pylephlebitis is defined as septic thrombophlebitis of the portal vein or one of its tributaries , usually secondary to suppuration either in the region drained by the portal venous system or in structures contiguous to the portal vein ( e.g. , the common bile duct ) .
pylephlebitis , that previously well - characterized complication of appendicitis , is rare now , owing to core expeditious surgical management of intra - abdominal infections and the advent of antibiotic therapy . despite this rarity ,
mortality remains high and the number of case reports dealing with this entity seems to have increased over the past 15 years .
the current widespread use of abdominal ultrasonography and ct may , in part , explain the recent increase in reported cases .
the 37-year - old man had a 5-days duration of fever , chills , small amount of watery diarrhea and yellowish skin discoloration .
his past medical and surgical history was unremarkable , but he recalled an episode of diffuse abdominal pain , nausea and vomiting more than 3 weeks earlier .
bowel sounds were slightly increased and minimal right upper and lower quadrant tenderness was presented .
peripheral white blood cell count was 11,300/mm ( segment neutrophil : 66% , metamyelocyte : 20% ) .
iu / l , gamma - gpt 68 iu / l , alkaline phosphatase 152 iu / l , total - bilirubin 16.79 mg / dl , direct  bilirubin 14.30 mg / dl , protein 5.54 g / dl and albumin 2.81 g / dl .
abdominal ultrasonography revealed a thrombus in the upper smv , lower extrahepatic portal vein and dilated smv .
doppler studies showed antegrade flow in the portal vein and space - occupying lesions in the liver .
a contrast - enhanced ct scan confirmed the portal vein thrombosis and also demonstrated superior mesenteric vein thrombosis(fig .
dirty fat sign , with streaky infiltration and enlarged lymph nodes , were noted in the right lower abdomen , adjacent to the cecum .
an inflammatory condition around the cecum , such as chronic perforated appendicitis , was highly suggested(fig .
a small amount of abnormal fluid was seen around the liver , right paracolic gutter and in the pelvis(fig .
treatment was done with imipenem alone 0.5g / iv q 6hours . on the 7th hospital day
, the patient s condition continued to improve and he was discharged 4 weeks later .
follow - up ct scan showed minor residual pericolonic inflammation , resolution of the multiple liver abscess and improvement of the portal vein thrombosis .
after 14 days from treatment with imipenem , his bilirubin level was lowered to near - normal level ( total - bilirubin 2.5 mg / dl , direct - bilirubin 1.3 mg / dl ) .
pylephlebitis or septic thrombophlebitis of the portal vein , a precursor of liver abscess , is an extremely rare and frequently fatal complication of diverticulitis . in 1846 , waller documented autopsy findings in a patient with appendicitis , including multiple liver abscesses and pylephlebitis .
he concluded that appendicitis was the direct cause of pylephlebitis and liver abscess . by the turn of the century , the incidence of pylephlebitis following appendicitis gradually diminished with the advent of antibiotics and early surgical treatment .
the true incidence of pylephlebitis is difficult to estimate , however , since the diagnosis may be obscured by either the inciting focus of infection or the liver abscesses resulting from  portal pyemia 
, such as acute diverticulitis , intestinal perforation , uterine infection , suppurative pancreatitis and pancreatic abscess formation , splenic abscess , perirectal abscess , hemorrhoid , epididymitis , omphalitis and inflammatory bowel disease . in our case ,
furthermore , the high morbidity and mortality of suppurative pylephlebitis and intrahepatic abscesses are , at least in part , attributable to the nonspecificity of the symptoms and signs and the limitations of available diagnostic modalities .
a clinician must be cognizant of both the nonspecificity of the clinical presentation and the limitations of the sensitivity of these diagnostic modalities .
nothing has superseded the necessity for a high index of clinical suspicion regarding these diagnoses .
diagnoses are based on clinical features , laboratory findings , blood culture and radiological examinations , or postmortem examination .
clinical feature includes fever , right upper quadrant pain , diarrhea , jaundice and hepatomegaly .
the clinical  pearl  that jaundice is rare in pylephlebitis , except in cases complicated by multiple liver abscesses , appears to be valid .
jaundice developed late ( no earlier than 5 days after the onset of symptoms ) since the relative absences of jaundice early in the illness helps distinguish pylephlebitis from ascending escherichia coli , followed by proteus mirabilis , klesiella pneumoniae , enterobacer species , pseudomonas species and gram - positive cocci ( staphylococcus aureus , streptococcus species ) .
