Does the presence of hepatic portal venous gas mandate an operation? A reassessment

The presence of HPVG has been said to constitute a mandatory indication for exploratory laparotomy, given the high incidence of concomitant bowel necrosis and abdominal sepsis. HPVG has also been associated with increased intraluminal pressure in the absence of bowel ischemia. Most cases are iatrogenic, usually due to barium enema or colonoscopy in patients with inflammatory bowel disease, but in a few cases, HPVG is associated with simple intestinal or gastric distention. The English literature on the subject describes only eight such cases. We recently treated a patient in whom HPVG was caused by intestinal pseudo-obstruction. Such an etiologic mechanism has not been previously reported. The relevance of this observation and a reassessment of the absolute obligation to operate prompted this review.