Question
A 79-year-old man with alcoholic cirrhosis was admitted for interstitial
pneumonia. After 4 weeks of prednisolone treatment, his condition
improved, and he was scheduled for discharge after the start of the
meal. A barium swallow examination was performed to assess swallowing
function, and repeated vomiting, abdominal pain and bloody stools
occurred 10 h later. His vital signs were stable, with no symptoms of
peritoneal irritation, and his serum C-reactive protein level was 0.29
mg/dL. Contrast-enhanced computed tomography (CT) showed extensive
hepatic portal venous gas (PVG) (Figure 1a) and barium retention in the
ileum and colon (Figure 1b), but there was no intestinal pneumatosis or
necrosis. What pathologies would you consider, and what is your
treatment plan for this patient?
Answer
PVG is a relatively rare pathology caused by severe abdominal disorders
including intestinal necrosis.[1] PVG is often
assumed to be a sign of poor clinical outcome and require emergency
surgery. However, some cases of PVG were reported to have resolved with
conservative therapy. In our case, conservative treatment, including a
nasogastric tube and antibiotics, quickly resolved the symptoms. Three
days later, CT showed PVG to have disappeared, and he had no relapse.
Two weeks later, he was discharged from the hospital.
PVG is often associated with intestinal pneumatosis or necrosis in adult
patients.[1] While colon obstruction and
perforation have been reported as complications of
barium,[2] PVG after barium examination is
extremely rare. This is the first report of PVG without intestinal
pneumatosis or necrosis after a barium swallow examination, and
emergency surgery was not required. Bowel distention and
mucosal damage can lead to
PVG,[3] and prednisolone is thought to make
intestinal mucosa vulnerable; therefore, caution should be exercised
during barium testing in patients undergoing prednisolone treatment.
Surgical interventions should be performed for patients with PVG caused
by bowel ischemia and perforation. Alternatively,
conservative therapy can be
considered for patients with PVG who have no bowel ischemia or
perforation.