Gas Leak in the Port: Portal Venous Gas Associated With Congenital Cytomegalovirus Colitis : JPGN Reports

Secondary Logo

Journal Logo

Video: Hepatology

Gas Leak in the Port: Portal Venous Gas Associated With Congenital Cytomegalovirus Colitis

Tominaga, Kentaro MD*; Haslam, David MD†,‡; Asai, Akihiro MD, PhD*,‡

Author Information
JPGN Reports 3(4):p e267, November 2022. | DOI: 10.1097/PG9.0000000000000267

A full-term 10-week-old male presented with persistent hematochezia. Physical examination revealed hepatomegaly. Growth was normal, without episodes of hypoglycemia nor signs of cardiac anomaly. Laboratory evaluation showed slight elevation of alanine transaminase (ALT) and aspartate transaminase (AST) with normal direct bilirubin and gamma-glutamyl transferase. Cytomegalovirus (CMV) was detected in urine and stools by PCR. The abdominal ultrasound showed echogenic particles flowing through portal veins, demonstrating portal venous gas (Video 1 The abdominal computed tomography was normal with no features of intestinal pneumatosis. Flexible sigmoidoscopy revealed multiple oozing ulcerations in the rectosigmoid colon (Fig. 1); histology showed nonspecific inflammatory cell infiltration without mucosal features of chronic ischemia. The biopsy samples were positive for CMV on PCR. He was treated with long-term oral ganciclovir for congenital CMV colitis, and hematochezia and portal venous gas resolved in 2 weeks. He is currently well at 18 months old.

A Video clip of liver ultrasound images. Transverse imaging of the liver captured air bubbles in the portal vein.
A photo capture image of the sigmoidoscopy. The black arrows indicate ulcers, which were covered with air bubble-containing secretion. The ulcers did not actively produce air bubbles after being flushed out with water.

Portal gas in infants is rare and often reflects severe damage to the intestinal mucosa. The most common cause of portal venous gas in children is necrotizing enterocolitis (NEC), with intestinal pneumatosis in premature newborns (1). Severe CMV colitis in immunocompromised adults can cause pneumatosis and portal venous gas. However, congenital CMV colitis has not been associated with portal venous gas (2,3). In a previous report, congenital CMV enterocolitis was diagnosed in 24.7% of cases with invasive congenital CMV infection among presumably immunocompetent newborns (4). Food protein-induced enterocolitis syndrome (FPIES) is an important differential diagnosis, because it can cause portal venous gas similar to NEC (5,6). Because of its higher prevalence, allergic proctocolitis can occur in conjunction with congenital CMV infection (7).

Our case lacked typical clinical features of NEC and FPIES. He was ultimately diagnosed with CMV colitis by PCR of colonic biopsy. This case highlights the importance of screening for congenital CMV colitis in infants with portal venous gas.


The corresponding author, Akihiro Asai, confirms that verbal informed consent was obtained from the patient for the publication of their information and imaging.


1. Lassandro G, Picchi SG, Romano F, et al. Intestinal pneumatosis: differential diagnosis. Abdom Radiol. 2022; 47:1529–1540.
2. Balasuriya HD, Abeysinghe J, Cocco N. Portal venous gas and pneumatosis coli in severe cytomegalovirus colitis. Anz J Surg. 2018; 88:113–114.
3. Cheong JL, Cowan FM, Modi N. Gastrointestinal manifestations of postnatal cytomegalovirus infection in infants admitted to a neonatal intensive care unit over a five year period. Arch Dis Child Fetal Neonatal Ed. 2004;89:F367–F369.
4. Frasca D, Blomberg BB. Inflammaging decreases adaptive and innate immune responses in mice and humans. Biogerontology. 2016;17:7–19.
5. Mennini M, Fiocchi AG, Cafarotti A, et al. Food protein-induced allergic proctocolitis in infants: Literature review and proposal of a management protocol. World Allergy Organ J. 2020;13:100471.
6. Guo Y, Si S, Jia Z, et al. Differentiation of food protein-induced enterocolitis syndrome and necrotizing enterocolitis in neonates by abdominal sonography. J Pediatr (Rio J). 2021;97:219–224.
7. Jonkhoff-Slok TW, Veenhoven RH, de Graeff-Meeder ER, et al. An immunocompetent infant with cow’s milk allergy and cytomegalovirus colitis. Eur J Pediatr. 1997;156:528–529.

Supplemental Digital Content

Copyright © 2022 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of the European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition.