Manuscript DoiAdvance : 10.1093/ecco-jcc/jjv125 Journal of Crohn's and Colitis Access published July 17, 2015
1 1
Hepatic portal venous gas after colonoscopy for ulcerative colitis: A case report
2 3
Takahide Shinagawa, Keisuke Hata, Toshiaki Watanabe
4 Department of Surgical Oncology, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo
6
113-8655, Japan
7
Phone No: +81-3-3815-5411
8
Fax No: +81-3-3811-6822
9
Email Address: [email protected]
us c
rip t
5
10 Correspondence to
12
Takahide Shinagawa
13
Department of Surgical Oncology, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo
14
113-8655, Japan
15
Phone No: +81-3-3815-5411
16
Fax No: +81-3-3811-6822
17
Email Address: [email protected]
te d
M
an
11
18
TT, KH, and TW looked after the patient. TT and KH wrote the manuscript. TW finally reviewed
20
and edited the manuscript and all authors contributed to the report. Written consent to publication
21
was obtained.
Ac
22
ce p
19
23
List of abbreviations
24
Hepatic portal venous gas: HPVG
25
Inflammatory bowel disease: IBD
26
Ulcerative colitis: UC
27
Computed tomography: CT
28 Copyright © 2015 European Crohn’s and Colitis Organisation (ECCO). Published by Oxford University Press. All rights reserved. For permissions, please email: [email protected]
Manuscript Doi : 10.1093/ecco-jcc/jjv125
2 29
To the editor Hepatic portal venous gas (HPVG) is a rare radiological finding with numerous etiologies. Bowel
31
necrosis is the most common life-threatening cause and typically urgent surgical exploration is
32
necessary. However, the finding of HPVG does not always indicate surgery in some conditions,
33
such as following an endoscopic procedure. We herein report an 18-year-old boy with ulcerative
34
colitis (UC) who presented with HPVG after a colonoscopic procedure and was successfully treated
35
conservatively.
us c
rip t
30
36
An 18-year-old boy suffering with persistent diarrhoea, haematochezia, and mild abdominal pain
38
was referred and admitted to the University of Tokyo Hospital. Colonoscopy revealed inflammation
39
from the rectum to the ascending colon, which was compatible with UC. The biopsy specimens
40
were also compatible with UC. Two hours after the examination, the patient suffered from a sudden
41
fever that peaked at 38.7oC without abdominal pain. The laboratory data showed a high level of
42
white blood cell (WBC) counts up to 41900/μL. Computed tomography (CT) of the abdomen and
43
pelvis was performed immediately, which unveiled HPVG without any evidence of free
44
intraperitoneal gas (Figure1). Intravenous antibiotic therapy was empirically administered and the
Ac
ce p
te d
M
an
37
45
patient’s body temperature and WBC counts returned to the normal limits (36.6oC and 8200/μL,
46
respectively) two days later. The patient was discharged ten days after colonoscopy.
47 48
HPVG is a rare radiological finding characterized by linear radiolucencies extending to within 2
49
cm of the periphery of the liver with numerous etiologies. Hussain et al. reviewed 275 cases of
Manuscript Doi : 10.1093/ecco-jcc/jjv125
3 HPVG and reported that the underlying causes of HPVG include: (1) bowel ischemia (61%), (2)
51
inflammation of the GI tract (16%), (3) obstruction and dilatation (9%), (4) sepsis (7%), (5)
52
iatrogenic injury and trauma and (6) cancer (2%) [1]. The present case falls into the category of
53
iatrogenic injury and trauma in addition to inflammation of the GI tract. Bowel necrosis is the most
54
common life-threatening cause of HPVG and typically urgent surgical exploration is necessary due
55
to an expected high mortality rate of 75% [2]. However, there are conditions in which the finding of
56
HPVG does not always indicate surgery, such as following an endoscopic procedure. This is the 9th
57
known case of HPVG after colonoscopy. In eight of the nine reported cases, the patients were
58
treated conservatively. The only case that required surgical procedures was a 22-year-old man with
59
Crohn’s disease [3]. In all cases, the patients survived and had underlying inflammatory bowel
60
disease (IBD), including two cases of UC and seven cases of Crohn’s disease (Supplemental Table)
61
[Supplementa References]. The present case, together with the previous reports, suggests that
62
medically stable patients with HPVG after undergoing colonoscopic procedures, especially IBD
63
patients, without peritoneal irritation signs or free air can be successfully managed with antibiotic
64
therapy and close observation.
