Gastric pneumatosis and gas in the portal venous system secondary to peptic ulcer

A 72-year-old woman presented to the emergency department with recurrent vomiting without abdominal pain. On physical examination, the patient was afebrile and her abdomen was soft and nontender with a giant abdominal-wall hernia. Upper endoscopy showed a deep, 3-cm ulcer at the gastric angulus. Computed tomography (CT) of the abdomen showed gastric dilatation with gas in the wall and a large part of the digestive tract within the hernia sac. CT imaging also revealed gas throughout the portal venous system. The patient declined surgery. Management was conservative and included correction of fluid and electrolyte balance, and nasogastric drainage for gastric decompression with good response.     

Sonographic demonstration of hepatic venous gas in mesenteric arterial thrombosis

Hepatic portal venous gas is an ominous prognostic sign in bowel necrosis from mesenteric arterial occlusion. Ultrasonic examination is a sensitive and accurate method of demonstrating portal venous gas. We describe a case where the ultrasonic diagnosis of portal venous gas led to the rapid diagnosis of bowel infarction. Ultrasound is an appropriate emergency examination in all patients with suspected mesenteric artery occlusion.     

A comparison of portal venous versus systemic venous drainage in pancreas transplantation

Background

The decision to utilize portal or systemic venous drainage in pancreas transplantation is surgeon- and center-dependent. Information regarding the superior method is based on single-center reports and animal models.

The pancreas and inflammatory bowel diseases

Summary This article reviews the literature and gives an overview on prevalence and possible explanations for pancreatic involvement in inflammatory bowel diseases (IBD). IBD patients have a markedly elevated risk for developing acute pancreatitis as well as pancreatic insuffiency. Multiple potential causes for pancreatitis in IBD patients exist. In the majority of cases acute pancreatitis appears to be related to drug side effects or local structural complications rather than a true extraintestinal manifestation of IBD. Nevertheless, some cases of acute pancreatitis remain unexplained. Prevalence of chronic pancreatitis in IBD patients also seems to be relatively high. However, etiology of pancreatic duct changes and/or the occurrence of exocrine insufficiency remain unclear. In most cases chronic pancreatitis is clinically unapparent, although in some patients it may be accompanied by clinically relevant exocrine insufficiency.     

Extrahepatic aneurysm of the portal venous system and portal hypertension

Portal venous aneurysm (PVA) is a rare condition characterized by dilatation of the portal venous system. PVA manifestation of symptoms is varied and depends on the aneurysm size, location and related-complications, such as thrombosis. While the majority of reported cases of PVA are attributed to portal hypertension, very little is known about the condition’s pathophysiology and clinical management remains a challenge. Here, we describe a 67-year-old woman who presented with complaint of dyspepsia and without a significant medical history, for whom PVA was incidentally diagnosed. The initial upper abdominal ultrasound revealed marked dilatation of the main portal vein, and subsequent contrast-enhanced computed tomography with angiography revealed a large aneurysm arising from the extrahepatic troncus portion of the portal vein, as well as gastroesophageal varices. A conservative approach using beta-blocker therapy was chosen. The patient was followed-up for 60 mo, during which time the asymptomatic status was unaltered and the PVA remained stable.     

The pancreas and inflammatory bowel diseases.

This article reviews the literature and gives an overview on prevalence and possible explanations for pancreatic involvement in inflammatory bowel diseases (IBD). IBD patients have a markedly elevated risk for developing acute pancreatitis as well as pancreatic insufficiency. Multiple potential causes for pancreatitis in IBD patients exist. In the majority of cases acute pancreatitis appears to be related to drug side effects or local structural complications rather than a true extraintestinal manifestation of IBD. Nevertheless, some cases of acute pancreatitis remain unexplained. Prevalence of chronic pancreatitis in IBD patients also seems to be relatively high. However, etiology of pancreatic duct changes and/or the occurrence of exocrine insufficiency remain unclear. In most cases chronic pancreatitis is clinically unapparent, although in some patients it may be accompanied by clinically relevant exocrine insufficiency.     

Anomalous venous connections involving the portal system

Five cases representing four different venous anomalies involving the portal system are described. The clinical importance of these anomalies, especially in patients with portal hypertension, is stressed.     

