A 64-year-old female presented to the emergency department (ED) in cardiac arrest. Her family members heard her fall in the bathroom and started CPR. EMS intubated the patient and 20 minutes of CPR was done en route. Return of spontaneous circulation (ROSC) was achieved after fifteen minutes of resuscitation in the ED.
At baseline, the patient ambulated with her walker and was conversant. She was having abdominal pain and nausea for the past three days after recently being diagnosed with a urinary tract infection. On arrival to the ED, the patient was pulseless with ventricular fibrillation. The patient received ten doses of epinephrine, two doses of sodium bicarbonate, calcium, amiodarone, magnesium, and one dose of naloxone during the resuscitation. One defibrillatory shock was administered. She was started on a norepinephrine drip and an amiodarone drip.
Computed tomography (CT) of the head was negative. CT of the chest was significant for left pneumothorax and left-sided subcutaneous emphysema. A pigtail chest tube was placed. After a few hours, she developed worsening abdominal distension. An abdominal CT scan revealed the images shown.
Vitals:
- Temp 90.4 degrees F
- HR 108
- BP 66/41 (improving to MAP 65 on vasopressors)
- Intubated
- SpO2 100%
Neurologic: Richmond Agitation and Sedation Scale (RASS) score of -5, not withdrawing from pain in any extremities, pupils fixed and dilated
Cardiac: Irregular tachycardic rythum
Pulmonary: Coarse breath sounds, crepitus in the anterior left chest wall
Abdomen: Distended but not rigid
Troponin: 0.33 ng/ml
Creative phosphokinase (CPK): 1024 IU/L
AST: 26 U/L
ALT: 72 U/L
Alkaline phosphatase: 110 IU/L
Total bilirubin: 0.2 mg/dL
Hepatic portal venous gas (HPVG) is the accumulation of gas in the portal vein and its branches. It usually indicates a life-threatening gastrointestinal problem. It typically requires emergency surgery, but if benign can be treated conservatively.
The most common cause is bowel ischemia.
Decreased blood flow to the bowel causes damage to the mucosal barrier, as well as over-distension of the bowel loops and proliferation of gas-forming bacteria. This results in the migration of gas from the bowel lumen into the mesenteric veins, which then flows to the portal system [1]. For this reason, pneumatosis intestinalis is sometimes concurrent in these cases.
When HPVG is associated with bowel ischemia, there is usually transmural necrosis and a high mortality rate (85 percent) [2]. There have been case reports describing pneumatosis intestinalis and HPVG after CPR. The pathophysiology is thought to be due to bowel ischemia resulting from poor mesenteric perfusion during CPR. This may be exacerbated by high doses of epinephrine during CPR, causing severe vasoconstriction [3].
Another proposed mechanism is over-distension of the stomach during bag-mask ventilation, resulting in mucosal tears and translocation of intraluminal air [5]. Lien et al. found that HPVG was more likely in older patients, unwitnessed arrest, prolonged resuscitation, and also in patients who received more epinephrine [4]. These patients were also less likely to have return of spontaneous circulation, survival to hospital admission, and survival to hospital discharge.
Take-Home Points
- It is important to consider the consequences and complications of cardiopulmonary resuscitation after ROSC is achieved.
- HPVG is associated with increased mortality, correlating with older age, prolonged resuscitation, and use of epinephrine.
- Although some cases of HPVG are surgical (such as mesenteric ischemia), those cases associated with CPR are unlikely to benefit from surgery given diffuse bowel ischemia.
- Abboud, B., El Hachem, J., Yazbeck, T., & Doumit, C. (2009). Hepatic portal venous gas: physiopathology, etiology, prognosis and treatment. World journal of gastroenterology:WJG, 15(29), 3585. PMCID: PMC2721230
- Hussain, A., Mahmood, H., & El-Hasani, S. (2008). Portal vein gas in emergency surgery. World Journal of Emergency Surgery, 3(1), 21. PMCID: PMC2490689
- Lai, C. F., Chang, W. T., Liang, P. C., Lien, W. C., Wang, H. P., & Chen, W. J. (2005). Pneumatosis intestinalis and hepatic portal venous gas after CPR. The American journal of emergency medicine, 23(2), 177-181.
- Lien, W. C., Chang, W. T., Huang, S. P., Chiu, H. M., Lai, T. I., Weng, T. I., … & Chen, W. J. (2004).Hepatic portal venous gas associated with poor outcome in out-of-hospital cardiac arrest patients. Resuscitation, 60(3), 303-307. PMID: 15050763
- Reuter, H., Bangard, C., Gerhardt, F., Rosenkranz, S., &Erdmann, E. (2011). Extensive hepatic portal venous gas and gastric emphysema after successful resuscitation. Resuscitation, 82(2), 238-239 PMID: 21134710
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