Successful Conservative Management of Hepatic Portal Venous Gas Following Percutaneous Endoscopic Gastrostomy: A Case Report

Background

Hepatic portal venous gas (HPVG) is a rare radiologic finding in numerous clinical situations that vary from life-threatening to benign conditions; its overall mortality rate is 39–75% [1–4].

It can be detected by plain abdominal radiography, CT scan, and ultrasound. In case of plain abdominal radiography and CT scan, HPVG is described as a branching radiolucency extending within 2 cm of the liver capsule. HPVG on imaging differs from biliary tract gas (aerobilia), which is usually more central and more than 2 cm away from the liver capsule [1]. CT scan has a higher sensitivity than radiography in detecting HPVG [1,3,5].

There are 3 hypotheses describing the physiopathology of HPVG: 1) increased pressure within the digestive tract allows gas to migrate through the bowel wall into the portal veinous circulation and finally into the liver; 2) disruption to the intestinal mucosa allows for the passage of gas formed by intraluminal bacteria into the portal venous system; 3) diffusion of gas from bacteria present in an intra-abdominal abscess or porto-mesenteric pyelophebitis [6,7].

The disease most commonly associated with HPVG and the one with the highest mortality (75%) is mesenteric vascular occlusion and subsequent intestinal necrosis [6]. However, numerous other clinical conditions are associated with HPVG, such as gastrointestinal dilatation, gastrointestinal inflammation, sepsis, endoscopic procedures, peptic ulcer disease, blunt trauma, and abdomino-pelvic malignancies [1–7]. Prognoses vary widely from innocuous to life-threatening conditions. The clinical presentation as well as a thorough understanding of the underlying disease is important to avoid unnecessary treatment. An algorithm has been proposed for the management of HPVG based on radiological, biological, and clinical findings: urgent surgery is recommended if HPVG is present on plain X-ray or on CT scan with concomitant suspicion of bowel ischemia (associated intestinal pneumatosis) and/or increased lactate levels with anion gap, and peritonitis. In the absence of bowel ischemia, a wait-and-see approach with conservative management and close monitoring may be preferred based on the patient’s clinical condition [8].

HPVG is a rare condition following PEG tube placement and no clear evidence-based recommendations exists in the literature [9–12]. The aim of this case report is to describe a feasible and safe way to manage HPVG as a late complication following PEG tube placement in clinically stable patients.

Case Report

We report the case of a 78-year-old man with a 1-year history of epidermoid cancer of the proximal third of the esophagus (20 cm from the dental arcade) staged as T3 N2 M0. He was initially treated with radiotherapy (50.4 G) and chemotherapy (Carboplatine and Fluoruracil, 3 cycles). The patient developed a post-radiation esophageal stenosis requiring multiple esophageal dilatations and the positioning of an esophageal stent that was complicated by an esophageal perforation that necessitated stent removal.

Radiological follow-up showed recurrent disease at the gastric-esophageal junction. Furthermore, 2 other stenotic lesions were present, as well as peritoneal carcinomatosis. A new gastroscopy was performed and a Forrest IIC lesion was diagnosed; biopsies confirmed an epidermoid carcinoma that was classed Sievert III. The patient also had hypertension, hypercholesterolemia, and gout.

Palliative radiotherapy was administered (40 Gy) and a 15-Fr PEG tube (PEXAT gastrostomy feeding tube) was positioned by gastroenterologists 1 month before admission to our department; both esophageal stenoses were crossable at that time. The patient also underwent an additional cycle of chemotherapy (Carboplatine and Fluorouracil) 10 days earlier. He was admitted to our Emergency Department for recurrent vomiting, intermittent abdominal pain, and a 24-h absence of stool. At arrival, blood pressure was 139/85 mmHg, heart rate was 104/min, oxygen saturation was 93% on ambient air, and body temperature was 36°C. Clinical examination showed generalized abdomen tenderness without signs of peritonitis, and abdominal sounds were reduced. Laboratory tests showed normal leucocytes and a C-reactive protein of 105 mg/L, as well as an AKIN I kidney failure with creatinine level at 103 µmol/L. A contrast-enhanced abdominal CT scan showed bowel distension without changes in caliber size. The images were compatible with a paralytic ileus as well as gastric distension with gastric wall pneumatosis and HPVG. Neither pneumoperitoneum nor free fluid were detected (Figure 1A).

