Hepatic venous gas signs- rare "death" imaging signs

The patient woman, 74 years old, was admitted to the hospital for 2 weeks due to "chills and abdominal discomfort"laboratory indicators indicate that the inflammatory markers are elevated and liver work is characterized by bile siltationAbdominal ultrasound and magnetic resonance pancreatic bile duct imaging did not show significant abnormalitiesCT Tip: Hepatic gate venous gas (HPVG), left lumbar muscle abscessat this time the patient's diagnosis can be clearly defined as: liver venous gashad emergency surgery on patients as their clinical performance deteriorated rapidlyThe procedure was found to be accompanied by a diverticulitous abscess and a ruptured vein under the intestinal membraneFinally, the patient was performed on a bowel resection and colonoscopy, and the patient recovered well after surgerylet's look at a special casewomen, dizziness, abdominal pain for 2 days, blood like white blood cell increase (more than 20,000), low blood pressure when admitted to hospital, admitted to the ICUBlood sugar 54.6, acidosisIt is said that the disease progressed very quickly, the film is very rare, but basically a glance will not forgetNow let's take a look at the patient's CTpatient CT: The sign of death
, "death sign" is what?a rare imaging sign
hepatic portalous venous gas (PVG) is a rare imaging sign that causes the abnormal accumulation of gas in the gate vein and the intra-hepatic venous branch of the gate, which is a rare imaging sign liver door venous gas CT: along the door veins walking with dead branches-like low-density shadow the door vein gas itself is independent lesions, resulting in many causes of the door vein gas, the cause of different prognosis is not the same Most common ischemia and necrosis in the intestines The sign sepsis, abdominal infections and other non-gastrointestinal lesions, and about 15% of PVGs are iexclusiveia ultrasound performance gray-scale ultrasound, the gas because of its high impedance and the appearance of high lesions, so HPVG is shown as a significantly high echo of spots in the liver gate veins and/or the substance of the liver, after silent shadow, and can flow along the normal physiological blood flow direction of the gate veins (to the liver) and flow (Figure 1 and Video 1) figure 1 Liver venous gas in 68-year-old male patients The horizontal cut surface (A) and the sagging cut surface (B) under the right rib show the essence of the liver of a number of speckled high echo, after the silent shadow if the amount of gas in the liver is large, because the gas-induced reverb artifacts may lead to the liver internal door veins display blurred, by two-dimensional ultrasound directobservation of the door vein effect is not good in addition, on two-dimensional ultrasound, the intra-hepatic venous gas is not easily distinguished from bile duct gas, liver venous gas and hepatic intra-intrasted emphysema (emphysema hepatic abscesses), these lesions can be shown as HPVG-like high intra-liver echo Although studies have concluded that HPVG tends to be peripherally distributed and gas is often temporarily present for identification, the characteristic is not accurate if there is a large amount of gas in the liver, and is often vaguely described as "intra-liver gas" Doppler ultrasound colored Doppler, HPVG can be characterized by intravenity turbulence When the spectrum Doppler is examined, the sample volume is placed in the door vein, which can be represented as a two-way, sharp, vertical "spike" superimposed on the door vein spectrum, due to the discontinuous occurrence of the high-pitched impedance between the bubble and the blood as the bubble flows through the beam Doppler ultrasound shows that HPVG is more specific than two-dimensional ultrasound, and that still or slow-flowing bubbles do not show similar spikes or turbulence on Doppler ultrasound if the patient is unable to fit in the control of breathing during the examination, placing the Doppler sample volume at the door vein may not be easy, and the Doppler spectrum may not be able to display a typical two-way high vertical spike waveform In addition, Doppler ultrasound also loses value if the liver is covered too much by the physical gas in the nest M-type ultrasound M super-high time resolution, as a supplement to 2D and Doppler ultrasound, most commonly used in heart examinations, rarely used in the abdomen previous authors (Ikeda, etc.) have used M-ultrasound to examine the gas in the heart cavity after a dive The author chose to use M-super-detecting the venous gas in the gate the authors found that in M super, a linear signal can be generated due to changes in the position and flow direction of the bubbles in the venous veins of the door, which can be characterized by the meteor shower feature (Figures 2 and 3), which is the flow trajectory of the bubbles in the venous veins of the door M-super-detection has a relatively low reliance on operators and less restrictions on HPVG checks During the examination, the M-type sampling line is placed in the channel