A 37-year-old Asian female with no significant medical or surgical history presented with acute diffuse abdominal pain, nausea and vomiting. Her physical exam and laboratory testing were unremarkable. She was diagnosed with viral gastroenteritis and discharged home. Her abdominal pain resolved but 3 days later she developed a fever of 102.6 °F with no focal symptoms. Physical exam revealed icterus but no abdominal tenderness or distention. Laboratory tests showed WBC 6.4 K/UL, platelet 38 K/UL, AST 89 U/L, ALT 155 U/L, alkaline phosphatase 321 U/L, and total bilirubin 2.6 mg/dL. Amylase and lipase were normal. A viral hepatitis panel, EBV and CMV PCR were negative. Patient was initially managed with supportive care but then developed sepsis with hypotension on the second hospital day. An abdominal and pelvic CT scan revealed an acutely perforated appendicitis with a 1.9×1.4 cm abscess. There was also an acute thrombus with extensive occlusion of the superior mesenteric vein, as well as septic emboli within the right hepatic lobe. The patient was started on broad-spectrum antibiotics and her blood cultures grew Bacteroides fragilis. She was also treated with systemic anticoagulation. She had significant clinical improvement and was discharged home to complete a 4-week course of antibiotics and a 3-month course of systemic anticoagulation. An appendectomy was planned after completing anticoagulation therapy.
Pylephlebitis or septic thrombophlebitis of the portal vein, is a rare complication of an intra-abdominal infection such as diverticulitis, appendicitis, and cholangitis. This condition is associated with high morbidity and mortality. Diagnosis can be challenging as the clinical presentation is often nonspecific. Patient may have no clinical features referable to the primary focus of infection. Manifestations related to the thrombosis may include jaundice from liver involvement and/or abdominal pain due to bowel ischemia. The diagnostic accuracy of ultrasound may be limited while contrast-enhanced CT can demonstrate thromboses in the portal vein system as well as the intra-abdominal source of infection. Prompt initiation of broad-spectrum antibiotics covering Gram-negative bacilli, anaerobes and aerobes is vital when pylephlebitis is suspected. The role of anticoagulation therapy is controversial.
Pylephlebitis is an uncommon complication of abdominal infections in the portal drainage system. Due to the high mortality rate, hospitalists should have a high clinical suspicion for patients with intra-abdominal sepsis and liver function abnormalities. Expedient diagnosis, timely administration of broad-spectrum antibiotics, consideration of systemic anticoagulation, and close collaboration with our surgical colleagues is crucial to a favorable outcome.
To cite this abstract:Xiong, T . PYLEPHLEBITIS: THE CLINICAL COMPLEXITIES AND CALL FOR COLLABORATION. Abstract published at Hospital Medicine 2017, May 1-4, 2017; Las Vegas, Nev. Abstract 794. Journal of Hospital Medicine. 2017; 12 (suppl 2). https://www.shmabstracts.com/abstract/pylephlebitis-the-clinical-complexities-and-call-for-collaboration/. Accessed February 25, 2020.