An Uncommon Cause of Fever and Abdominal Pain

1University of Wisconsin School of Medicine and Public Health, Madison, WI

Meeting: Hospital Medicine 2014, March 24-27, Las Vegas, Nev.

Abstract number: 365

Case Presentation:

A 39‐year‐old woman with a history of gastric bypass complicated by dysmotility, which led to choledochoduodenostomy and two loop jejunoduodenostomies with subsequent revision to standard gastric bypass anatomy, presented with increased abdominal pain. She was maintained on high‐dose opiates for chronic abdominal pain. She was afebrile and hemodynamically stable. Labs were entirely normal. CT abdomen showed stable anatomy, stable pneumobilia, and a high stool burden; she was aggressively laxated. After several bowel movements, her abdominal pain returned to baseline, and she was discharged. She presented 1 day later with increased‐intensity abdominal pain, myalgias, and a reported fever of 105 degrees Fahrenheit at home. She was found to be afebrile and tachycardic but normotensive. She had no other localizing symptoms, in particular no respiratory complaints. Labs revealed an increase in total bilirubin to 1.3 mg/dL and a decrease in platelet count to 109,000. RUQ ultrasound revealed no acute abnormalities. She was fluid resuscitated, admitted, and monitored; a viral syndrome was considered the most likely cause of symptoms. Evaluations for viral hepatitis and hemolysis were negative. CT was deferred given the scan 2 days prior and multiple prior scans.

On hospital day 2, she became febrile to 102 degrees Farenheit and bilirubin rose to 1.6 mg/dL. She was started on antimicrobials; vitals normalized rapidly, as did labs. An MRCP revealed thrombosis of the left portal and mid‐hepatic veins, with a 1cm fluid collection in the porta hepatitis. She was started on anticoagulation. Blood cultures grew Fusobacterium at 9 hours. Her bilirubin and blood counts normalized rapidly, and she was discharged on long‐term antibiotics and anticoagulation.

She was diagnosed with pylephlebitis, attributed to probable cholangitis in the absence of other identified source.

Discussion:

Pylephlebitis, a septic thrombophlebitis of the portal vein, is an uncommon complication of abdominal infections such as diverticulitis and appendicitis. In this case, despite the altered GI anatomy, the initial index of suspicion for such an infection was low. Moreover, the chronic nature of the abdominal pain and the recent stable imaging proved a distraction. No obvious inciting infection was identified, and the abscess was deemed more likely a complication than a cause. The partial hepatic vein thrombosis is another unusual feature; there was no prior thrombotic episode, and the hypercoagulable workup was negative. There is a dearth of randomized data on management; by AASLD guidelines, anticoagulation and antibiotics are a class I recommendation in this situation, and longitudinal follow‐up has been arranged.

Conclusions:

Patients with fever and abdominal pain merit further advanced workup. The constellation of hyperbilirubinemia and thrombocytopenia with fever and abdominal pain should prompt consideration of pylephlebitis.

To cite this abstract:

Caponi B, Pistner A. An Uncommon Cause of Fever and Abdominal Pain. Abstract published at Hospital Medicine 2014, March 24-27, Las Vegas, Nev. Abstract 365. Journal of Hospital Medicine. 2014; 9 (suppl 2). https://www.shmabstracts.com/abstract/an-uncommon-cause-of-fever-and-abdominal-pain/. Accessed April 1, 2020.

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