous Gas
Portal venous gas (PVG) has historically been associated with acute abdominal catastrophe and high mortality rates. Noted radiographically first in neonates¹ and later in adults,² PVG has portended a uniformly fatal prognosis. Most commonly found with pneumatosis intestinalis, PVG has indicated the late stages of mesenteric ischemia and has traditionally mandated immediate operative exploration.³ With recent advances in radiological techniques and the ubiquity of CT scans, PVG has been associated with other types of abdominal pathological findings including bowel obstruction, inflammatory bowel disease, and pancreatitis; intra-abdominal infections such as diverticulitis, cholangitis, and portal pyelophlebitis; and various invasive endoscopic and intravascular procedures such as esophagogastroduodenoscopy, endoscopic retrograde cholangiopancreatography, colonoscopy, CT-guided abscess drainage, and visceral artery embolizations.⁴ Owing to lower mortality rates, PVG has been managed nonoperatively with greater success, calling into question mandatory surgery.⁵ The recent decrease in mortality rates may be due to the greater sensitivity of CT scans when compared with plain radiographs in diagnosing PVG and thus earlier diagnosis before fulminant disease has occurred.⁴ Careful evaluation of the clinical situation and other associated CT findings can help elucidate which patients may benefit from surgery and which patients will be best managed nonoperatively. This patient was treated conservatively with judicious fluid resuscitation and nasogastric suctioning. Her bowel obstruction resolved and she was eventually discharged to home.

In conclusion, PVG has traditionally been associated with acute abdominal catastrophe and high mortality, mandating immediate exploratory laparotomy. Today, the increased sensitivity of contemporary radiologic modalities has considerably expanded the differential diagnosis of PVG. Since PVG can be identified in numerous clinical conditions that do not necessarily require immediate surgical intervention, a careful reassessment of historical treatment algorithms is in order. Optimal management of PVG therefore may not necessarily warrant surgery.

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Submissions The Editor welcomes contributions to the Image of the Month. Manuscripts should be submitted via our online manuscript submission and review system (http://manuscripts.archsurg.com). Articles and photographs accepted will bear the contributor's name. Manuscript criteria and information are per the Instructions for Authors for Archives of Surgery (http://archsurg.ama-assn.org/misc/ifora.dtl). No abstract is needed, and the manuscript should be no more than 3 typewritten pages. There should be a brief introduction, 1 multiple-choice question with 4 possible answers, and the main text. No more than 2 photographs should be submitted. There is no charge for reproduction and printing of color illustrations.

AUTHOR INFORMATION

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Correspondence: Daniel Kaufman, MD, Department of Plastic and Reconstructive Surgery, Montefiore Medical Center, Albert Einstein School of Medicine, 3353 Bainbridge Ave, Bronx, NY 10467 (dkaufmanmd{at}gmail.com).

Accepted for Publication: January 5, 2007.

Financial Disclosure: None reported.

Author Contributions: Study concept and design: Kaufman and Schwartzman. Acquisition of data: Kaufman and Kang. Analysis and interpretation of data: Kaufman and Kang. Drafting of the manuscript: Kaufman and Kang. Critical revision of the manuscript for important intellectual content: Kaufman and Schwartzman. Obtained funding: Kaufman. Administrative, technical, and material support: Kaufman and Kang. Study supervision: Kaufman and Schwartzman.

REFERENCES

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1. Wolfe JN, Evans 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):486-488. ISI | PUBMED 2. Susman N, Senturia HR. Gas embolization of the portal venous system. Am J Roentgenol Radium Ther Nucl Med. 1960;83:847-850. ISI | PUBMED 3. Traverso LW. Is hepatic portal venous gas an indication for exploratory laparotomy? Arch Surg. 1981;116(7):936-938. FREE FULL TEXT 4. Iannitti DA, Gregg SC, Mayo-Smith WW, Tomolonis RJ, Cioffi WG, Pricolo VE. Portal venous gas detected by computed tomography: is surgery imperative? Dig Surg. 2003;20(4):306-315. FULL TEXT | ISI | PUBMED 5. Hong JJ, Gadaleta D, Rossi P, Esquivel J, Davis JM. Portal vein gas, a changing clinical entity: report of 7 patients and review of the literature. Arch Surg. 1997;132(10):1071-1075. FREE FULL TEXT

SECTION EDITOR: CARL E. BREDENBERG, MD

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Image of the Month—Quiz Case
Daniel Kaufman, Kuang H. Kang, and Alexander Schwartzman
Arch Surg. 2008;143(8):803.
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