us c
an
M
te d
ce p
Ac
65
rip t
50
66
Manuscript Doi : 10.1093/ecco-jcc/jjv125
4 67
FUNDING
68
This work was supported by no funding sources. The authors declare that they have no competing
69
interests.
ACKNOWLEDGEMENTS
72
We thank Brian Quinn for checking the language of this article.
us c
71
rip t
70
Ac
ce p
te d
M
an
73
Manuscript Doi : 10.1093/ecco-jcc/jjv125
5 74 References
76
1. Hussain A, Mahmood H, Hasani SE. Portal vein gas in emergency surgery. World J Emerg Surg
77
2008;3:21
78
2. Kinoshita H, Shinozaki M, Tanimura H, et al. Clinical features and management of hepatic portal
79
venous gas. Arch Surg 2001; 136: 1410-1414
80
3. Huycke A, Moeller DD. Hepatic portal venous gas after colonoscopy in granulomatous colitis.
81
Am J Gastroenterol 1985;80:637-638
us c
rip t
75
82
an
83 84
Ac
ce p
te d
M
85
Manuscript Doi : 10.1093/ecco-jcc/jjv125
6 86 Figure Legends
88
Figure1. An abdominal computed tomography scan demonstrated the collection of gas in the
89
peripheral branches of the hepatic portal vein in the patient following colonoscopy (A: axial plane,
90
B: coronal plane).
Ac
ce p
te d
M
an
us c
rip t
87
Manuscript Doi : 10.1093/ecco-jcc/jjv125
Ac ce
pt
ed
M
an
us
cr
ip t
Figure 1
1 1
Hepatic portal venous gas after colonoscopy for ulcerative colitis: A case report
2 3
Takahide Shinagawa, Keisuke Hata, Toshiaki Watanabe
4 Department of Surgical Oncology, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo
6
113-8655, Japan
7
Phone No: +81-3-3815-5411
8
Fax No: +81-3-3811-6822
9
Email Address: [email protected]
us c
rip t
5
10 Correspondence to
12
Takahide Shinagawa
13
Department of Surgical Oncology, The University of Tokyo, 7-3-1, Hongo, Bunkyo-ku, Tokyo
14
113-8655, Japan
15
Phone No: +81-3-3815-5411
16
Fax No: +81-3-3811-6822
17
Email Address: [email protected]
te d
M
an
11
18
TT, KH, and TW looked after the patient. TT and KH wrote the manuscript. TW finally reviewed
20
and edited the manuscript and all authors contributed to the report. Written consent to publication
21
was obtained.
Ac
22
ce p
19
23
List of abbreviations
24
Hepatic portal venous gas: HPVG
25
Inflammatory bowel disease: IBD
26
Ulcerative colitis: UC
27
Computed tomography: CT
28 Copyright © 2015 European Crohn’s and Colitis Organisation (ECCO). Published by Oxford University Press. All rights reserved. For permissions, please email: [email protected]
Manuscript Doi : 10.1093/ecco-jcc/jjv125
2 29
To the editor Hepatic portal venous gas (HPVG) is a rare radiological finding with numerous etiologies. Bowel
31
necrosis is the most common life-threatening cause and typically urgent surgical exploration is
32
necessary. However, the finding of HPVG does not always indicate surgery in some conditions,
33
such as following an endoscopic procedure. We herein report an 18-year-old boy with ulcerative
34
colitis (UC) who presented with HPVG after a colonoscopic procedure and was successfully treated
35
conservatively.
