Pylephlebitis and mesenteric thrombophlebitis in sigmoid diverticulitis: medical approach, delayed surgery

Portal-Mesenteric Suppurative Emphysematous Pylephlebitis: A Case Report

Suppurative thrombophlebitis of the portal-mesenteric venous system occurring in the setting of abdominal inflammatory and infectious processes is a serious condition that can lead to septic shock, bowel ischemia, hepatic abscess, and death if unrecognized. Diagnosis is often delayed because symptoms are aspecific and pain at the primary site of infection may be mild. Contrast-enhanced CT scans can diagnose both portal thrombosis and a primary infection site. Treatment may include early resective surgery in case of appendicitis or diverticulitis, in association with large-spectrum antibiotics and possibly anticoagulation. A characteristic of suppurative thrombophlebitis, whether splanchnic or systemic, is the latency before the effects of antibiotic therapy are seen. Anticoagulation can be administered to avoid extension to the superior mesenteric vein. We presented a critically ill 53-year-old man with chronic colonic diverticulitis complicated by suppurative emphysematous portal-mesenteric thrombophlebitis with only a slow response to large-spectrum antibiotics.

Pylephlebitis With Splenic and Mesenteric Vein Thrombosis in a Patient With Diverticulitis

Diverticulitis is a common gastrointestinal complaint that refers to inflammation of colonic diverticula. Its incidence has increased partly due to the increase in prevalence of diverticulosis, which results from poor dietary habits and chronic constipation. An acute diverticulitis episode can vary in severity, ranging from outpatient management of mild abdominal discomfort to inpatient admission requiring emergent surgery. Some common complications associated with diverticulitis include bowel wall perforation, microperforation, abscess formation, bowel obstruction, and colonic fistulas. A lesser-known complication of diverticulitis is pylephlebitis. Pylephlebitis refers to thrombosis of the portal vein resulting from sepsis secondary to an intra-abdominal or pelvic infection. Initially thought to be most associated with appendicitis, literature has emerged that implicates diverticulitis as the most likely culprit. Less frequently, pylephlebitis can also include thrombosis of the abdominal vasculature that drains into the portal vein such as the mesenteric veins and splenic vein. Despite antibiotic therapy, mortality in patients with pylephlebitis is high as it can lead to bowel ischemia, liver failure, or liver abscesses. While antibiotic therapy is the mainstay of treatment, anticoagulation can also be used in conjunction, especially when thrombosis extends beyond the portal vein. Herein, we present a case of a patient who was diagnosed with pylephlebitis with thrombosis extension into the splenic and mesenteric veins, which resulted from an episode of severe sigmoid diverticulitis. Our patient was treated medically with antibiotics and anticoagulation and underwent a loop transverse colostomy with full recovery. He was discharged with intravenous antibiotics and long-term anticoagulation. We present this case to highlight a rare complication of an otherwise common pathology and describe our management that led to a positive outcome for this patient.

Suppurative Thrombosis of the Portal Vein (Pylephlebits): A Systematic Review of Literature

Suppurative portal vein thrombosis (pylephlebitis) is an uncommon condition usually associated with an intra-abdominal infection or inflammatory process. In this study, we aimed to synthesize data on previously published cases according to the PRISMA guidelines. A total of 103 patients were included. Patients were more commonly male (71.8%) and had a mean age of 49 years. The most common infection associated with pylephlebitis was diverticulitis (n = 29, 28.2%), and Escherichia coli was the most isolated pathogen (n = 21, 20.4%). Blood cultures were positive in 64 cases (62.1%). The most common site of thrombosis was the main portal vein (PV) in 59 patients (57.3%), followed by the superior mesenteric vein (SMV) in 40 patients (38.8%) and the right branch of the PV in 30 patients (29.1%). Sepsis developed in 60 patients (58.3%). The mortality rate in our review was 8.7%, and independent risk factors for mortality were the presence of pertinent comorbidities (OR 5.5, p = 0.02), positive blood cultures (OR 2.2, p = 0.02), and sepsis (OR 17.2, p = 0.049).