Percutaneous transhepatic catheterization of the portal venous system

During recent years, percutaneous transhepatic catheterization of the portal venous system has become the most accurate procedure for investigation of the portal system. The procedure can be performed under local analgesia, is relatively simple, and complications are rare. The success rate is high, approximately 90%, especially when the liver hilum is localized by ultrasonography prior to catheterization. The free portal pressure can be measured. Selective catheterization of all portal tributaries can be performed. The indications are: portography in patients with cirrhosis of the liver and portal hypertension for delineation of collateral vein systems including gastro-oesophageal varices; visualization of veins that may be used for portosystemic shunt operations; postoperative control of shunt patency; diagnosis of portal and hepatic vein thrombosis; localization of stenosis in the portal vein system; pre-operative evaluation of patients with tumours in the biliary tract and pancreas; obliteration of bleeding oesophageal varices; and verification and localization of endocrine pancreatic tumours making curative resection possible. Further, transhepatic catheterization of the portal system may be used in research on the development of portal hypertension, collateral veins, variceal bleeding, and for haemodynamic, metabolic and pharmacologic studies in the gastrointestinal tract.     

Use of an interpositional venous graft posterior to the pancreas for LDLT patients with portal vein thrombosis

Portal vein thrombosis is a risk factor in patients who require liver transplantation, because it is often difficult to treat portal vein thrombosis, especially when it involves the confluence of the superior mesenteric vein and splenic vein. Since some transplant centers that perform living-donor liver transplantation do not have cryopreserved cadaveric vein grafts available and do not use graft veins that are long enough for a jump graft, it is difficult to reconstruct the portal vein with interpositional vein grafts in patients with portal vein thrombosis. We describe the treatment of portal vein thrombosis with an interpositional vascular graft posterior to the pancreas in a living-donor liver transplantation patient without using a jump graft. This method provided a shorter rout between the donor and recipient portal vein than a jump graft. Our experience suggests that this solution can be helpful in treating portal vein thrombosis.     

Hereditary pancreatitis: a model for inflammatory diseases of the pancreas

Acute and chronic pancreatitis remain among the most recalcitrant of all diseases to investigation and intervention. In the majority of patients, excessive alcohol consumption is associated with development of the disease. Therefore, several theories have been proposed seeking to explain the relationship between alcohol and the development of acute and chronic pancreatitis. However, recent investigations in hereditary pancreatitis provided important insights into chronic pancreatitis pathogenesis and offer an important model for understanding pancreatic inflammation. This article highlights several advances gained from investigating hereditary pancreatitis kindreds, and reviews the TIGAR-O risk/aetiology classification system. Finally, the major independent theories on development of chronic pancreatitis are reviewed with respect to the SAPE hypothesis of chronic pancreatitis pathogenesis.     

Extrahepatic portal venous thrombosis: frequent recognition of associated diseases

Twelve patients with obstruction of the extrahepatic portal venous system were seen at the Tufts-New England Medical Center between 1970 and 1979; a cause for the portal vein thrombosis was detected in 11. These included pancreatic disease (4); hematologic disorders (2); postoperative complications of laparotomy (3); transhepatic gelfoam embolization of the portal vein (1); and exchange transfusion via the umbilical vein (1). Clinical features included frequent self-limited episodes of bleeding from esophageal or gastric varices; and no characteristic or clinically helpful laboratory findings. The diagnosis was usually made in patients by identifying clots in the portal vein on selective angiography of the celiac and/or superior mesenteric arteries in which the venous phase was examined. Attempts at surgical correction were largely unsuccessful. Further thrombotic episodes occurred in three patients, and led to death in one. Two patients were given chronic anticoagulation with Coumadin and Persantin for 1 and 11/2 years, respectively without further thrombosis or gastrointestinal bleeding. However, it not yet possible to assess the risks and benefits of such therapy.     

Complications of percutaneous transhepatic catheterization of the portal venous system in patients with portal hypertension

We report here complications of percutaneous transhepatic catheterization of the portal venous system in 170 Japanese patients with portal hypertension. All patients underwent percutaneous transhepatic portography and percutaneous transhepatic obliteration of oesophagogastric varices was also performed in 29 patients. After retraction of the catheter, the puncture canal was plugged with gelatin sponge in 150 subjects and with one steel coil in 20 others. The overall complication rate was 16.5%. Intraperitoneal bleeding occurred in 10.6% of patients and 2.9% required blood transfusion. In these patients with intraperitoneal bleeding, the gelatin sponge was used for plugging after retraction of the catheter, while in the 20 patients with a steel coil plug, haemoperitoneum never occurred. Right pleural effusion was recognized in 3.5% of patients, intraperitoneal bile leakage in 1.8% and deterioration of liver function due to arteriovenous fistula in 0.6%. By univariate and multivariate analyses, female gender was the only risk factor for intraperitoneal bleeding among 150 patients investigated by percutaneous transhepatic catheterization of the portal venous system with gelatin sponge plugging. Intraperitoneal bleeding is the most important complication in patients with portal hypertension; it is difficult to predict intraperitoneal bleeding before retraction of the catheter in patients for whom gelatin sponge is used. Thus, for patients undergoing percutaneous transhepatic catheterization of the portal venous system, close follow up is recommended.