us c
rip t
30
36
An 18-year-old boy suffering with persistent diarrhoea, haematochezia, and mild abdominal pain
38
was referred and admitted to the University of Tokyo Hospital. Colonoscopy revealed inflammation
39
from the rectum to the ascending colon, which was compatible with UC. The biopsy specimens
40
were also compatible with UC. Two hours after the examination, the patient suffered from a sudden
41
fever that peaked at 38.7oC without abdominal pain. The laboratory data showed a high level of
42
white blood cell (WBC) counts up to 41900/μL. Computed tomography (CT) of the abdomen and
43
pelvis was performed immediately, which unveiled HPVG without any evidence of free
44
intraperitoneal gas (Figure1). Intravenous antibiotic therapy was empirically administered and the
Ac
ce p
te d
M
an
37
45
patient’s body temperature and WBC counts returned to the normal limits (36.6oC and 8200/μL,
46
respectively) two days later. The patient was discharged ten days after colonoscopy.
47 48
HPVG is a rare radiological finding characterized by linear radiolucencies extending to within 2
49
cm of the periphery of the liver with numerous etiologies. Hussain et al. reviewed 275 cases of
Manuscript Doi : 10.1093/ecco-jcc/jjv125
3 HPVG and reported that the underlying causes of HPVG include: (1) bowel ischemia (61%), (2)
51
inflammation of the GI tract (16%), (3) obstruction and dilatation (9%), (4) sepsis (7%), (5)
52
iatrogenic injury and trauma and (6) cancer (2%) [1]. The present case falls into the category of
53
iatrogenic injury and trauma in addition to inflammation of the GI tract. Bowel necrosis is the most
54
common life-threatening cause of HPVG and typically urgent surgical exploration is necessary due
55
to an expected high mortality rate of 75% [2]. However, there are conditions in which the finding of
56
HPVG does not always indicate surgery, such as following an endoscopic procedure. This is the 9th
57
known case of HPVG after colonoscopy. In eight of the nine reported cases, the patients were
58
treated conservatively. The only case that required surgical procedures was a 22-year-old man with
59
Crohn’s disease [3]. In all cases, the patients survived and had underlying inflammatory bowel
60
disease (IBD), including two cases of UC and seven cases of Crohn’s disease (Supplemental Table)
61
[Supplementa References]. The present case, together with the previous reports, suggests that
62
medically stable patients with HPVG after undergoing colonoscopic procedures, especially IBD
63
patients, without peritoneal irritation signs or free air can be successfully managed with antibiotic
64
therapy and close observation.
us c
an
M
te d
ce p
Ac
65
rip t
50
66
Manuscript Doi : 10.1093/ecco-jcc/jjv125
4 67
FUNDING
68
This work was supported by no funding sources. The authors declare that they have no competing
69
interests.
ACKNOWLEDGEMENTS
72
We thank Brian Quinn for checking the language of this article.
us c
71
rip t
70
Ac
ce p
te d
M
an
73
Manuscript Doi : 10.1093/ecco-jcc/jjv125
5 74 References
76
1. Hussain A, Mahmood H, Hasani SE. Portal vein gas in emergency surgery. World J Emerg Surg
77
2008;3:21
78
2. Kinoshita H, Shinozaki M, Tanimura H, et al. Clinical features and management of hepatic portal
79
venous gas. Arch Surg 2001; 136: 1410-1414
80
3. Huycke A, Moeller DD. Hepatic portal venous gas after colonoscopy in granulomatous colitis.
81
Am J Gastroenterol 1985;80:637-638
us c
rip t
75
82
an
83 84
Ac
ce p
te d
M
85
Manuscript Doi : 10.1093/ecco-jcc/jjv125
6 86 Figure Legends
88
Figure1. An abdominal computed tomography scan demonstrated the collection of gas in the
89
peripheral branches of the hepatic portal vein in the patient following colonoscopy (A: axial plane,
90
B: coronal plane).
Ac
ce p
te d
M
an
us c
rip t
87
Manuscript Doi : 10.1093/ecco-jcc/jjv125
Ac ce
pt
ed
M
an
us
cr
ip t
Figure 1
