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Hepatic portal venous gas 


The CT scan of the abdomen and pelvis depicts portal venous gas throughout the liver (Figure A, B, white arrows). Hepatic portal venous gas is traditionally regarded as an ominous radiologic sign and appears as a branching area of low attenuation on CT scanning extending to within 2 cm of the liver capsule.1 It is commonly associated with numerous underlying abdominal diseases, ranging from benign processes to potentially lethal etiologies requiring immediate surgical intervention. The mechanism of hepatic portal venous gas can involve mechanical injury to the bowel lumen or gas-producing bacteria in the intestine.2 In the specific case of caustic ingestion of H2O2, the presence of bubbles in the portal vein could result from the oxygen generated by the caustic after passage through damaged gastric mucosa or from generation of oxygen in the blood after absorption of the caustic.3 
Despite numerous reports of satisfactory outcomes with conservative management, the discovery of portal venous gas should not be dismissed quickly. Ultimately, management should be tailored to the underlying etiology and may include urgent surgical intervention. When appropriate, conservative management may include intravenous fluids and proton pump inhibitors.2,3 However, in cases involving caustic ingestion and massive gas embolization, providers should maintain a high index of clinical suspicion for neurologic as well as cardiac complications, because these complications may benefit from hyperbaric oxygen therapy.2 
In this case, the patient had severe symptoms. Therefore, a decision was made to treat him with intravenous fluids, proton pump inhibitors, and two rounds of hyperbaric oxygen therapy. The patient ultimately had an uneventful recovery. 
The quiz authors disclose no conflicts. 
 
References 
1. Sebastia C et al. Radiographics. 2000 Sep-Oct;20(5):1213-24. 
2. Abboud B et al. World J Gastroenterol. 2009 Aug 7;15(29):3585-90. 
3. Lewin M et al. Eur Radiol. 2002 Dec;12(Suppl 3):S59-61. 
 

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Hepatic portal venous gas 


The CT scan of the abdomen and pelvis depicts portal venous gas throughout the liver (Figure A, B, white arrows). Hepatic portal venous gas is traditionally regarded as an ominous radiologic sign and appears as a branching area of low attenuation on CT scanning extending to within 2 cm of the liver capsule.1 It is commonly associated with numerous underlying abdominal diseases, ranging from benign processes to potentially lethal etiologies requiring immediate surgical intervention. The mechanism of hepatic portal venous gas can involve mechanical injury to the bowel lumen or gas-producing bacteria in the intestine.2 In the specific case of caustic ingestion of H2O2, the presence of bubbles in the portal vein could result from the oxygen generated by the caustic after passage through damaged gastric mucosa or from generation of oxygen in the blood after absorption of the caustic.3 
Despite numerous reports of satisfactory outcomes with conservative management, the discovery of portal venous gas should not be dismissed quickly. Ultimately, management should be tailored to the underlying etiology and may include urgent surgical intervention. When appropriate, conservative management may include intravenous fluids and proton pump inhibitors.2,3 However, in cases involving caustic ingestion and massive gas embolization, providers should maintain a high index of clinical suspicion for neurologic as well as cardiac complications, because these complications may benefit from hyperbaric oxygen therapy.2 
In this case, the patient had severe symptoms. Therefore, a decision was made to treat him with intravenous fluids, proton pump inhibitors, and two rounds of hyperbaric oxygen therapy. The patient ultimately had an uneventful recovery. 
The quiz authors disclose no conflicts. 
 
References 
1. Sebastia C et al. Radiographics. 2000 Sep-Oct;20(5):1213-24. 
2. Abboud B et al. World J Gastroenterol. 2009 Aug 7;15(29):3585-90. 
3. Lewin M et al. Eur Radiol. 2002 Dec;12(Suppl 3):S59-61. 
 

Hepatic portal venous gas 


The CT scan of the abdomen and pelvis depicts portal venous gas throughout the liver (Figure A, B, white arrows). Hepatic portal venous gas is traditionally regarded as an ominous radiologic sign and appears as a branching area of low attenuation on CT scanning extending to within 2 cm of the liver capsule.1 It is commonly associated with numerous underlying abdominal diseases, ranging from benign processes to potentially lethal etiologies requiring immediate surgical intervention. The mechanism of hepatic portal venous gas can involve mechanical injury to the bowel lumen or gas-producing bacteria in the intestine.2 In the specific case of caustic ingestion of H2O2, the presence of bubbles in the portal vein could result from the oxygen generated by the caustic after passage through damaged gastric mucosa or from generation of oxygen in the blood after absorption of the caustic.3 
Despite numerous reports of satisfactory outcomes with conservative management, the discovery of portal venous gas should not be dismissed quickly. Ultimately, management should be tailored to the underlying etiology and may include urgent surgical intervention. When appropriate, conservative management may include intravenous fluids and proton pump inhibitors.2,3 However, in cases involving caustic ingestion and massive gas embolization, providers should maintain a high index of clinical suspicion for neurologic as well as cardiac complications, because these complications may benefit from hyperbaric oxygen therapy.2 
In this case, the patient had severe symptoms. Therefore, a decision was made to treat him with intravenous fluids, proton pump inhibitors, and two rounds of hyperbaric oxygen therapy. The patient ultimately had an uneventful recovery. 
The quiz authors disclose no conflicts. 
 
References 
1. Sebastia C et al. Radiographics. 2000 Sep-Oct;20(5):1213-24. 
2. Abboud B et al. World J Gastroenterol. 2009 Aug 7;15(29):3585-90. 
3. Lewin M et al. Eur Radiol. 2002 Dec;12(Suppl 3):S59-61. 
 

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A 52-year-old man with no past medical or surgical history presented to the emergency department after accidental ingestion of 300 mL of a colorless liquid from his refrigerator. The patient instantly noticed a bitter taste in his mouth as well as burning sensation throughout his oropharynx and esophagus. Immediately after ingestion, the patient also experienced severe retching and emesis. On initial presentation, the patient was hemodynamically stable. There was no evidence of pneumoperitoneum, nor cardiac or neurologic symptoms suggesting air embolism. A computed tomography (CT) scan of his abdomen and pelvis revealed the images displayed in Figure A, B. Further history revealed ingestion of unlabeled 35% hydrogen peroxide (H2O2). 
How should this condition be managed?

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