A case of pylephlebitis complicating an acute appendicitis: Uncommon cholangitis-like situation

Portal vein thrombosis after laparoscopic appendectomy for acute appendicitis: A case report

RATIONALE

Portal vein thrombosis (PVT) has a complex pathophysiologic pathway and may cause life-threatening clinical complications. Malignancies, hepatic cirrhosis, auto-immune disorders, previous splenectomy, and other causes of thrombocytosis (over 1,000,000/mL) are the most common causes of PVT. On the other hand, hematologic disorders and infectious processes in the abdominal cavity may cause PVT uncommonly. We present a case of PVT following acute appendicitis and laparoscopic appendectomy in this report.

PATIENT CONCERNS

A 32-year-old male was admitted to our emergency room due to lower quadrant pain and vomiting. Acute appendicitis was diagnosed and after a routine laparoscopic appendectomy, the patient was discharged. The patient was admitted to the emergency room with nonspecific epigastric pain on postoperative day 30.

DIAGNOSES

Portal vein thrombosis was diagnosed by computed tomography. Hematologic investigations revealed a homozygous mutation of the methylene tetrahydrofolate 1298 gene.

INTERVENTIONS

Immediate low-molecular-weight heparin administration was initiated. The gastrointestinal system council and interventional radiology team opted for a medical approach and converted the low-molecular-weight heparin to apixaban.

OUTCOMES

The computed tomography revealed the complete resolution of the thrombus on postoperative day 100.

LESSONS

Laparoscopic appendectomy can be complicated by portomesenteric axis thrombosis. When unusual findings are encountered during the postoperative follow-up period, rapid and detailed examinations should be performed.

A case of multidrug-resistant intractable pylephlebitis and intra-abdominal abscess due to perforated appendicitis successfully treated with open abdominal management

BACKGROUND

Pylephlebitis, a rare and lethal form of portal venous septic thrombophlebitis, often arises from infections in regions drained by the portal vein. Herein, we report a case of peritonitis with portal vein thrombosis due to acute severe appendicitis, managed with intensive intraperitoneal drainage via open abdominal management (OAM).

CASE PRESENTATION

A 19-year-old male with severe appendicitis, liver abscesses, and portal vein thrombosis developed septic shock and multi-organ failure. After emergency interventions, the patient was admitted to the intensive care unit. Antibiotic treatment based on cultures revealing multidrug-resistant Escherichia coli and Bacteroides fragilis and anticoagulation therapy (using heparin and edoxaban) was initiated. Despite continuous antibiotic therapy, the laboratory results consistently showed elevated levels of inflammatory markers. On the 13th day, open abdominal irrigation was performed for infection control. Extensive intestinal edema precluded wound closure, necessitating open-abdominal management in the intensive care unit. Anticoagulation therapy was continued, and intra-abdominal washouts were performed every 5 days. On the 34th day, wound closure was achieved using the anterior rectus abdominis sheath turnover method. The patient recovered successfully and was discharged on the 81st day.

CONCLUSIONS

Alongside appropriate antibiotic selection, early surgical drainage and OAM are invaluable. This case underscores the potential of anticoagulation therapy in facilitating safe surgical procedures.

Pylephlebitis combined with septic shock secondary to acute nonperforated appendicitis: a case report

Pylephlebitis, which is a type of septic thrombophlebitis of the portal vein, is a rare and life-threatening complication that commonly occurs following appendicitis. However, nonspecific abdominal complaints and fever can impede the diagnosis of pylephlebitis. Timely use of appropriate antibiotics and anticoagulants is paramount for treating this condition. We present a case of pylephlebitis and septic shock caused by acute nonperforated appendicitis. A 32-year-old man presented with migratory right lower abdominal pain. Blood cultures showed the presence of Escherichia coli. Blood test results showed increased bilirubin concentrations and coagulation factor abnormalities. A computed tomographic abdominal scan showed that the portal vein had a widened intrinsic diameter. After intensive care treatment with antibiotics, antishock therapy, anticoagulants, and other supportive treatments, the infection was monitored, the abdominal pain disappeared, and the jaundice subsided. Laparoscopic appendectomy was performed. Histopathology showed acute suppurative appendicitis, and no abnormalities were observed during the follow-up period after discharge. A multidisciplinary approach is mandatory for the decision-making process in the presence of pylephlebitis caused by appendicitis to obtain a correct diagnosis and prompt treatment. Similarly, the timing of appendectomy is important for minimizing intra- and postoperative complications.

[Pylephlebitis related to acute appendicitis. Case and review]

Background

The pilephlebitis is the septic thrombophlebitis of the portal venous system ranging from asymptomatic to severe complications. Diagnosed based on imaging tests, and their treatment is based on antibiotics and anticoagulant therapy.

Clinic case

24 years male, appendectomy 12 days before. Readmission for 3 days with fever, jaundice and choluria; hyperbilirrubinemia. Intravenous contrast CT is performed, showed thrombus in portal, splenic and mesenteric vein system. Diagnosis of pylephlebitis is established, initiating managed with antibiotics and anticoagulant, with favorable clinical outcome. The pylephlebitis has an estimated incidence of 2.7 cases per year, with an unspecified clinical picture ranging from asymptomatic to severe cases with septic shock and hepatic failure. There may be accompanying fever and abdominal pain in more than 80% of the cases and presenting in some cases with leukocytosis and hyperbilirrubinemia. Intravenous contrast CT is the gold standard. The treatment is based on 4 points: Septic focus control, antibiotics, early anticoagulant and resolution of complications.

Conclusions

The pylephlebitis should be taken into consideration as a possible secondary complication of intraabdominal infections. A timely diagnosis with a imaging tests and apply treatment reduce their morbidity and mortality.

Pylephlebitis: A Systematic Review on Etiology, Diagnosis, and Treatment of Infective Portal Vein Thrombosis

Pylephlebitis, defined as infective thrombophlebitis of the portal vein, is a rare condition with an incidence of 0.37-2.7 cases per 100,000 person-years, which can virtually complicate any intra-abdominal or pelvic infections that develop within areas drained by the portal venous circulation. The current systematic review aimed to investigate the etiology behind pylephlebitis in terms of pathogens involved and causative infective processes, and to report the most common symptoms at clinical presentation. We included 220 individuals derived from published cases between 1971 and 2022. Of these, 155 (70.5%) were male with a median age of 50 years. There were 27 (12.3%) patients under 18 years of age, 6 (2.7%) individuals younger than one year, and the youngest reported case was only 20 days old. The most frequently reported symptoms on admission were fever (75.5%) and abdominal pain (66.4%), with diverticulitis (26.5%) and acute appendicitis (22%) being the two most common causes. Pylephlebitis was caused by a single pathogen in 94 (42.8%) cases and polymicrobial in 60 (27.2%) cases. However, the responsible pathogen was not identified or not reported in 30% of the included patients. The most frequently isolated bacteria were Escherichia coli (25%), Bacteroides spp. (17%), and Streptococcus spp. (15%). The treatment of pylephlebitis consists initially of broad-spectrum antibiotics that should be tailored upon bacterial identification and continued for at least four to six weeks after symptom presentation. There is no recommendation for prescribing anticoagulants to all patients with pylephlebitis. However, they should be administered in patients with thrombosis progression on repeat imaging or persistent fever despite proper antibiotic therapy to increase the rates of thrombus resolution or decrease the overall mortality, which is approximately 14%.