HPVG is not an independent disease. It is usually accompanied by digestive tract diseases, and it often has a relatively short duration. HPVG was first described by Wolfe and Evans in 1955 in infants with fatal necrotizing enterocolitis. The first case of HPVG in an adult was reported in 1960 by Susman and Senturia in a patient with superior mesenteric artery thrombosis. Since then, HPVG has been reported to occur with a variety of abdominal diseases, such as inflammatory bowel disease, bowel ischemia, bowel obstruction, gastric ulcer, closed abdominal trauma, intra-abdominal abscess, and diverticulitis. HPVG is a critical condition as the mortality was as high as 75% in a 1978 review of 64 cases. A 2001 review of 182 cases revealed an overall mortality of 39%, in which only 3% of the HPVG cases were associated with an intraperitoneal tumor. Thus, cases of HPVG complicated by colon cancer are very rare. Recently, Ginesu et al reported 1 case of HPVG in a patient who underwent a left colectomy for descending colon cancer; the patient was treated conservatively, and his symptoms resolved. In addition, 2 cases of HPVG occurred during the course of chemotherapy in advanced colorectal cancer patients.[8,9] In our case, HPVG was found before the operation, and the patient was surgically cured.
HPVG is mainly diagnosed by x-ray, abdominal CT, and ultrasonography. The criterion of x-ray for HPVG is a branching radiolucency extending to within 2 cm of the liver capsule. However, the sensitivity is low, detection is difficult, and it is easily overlooked. Ultrasonography and CT scan are superior to abdominal radiographs in identifying HPVG. Ultrasonography is very sensitive for HPVG detection. Moving echogenic particles in the portal venous system and highly echogenic patches within the hepatic parenchyma are the typical ultrasonographic features of HPVG. However, the use of ultrasound is limited because it is more dependent on the operator's experience and it is difficult to detect the etiology. The CT scan has a higher sensitivity to diagnosis HPVG, and it can help to detect underlying diseases.[12,13] Case reports of HPVG associated with benign etiologies have increased with the wide use of CT, which might be one reason for the decrease in mortality of HPVG. In addition, CT can predict the prognosis of HPVG. A recent study showed that outside of shock situations, HPVG involving 2 or fewer hepatic segments without pneumatosis intestinalis had a good predicted outcome. The typical radiographic pattern of CT was represented by tubular lucency branching from the portal vein to the liver capsule, and the gas lucency can be noted even 2 cm beneath the liver capsule. In this case, HPVG was detected by abdominal CT and a malignant tumor in the splenic flexure of the colon was found, which provided the basis for follow-up treatment. Therefore, an abdominal CT is an effective method for diagnosing and monitoring HPVG, and it should be used as the primary diagnostic tool.
At present, the mechanism for HPVG is not well understood. There are 2 main theories proposed for the pathophysiologic etiology of HPVG: mechanical versus bacterial. Intestinal obstruction, intestinal ischemia, inflammatory bowel disease, gastrointestinal neoplasms, and colonoscopy can damage the intestinal mucosa. Such an injury may provide a portal for intraluminal gas to enter the intestinal wall and eventually enter the portal venous system. However, HPVG has been associated with an intra-abdominal abscess without mucosal damage in some cases. In these circumstances, the gas in the portal venous was produced by a gas-forming organism.[15,16] We think there are 2 possible reasons why HPVG was so pronounced in this case. First, the blood culture and the intraoperative pus culture showed the growth of K pneumonia, which is an opportunistic pathogen. K pneumonia can produce gas and acid by decomposing glucose. K pneumonia is a common pathogen of pyogenic liver abscesses. The incidence of pyogenic liver abscesses caused by K pneumonia has been increasing in Asian countries and the United States.[17,18] A case of emphysematous gastritis caused by K pneumonia has been reported by Al-Jundi and Shebl, and gas was found in both the stomach wall and the liver portal venous by CT scan. In our case, an abscess caused by K pneumonia was formed between the colon cancer and the spleen. K pneumonia propagated in the intestinal wall and portal vein system, which produced gas leading to HPVG. Second, this patient suffered from an incomplete intestinal obstruction. His intestinal mucosa was damaged due to the increased pressure in the intestine, the expansion of the intestinal canal, and ischemic necrosis of the tumor. As a result, the gas in the intestine could enter the portal system. Based on the above analysis, we speculate that the significant reduction of gas before the operation was also associated with 2 factors. First, the use of antibiotics inhibited the reproduction of K pneumonia. Second, perforation of the intestine reduced the internal pressure of the intestine and caused some of the gas to enter the abdominal cavity.
HPVG requires conservative treatment and surgical treatment, which should be based on the underlying cause of the disease. Nelson et al designed an “ABC” algorithm, which stressed that operative treatment, close monitoring, and medical treatment should be carried out according to the patient's condition. Surgical intervention is generally recommended for cases of intestinal ischemia and necrosis, while close monitoring is advised in patients with a disease of benign etiology and nonischemic conditions. Wayne et al established a scoring system for HPVG, which could help to determine whether mesenteric ischemia occurred. In our case, the underlying cause of HPVG was colon cancer. At first, the patient was in good general condition, so he was treated conservatively while waiting for further examination. An intestinal perforation occurred during the treatment, so emergency surgery was immediately performed. HPVG disappeared completely 1 week after the operation and the patient recovered well, so the treatment for this patient was timely and appropriate. At the same time, we are also thinking that it may be better to operate before intestinal perforation, which will avoid the risk of severe abdominal infection, pancreatic leakage, and other complications associated with intestinal perforation.
Our case has the following characteristics. It is a case of adult HPVG, and the combined disease was colon cancer. The imaging performance was very typical, and large volumes of gas were found in the hepatic portal vein, splenic vein, and superior mesenteric vein. The gas may be produced by K pneumonia. The gas was significantly reduced after intestinal perforation. The prognosis of this patient was good after surgery.
Various diseases can cause HPVG, including colon cancer, although it is rare. The prognosis of HPVG is closely related to the underlying pathology. Abdominal CT is an effective method for diagnosing and monitoring HPVG. Blood culture or drainage culture is also an important method that can help to identify the underlying cause. K pneumonia is a potential gas-producing microorganism that may be associated with HPVG. We must attach great importance to HPVG in clinical practice, and surgery should be performed early when there are signs of intestinal ischemia, necrosis, or perforation.
We thank LetPub (www.letpub.com) for its linguistic assistance during the preparation of this manuscript.
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Keywords:Copyright © 2017 The Authors. Published by Wolters Kluwer Health, Inc. All rights reserved.
hepatic portal venous gas; colon cancer; Klebsiella pneumonia; perforation