The patient was admitted to our department and conservative management for ileus was started with fluid resuscitation. The PEG was put to suction at −15 cmH2O. Serial clinical evaluations were unremarkable, with a depressible abdomen and no abdominal pain. Stool was restored at day 2 and biological findings showed a gradual reduction of C-reactive protein levels at 24.8 mg/L on day 3, with resolution of kidney failure. The pain was well managed. A CT scan on day 5 showed an almost complete resolution of HPVG (Figure 1B).

Enteral nutrition via the PEG was restored on day 6 without complication; the patient was discharged on the same day to the Geriatrics Department. No antibiotics were administrated during the hospitalization. No recurrence of paralytic ileus or HPVG were recorded in the following 2 months, and PEG nutrition was well tolerated. Chemotherapy was resumed 2 weeks later without any delay or further complications.

Discussion

PEG tube placement is a common intervention. It is a safe way to feed patients with a functional gastrointestinal system who require long-term artificial nutrition. This procedure is performed mainly endoscopically, with low morbidity rates. Nonetheless, complications associated with this procedure have been described: wound infection, tube or stoma leakage that can lead to peritonitis, displacement, obstruction, bleeding, buried bumper syndrome, bowel perforation, necrotizing fasciitis, and metastatic seeding have been described [13]. Some of these complications can have serious consequences for the patient and may occur months or years after the procedure.

HPVG has been described as an immediate or late complication of PEG tube placement, but there is no consensus about its management due to the rarity of this condition. To date, just 4 cases describing this condition have been published [9–12]. Of these, only 2 reported a successful conservative management outcome [9,12]. In both cases, antibiotics were administrated, although in 1 case antibiotics were administrated to treat a concomitant infection rather than HPVG itself [9].

Our case report adds to the limited information available on HPVG following PEG tube placement. The novelty of this case is the successful conservative management of HPVG without the use of antibiotics, supporting that HPVG was due to a mechanical condition. Additionally, our case provides insights into the conservative management of HPVG related to the clinical presentation of the patient.

Due to the absence of fever and hemodynamic instability, coupled with a reassuring clinical examination that showed no signs of peritonitis, we opted not to administer antibiotics, despite elevated CRP levels at admission. As described above, CRP was the only elevated inflammatory marker. We monitored the patient closely to identify rapidly worsening of the clinical condition to react rapidly if needed.

One of the life-threatening diseases leading to HPVG to rule out before conservative management is emphysematous gastritis. This critical condition is related to high inflammatory markers on blood tests, severe abdominal pain, and evidence of bacterial infection [14]. In our case, despite the evidence of gastric wall pneumatosis, bacterial infection leading to emphysematous gastritis was ruled out due to the reassuring clinical condition of the patient, absence of fever, and normal white blood cells count.

We attributed the appearance of HPVG to the onset of the ileus that led to an increased gastric pressure causing gastric wall pneumatosis originating from PEG tube site insertion, through the stomach wall, and finally HPVG. The resolution of HPVG after transit restoration support this hypothesis. We hypothesized that the normalization of bowel pressure and suction through the PEG stopped gas from penetrating the gastric wall. This is supported by the abdominal CT scan on day 5 showing near complete resolution of HPVG.

Furthermore, we observed a clinical improvement without antibiotics administration. This fact supports the hypothesis that HPVG was purely a mechanical condition without bowel bacterial overgrowth or ischemia. This conservative management and close monitoring allowed rapid resolution of HPVG with the resumption of enteral nutrition via the PEG and a minimal delay of the oncological treatment.

Conclusions

HPVG can be a benign finding after PEG positioning and can be associated with ileus and consequent increase of gastric pressure. Conservative management is viable in asymptomatic and hemodynamically stable patients, once life-threatening associated diseases like bowel necrosis have been ruled out.