more recently , coloenteric anaerobic bacteria ( clostridia , bacteroides , fusobacterium and anaerobic streptococcus species ) have been isolated with increasing frequency , as a consequence of both improved culture techniques and selective pressure by the prevalent use of antibiotics . in our case ,
modern radiological imaging techniques provide supportive diagnostic evidence . with regard to diagnostic imaging in pylephlebitis
, the current series suggests that ultrasonography is a useful modality for demonstrating portal vein thrombosis .
ct scanning also shows promise in this regard , and may be less operator - dependent than ultrasonography . in the setting of probable intra - abdominal infection , ct scanning may be the most reasonable initial choice for imaging , given its proven ability to detect not only thrombi but pericolonic abscesses as well .
early in the disease process , hepatic infection and inflammation are microscopic , and contrast ct may demonstrate patchy areas of attenuated hepatic parenchyma . later
in the clinical course , parenchymal hepatic infection may coalesce to form multiple microabscess , or a single macroabscess amenable to percutaneous ct - guided drainage .
also in our case , inhomogenous patchy infiltration in the hepatic parenchyme was observed at the time of diagnosis , and resolution of these lesions were observed in follow - up film .
although modern imaging techniques have allowed the early diagnosis of pylephlebitis , the patient s history and physical examination still provide clues to the diagnosis . on the basis of treatments
, it appears that empirical antibiotic therapy for a patient with suspected pylephlebitis should include broad coverage for enteric facultative gram - negative bacilli and agents active against anaerobes , especially b. fragilis , and coverage for aerobic streptococcus species .
the ideal duration of antibiotic therapy for pylephlebitis is unclear . given the frequency of liver abscess as a complication of pylephlebitis , however , a minimum 4 weeks of therapy seems prudent since developing abscesses may not be visualized on ct scans .
patients with demonstrated macroscopic liver abscess complicating pylephlebitis should probably receive at least 6 weeks of antibiotic therapy , with or without drainage .
in our case , imipenem ( 2.0g / d ) monotherapy was performed for 2 weeks and resulted in complete resolution of hepatic lesions . no further treatment was performed .
the role of anticoagulation in the treatment of pylephlebitis is controversial . in prior writings ,
all of these opinions appear to have been based on limited data and personal experience , since no formal study of anticoagulation in pylephlebitis has ever been done . despite such evidence that heparin may not be critical for the survival of patients with pylephlebitis
, the possibility exists that anticoagulation might benefit some patients by decreasing the chance of septic embolization to the liver from infected portal thrombi and pulmonary emboli .
surgical intervention for pylephlebitis typically involves opening and drainage of the focus of infection , separation of large vessels of the portal system from the focus of infection ( i.e. , pericolonic or hepatic abscess ) rather than surgery on the infected vessels themselves . in our patient , a previously healthy patient presented with nonspecific symptoms and fever .
bacteroides fragilis was grown from blood , which clearly suggested an intra - abdominal origin .
appendicitis was the most likely cause of sepsis , confirmed by abdominal ct , with seeding to the portal vein and liver .
no surgical intervention was performed , since the intra - abdominal phlegmonous process responded to antibiotic therapy .
outcome depends on multiple factors , including age greater than 70 years , multiple liver abscess , combination of hepatic abscess and pylephlebitis , concomitant intrahepatic and extrahepatic abscesses , usually subphrenic , deterioration of liver function due to intrahepatic infection , particularly jaundice , and hypoalbuminemia .
although radiological imaging studies ( e.g. contrast - enhanced abdominopelvic ct scan ) facilitates diagnoses , early suspicion and prompt antibiotic therapy can lead to resolution of portal vein thrombosis and multiple liver abscesses thus resulting in recovery . in conclusion
, pylephlebitis is an uncommon complication of suppurative infections ( most often diverticulitis ) in the portal drainage area .
although rare , pylephlebitis is a treatable but often lethal complication of intra - abdominal sepsis , pylephlebitis should be suspected in patients with intra - abdominal sepsis with liver function abnormalities .
the timely administration of broad - spectrum antibiotics appears to be the most critical component of therapy for pylephlebitis .
 pylephlebitis usually occurs secondary to infection in the region drained by the portal venous system . 
 a most common antesecent focus of infection is diverticulitis and the most common blood isolate is e. coli ( 54% ) , followed by proteus mirabilis ( 23% ) . 
 overall mortality is 32% and most of the patients who had died had severe sepsis prior to the initiation of antibiotic therapy . 
 we describe a case of pylephlebitis which had appendicitis and consequent septic thrombosis of the portal vein and its branches , with dissemination of infection to the liver . the patient had recovered due to timely antibiotic treatment alone and resulted in complete resolution . 
 early diagnosis and treatment are basic to a favorable clinical course . 
INTRODUCTION
CASE REPORT
DISCUSSION