Pylephlebitis — a rare complication of a fish bone migration mimicking metastatic pancreatic cancer: A case report

BACKGROUND

Pylephlebitis is a rare condition, poorly recognized by clinicians and with few references. In this case, the clinical appearance resembled the clinical course of a pancreatic cancer and was originated by the ingestion of a fish bone, making the case more interesting and rare.

CASE SUMMARY

A 79-year-old female presented to the emergency department with fever, loss of appetite and jaundice. Tenderness in the right upper quadrant was present. Inflammation marker were high. A computed tomography (CT) scan revealed gallstones and aspects compatible with acute pancreatitis. The patient was admitted to surgery ward and has her condition aggravated. A magnetic resonance revealed multifocal liver lesions. Later, a cholangiopancreatography and an endoscopic ultrasound (US) were able to diagnose the condition. Specific treatment was implemented and the patient made a complete recovery.

CONCLUSION

In conclusion, this case report demonstrates for the first time the diagnosis of an unusual case of pylephlebitis complicated by the migration of a fish bone, mimicking metastatic pancreatic cancer. Clinical presentation and traditional imaging studies, such as transabdominal US and CT, remain the standard for diagnosing this condition.

Pylephlebitis: A Case of Inferior Mesenteric Vein Thrombophlebitis in a Patient with Acute Sigmoid Diverticulitis—A Case Report and Clinical Management Review

Pylephlebitis is a rare complication of intra-abdominal infections and describes thrombosis and infection as two different pathophysiological phenomena in the cause of this disease. The nonspecific presentation of disease makes its diagnosis difficult and thus leads to high mortality. The treatment comprises antibiotics and also includes controversial use of anticoagulation in these patients. Here, we present a patient with past medical history of human immunodeficiency virus and past diverticulitis who presented with fever, chills, diarrhea, neck pain, and photophobia. He was diagnosed with acute sigmoid diverticulitis with associated inferior mesenteric vein thrombophlebitis. He improved after intravenous antibiotics and anticoagulation and was discharged. He underwent sigmoid colectomy 3 months after his initial presentation and was advised to take anticoagulation for a total of 6 months.

Superior mesenteric vein thrombosis as a complication of cecal diverticulitis: A case report

Pylephlebitis is an uncommon complication of uncontrolled intra-abdominal infection that is associated with high morbidity and mortality. We present our experience with a unique case of cecal diverticulitis and septic thrombophlebitis of the superior mesenteric vein that was promptly diagnosed with high-resolution imaging and blood cultures. Antibiotic and anticoagulation therapy was instituted on confirming the diagnosis with magnetic resonance imaging (MRI) to control the infection and prevent propagation of the thrombus. Our case report raises awareness about a rare and potentially fatal condition and provides appropriate imaging supplementation to aid in timely diagnosis.

Pylephlebitis: a Review of 95 Cases

Pylephlebitis, or suppurative thrombophlebitis of the portal mesenteric venous system occurring in the setting of abdominal inflammatory processes, is a rare but deadly disease commonly associated with diverticulitis. We review our institutional experience in the management of patients with this condition. A retrospective review of medical records from 2002 to 2012 was performed. Patients with a portal mesenteric vein thrombosis (PMVT) within 30 days of an intra-abdominal inflammatory process were identified and evaluated. Ninety-five patients were included. The mean patient age at presentation was 57 years (range, 24-88). The most common associated processes were pancreatitis (31 %), followed by diverticulitis (19 %). Bacteremia was noted in 34 (44 %) patients. The most common organism cultured was Streptococcus viridans. Antibiotic and anticoagulation therapy was given in 86 (91 %) and 78 (82 %) patients, respectively. Overall, we report an 11 % mortality rate. Albeit rare, pylephlebitis most commonly was manifested in the setting of pancreatitis. Treatment should be individualized to culture results and extent of thrombosis. If diagnosed early and managed appropriately, a favorable outcome is possible.