Infantile Hypertrophic Pyloric Stenosis - A Rare Cause of Hepatoportal Venous Gas

Abstract

Hepatic portal venous gas (HPVG) is usually associated with necrotizing enterocolitis or bowel ischemia in infants but it's a rare finding with hypertrophic pyloric stenosis (HPS). In such cases, portal venous gas is a benign incidental finding and does not advocate any delay in the surgical treatment. We report this atypical case of 3 weeks old male infant with HPS having portal venous gas that was detected on abdominal ultrasound. Our patient with a history of term delivery was brought to the pediatric department of Combined Military Hospital Lahore on 25th of November, 2013 with complaints of vomiting and constipation for the last 4 days. Physical examination showed that the infant was lethargic and mildly dehydrated with soft and non-tender abdomen. Baseline blood tests revealed metabolic alkalosis with hemoglobin and total leukocyte count within normal limits. Plain xray abdomen showed a distended stomach with no signs of gut obstruction. Abdominal ultrasonography revealed a severely thickened and lengthened pylorus suggestive of hypertrophic pyloric stenosis. Moreover, ultrasound also showed multiple echogenic foci diffusely involving the both lobes of otherwise normal sized liver. Moving air bubbles were also detected in the extra and intra hepatic portal and splenic veins on dynamic scanning confirming the presence of portal venous gas. The infant underwent Ramstedt's pyloromyotomy for HPS. The infant showed a steady recovery and ultrasonography performed at 2nd post op day detected no signs of gas within the hepato portal veins.