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Diverticulitis complicated by pylephlebitis: a case report
© Gajendran et al; licensee BioMed Central Ltd. 2011
Received: 3 June 2011
Accepted: 10 October 2011
Published: 10 October 2011
Pylephlebitis is defined as septic thrombophlebitis of the portal venous system, usually secondary to infection or inflammation in the abdomen. In the current report, we present a case of pylephlebitis that complicated the course of a very common pathology, diverticulitis.
A 62-year-old Caucasian woman with a history of sigmoid diverticulitis presented to our facility with a three-week history of abdominal pain, fevers, chills, loss of appetite and fatigue. Her laboratory test results showed leukocytosis and elevated alkaline phosphatase. A computed tomography scan revealed portal vein thrombosis and a sigmoid diverticulitis with an abscess. Our patient was given pipercillin-tozabactam followed by sigmoid colectomy and loop transverse colostomy. A peritoneal fluid sample culture grew Escherichia coli. Our patient had an uneventful post-operative course and the leukocytosis resolved in the next four days. She improved clinically and was discharged home on ertapenem and enoxaparin. A follow-up computed tomography scan two weeks later showed a new pelvic abscess that was drained by a pigtail catheter but there was no change in the portal venous thrombus. A repeat computed tomography scan one month later revealed resolution of the pelvic abscess but persistence of portal vein thrombus, for which enoxaparin was continued.
This is a classic case of pylephlebitis that demonstrates the importance of recognizing that the portal vein thrombus is infected and treating the condition appropriately.
Pylephlebitis is defined as septic thrombophlebitis of the portal venous system, usually secondary to infection or inflammation in the abdomen. The common causes include diverticulitis, appendicitis or cholangitis . Pylephlebitis has to be differentiated from the bland portal vein thrombus. Bland portal vein thrombosis is more common than pylephlebitis and the management is different. Here, we present a case of pylephlebitis that complicated the course of a very common pathology, diverticulitis.
Unlike bland portal vein thrombosis, pylephlebitis is more commonly associated with liver abscesses and bacteremia . Escherichia coli and Bacteroides fragilis are the most common isolates in blood . Doppler ultrasound, CT scanning and MRI scanning of the abdomen has improved the ability to diagnose pylephlebitis . CT scanning demonstrates portal vein thrombus as a non-enhancing, low-density thrombus within the vessel lumen with non-homogeneous enhancement of the hepatic parenchyma . MRI can help to distinguish acute from chronic portal vein thrombosis . Management of pylephlebitis is best achieved by treating the primary source using broad-spectrum intravenous antibiotics and surgical intervention (appendectomy or colectomy with abscess drainage) [1, 2]. Early diagnosis and treatment is critical. The role of anticoagulation in the treatment of pylephlebitis is controversial .
Written informed consent was obtained from the patient for publication of this case report and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
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