door vein (Figure 2) or the liver substance outside the blood vessel (Figure 3), the former requires the patient's breathing cooperation, while the latter does not Figure 2 Is the same patient as Figure 1 The liver gate venous gas shows a high echo of the diagonal line in different directions on the M-type ultrasound, i.e the "meteor shower" sign (Figure A), which is more clearly amplified locally (Figure B, arrow) The patient can be combined with the breath, the triangular arrow below Figure B shows smooth ness, no ups and downs Figure 3 Liver veins build up in an 87-year-old irritable patient Figure A is a dot-like high echo showing multiple silent shadows in the liver through the oblique sans in the right-hand , with a high echo of the diagonal line with different directions visible on the M-curve
, showing a "meteor shower" sign; HPVG's meteor shower signs can be displayed on a single image and are easy to add to diagnostic reports, making it easier for clinicians to understand image reports II, why did the "Sign of Death" happen? a sign that appears with digestive disease
III, a disease that is very similar to the "sign of death" pvG needs to be identified with bile duct gas
PVG is a rare radiology discovery, manifested as the condosyliabilit region of the venous system of the liver circumliex and the menenteriography vein system The area of the reduction of the PVG needs to be identified with the bile duct gas: PVG is shown as a dead-branchgas-like low density zone, the gas is mostly located on the edge of the liver and the left leaf, may be due to the blood flow in the direction of the peripheral venous vents of the inner liver, and the position of the bile duct gas is relatively fixed bile duct gas gas is often located in the liver gate area, to the left and right liver tube-based, mostly scattered discontinuous gas shadow, because of the direction of bile flow so that the bile duct gas is mostly located in the center of the liver, often accompanied by biliary surgery or a history of bile infection the white arrow in the picture shows: the bile duct gas four, "the sign of death" terrible? positioned and visible in the section of the gate vein, the mortality rate is higher
a recent study of 209 PATIENTs with PVG found that age, peritonitis signs, high blood urea nitrogen and intestinal ischemia or intestinal necrosis are closely related In addition, the accumulation of gas occurs at the venous area of the special gated intestinal membrane vein system, known as arched or sectional vascular (the arcade and segmentalals), and is considered to be an indicator of poor prognosis PVG patients with further signs of intestinal necrosis, especially those positioned and visible on the venous section of the gate, had a higher mortality rate ('50%) of cases A 58-year-old woman, known as chronic intestinal membrane ischemia-associated progressive post-meal pain and supple, was treated for increased pain and fever (38.2 degrees C) Past history of patients: myocardial infarction, history of smoking physical examination showed diffuse abdominal tenderness and severe sepsis (pulse 135bpm, blood pressure 80/40 mmHg) laboratory examination: increased white blood cell count (22,000/mL) and lactic acid increase (8.8 mmol/L) The CT results (A, B, C) and the inoperative (D) see the figure below (this case comes from the network) Figure A: CT shows a large amount of gas build-up with low liver perfusion, as well as left hemangioma (arrow pointing); Figure B: Dilated fluid gas in the intestinal tract with venous system (indicated by arrow); Figure C: Diffuse aorta wall Calcification, abdominal stem and intestinal membrane arterial filling deficiency defects; Figure D: emergency opening surgery on patients, in which the fluid in the menstrual veins can be seen; and the dispersion, irreversible intestinal obstruction was found, considering that the patient cannot be cured died of multiple organ failure after 9 hours of ! early interventions treatment often have a better prognosis for patients Treatments usually have both surgical treatments and conservative treatments Different treatments are mainly based on the cause and condition of the patient conservative treatment (fasting, gastrointestinal decompression, nutritional support, necessary empirical anti-infection and other comprehensive treatment) is feasible for patients with stable vital signs, benign lesions, no peritonitis symptoms, and low gas build-up patients with a history of vomiting, age 60, increased white blood cells, sepsis and acidosis require a caesarean section When conservative treatment conditions do not improve significantly, active surgical treatment, such as caesarean section testing, can also improve the survival rate of patients this article is compiled from: emergency medical information, Dr Fu Wei, ultrasound time, Medsci, Huang Lianghui and other "research progress of liver-gate venous gas", Dinghu image, from imaging medicine and nuclear medicine Source: Radiological Salon Review: 166YKrv (No Nickname) 2020-4-13 Review: terrible (from: MedSciApp )