Pylephlebitis: a Review of 95 Cases

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.

A unique case of hypervirulent Klebsiella pneumoniae acute cholecystitis complicated by portal vein thrombophlebitis: A case report and literature review

Hypervirulent Klebsiella pneumoniae remains a significant global public health concern, characterized by a unique syndrome involving monomicrobial primary pyogenic liver abscesses, often leading to metastatic complications such as endophthalmitis, meningitis, and other infections. These infections are frequently observed in immunocompetent hosts or diabetic patients, particularly those of Asian ethnicity. In this report, we present the case of a 66-year-old Burmese female, currently residing in the United States, who presented with severe swelling, pain, discharge, and vision loss in her left eye, along with abdominal pain. Subsequent investigation revealed monomicrobial Klebsiella pneumoniae acute cholecystitis with an adjacent liver abscess, complicated by bacteremia, endogenous endophthalmitis, and portal vein thrombosis. Treatment with ceftriaxone proved successful in addressing her intra-abdominal infections, while anticoagulation therapy was initiated following multidisciplinary discussions among all involved subspecialties. Early diagnosis and the timely administration of appropriate treatment are crucial in reducing mortality and preventing further complications.

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 Caused by Bacillus subtilis and Fusobacterium nucleatum

A 90-year-old man presented with a 3-day history of general malaise. He was febrile (39.3°C) but the initial evaluation did not reveal the cause of the fever. After admission, Bacillus subtilis and Fusobacterium nucleatum were grown from multiple sets of blood cultures. In addition, contrast-enhanced computed tomography revealed thrombi in the portal vein and superior mesenteric vein; he was diagnosed with pylephlebitis. After receiving antimicrobial treatment and anticoagulation, the patient was cured. Pylephlebitis is a rare condition and may be the cause of unknown fevers. This is the first reported case of pylephlebitis caused by Bacillus subtilis.

Intestinal Obstruction as Initial Presentation of Idiopathic Portal and Mesenteric Venous Thrombosis: Diagnosis, Management, and Literature Review

It is quite common for portal vein thrombosis to occur in subjects who present predisposing conditions such as cirrhosis, hepatobiliary malignancies, infectious or inflammatory abdominal diseases, or hematologic disorders. The incidence of idiopathic portal vein thrombosis in non-cirrhotic patients remains low, and despite the intensive workup that is performed in these cases, in up to 25% of cases, there is no identifiable cause. If portal vein thrombosis is untreated, complications arise and include portal hypertension, cavernous transformation of the portal vein, gastroesophageal and even small intestinal varices, septic thrombosis, or intestinal ischemia. However, intestinal ischemia develops as a consequence of arterial thrombosis or embolism, and the thrombosis of the mesenteric vein accounts for about 10% of cases of intestinal ischemia. Although acute superior mesenteric vein thrombosis can cause acute intestinal ischemia, its chronic form is less likely to cause acute intestinal ischemia, considering the possibility of developing collateral drainage. Ileus due to mesenteric venous thrombosis is rare, and only a small number of cases have been reported to date. Most patients experience a distinct episode of acute abdominal pain due to ischemia, and in the second phase, they develop an obstruction/ileus. Acute superior mesenteric venous thrombosis is a rare condition that is still associated with a high mortality rate. The management of such cases of superior mesenteric venous thrombosis is clinically challenging due to their insidious onset and rapid development. A prompt and accurate diagnosis followed by a timely surgical treatment is important to save patient lives, improve the patient survival rate, and conserve as much of the patient's bowel as possible, thus leading to fewer sequelae.

Pylephlebitis-induced acute liver failure: A case report and review of literature

BACKGROUND

Pylephlebitis is an extremely rare form of septic thrombophlebitis involving the portal vein, carrying high rates of morbidity and mortality.

CASE SUMMARY

We present a case of a 42-year-old male with no past medical history who presented with acute onset of abdominal pain and altered mental status with laboratory tests demonstrating new-onset acute liver failure. Pylephlebitis was determined to be the underlying etiology due to subsequent workup revealing polymicrobial gram-negative anaerobic bacteremia and complete thrombosis of the main and left portal veins. To our knowledge, this is the first documented case of acute liver failure as a potential life-threatening complication of pylephlebitis.

CONCLUSION

Our case highlights the importance of considering pylephlebitis in the broad differential for abdominal pain, especially if there are co-existing risk factors for hypercoagulability. We also demonstrate that fulminant hepatic failure in these patients can potentially be reversible with the immediate initiation of antibiotics and anticoagulation.

Septic Pylephlebitis in the Setting of COVID-19 Infection: A Case Report

Portal vein thrombophlebitis is a rare complication that can occur in various hypercoagulable states, including COVID-19. We are presenting a 74-year-old female with a history of hypertension, diabetes, and lymphoma who contracted the COVID-19 infection and presented with persistent fever, leukocytosis, and mild epigastric tenderness. She developed hypotension, acute hypoxic respiratory failure, and worsening leukocytosis with bandemia and was diagnosed with portal vein thrombosis (PVT) and superior mesenteric vein thrombosis. The patient received broad-spectrum IV antibiotics and full anticoagulation therapy with heparin and was discharged on oral Warfarin after completing 14-day antibiotic therapy. She presented again with recurrent watery diarrhea, fever, abdominal pain, and fatigue and was diagnosed with pylephlebitis and multiple small liver abscesses. The patient was treated with antibiotics for six weeks and was discharged on warfarin, furosemide, and spironolactone with close outpatient follow-up. Prolonged fever in COVID-19 patients can indicate extensive thrombosis at unusual sites, which can lead to major morbidity and mortality in patients.

A Young Male With Non-cirrhotic Cryptogenic Portal Cavernoma: An Authoritative Case Study

The growth of several porto-portal collateral veins encircling an existing stenosed or obstructed entry vein is an uncommon condition known as portal cavernoma. It is traditionally shown as the entry vein thrombosis (portal vein thrombosis - PVT) outcome. A male of 25 years with stomach discomfort for three days that was acute, nonprogressive, and was not accompanied by fever, loose stools, or vomiting. After he had undergone abdominal ultrasonography, portal vein thrombosis was discovered, and based on no involvement of suprahepatic veins according to ultrasonography, Budd-Chiari syndrome was ruled out. It was accompanied by dilated periportal tortuous veins and visible mesenteric and peri-splenic collaterals. Moderate splenomegaly was also present. All these features on ultrasound were suggestive of the "portal cavernoma" formation. The patient is not an alcoholic and does not have any chronic, hereditary, or metabolic liver disease. Thrombophilia and cancer screening through tumor markers were also negative. We, with this, present a rare case of non-cirrhotic idiopathic portal cavernoma. This rare case contributes to advancing medical and scientific knowledge that will encourage further dialogue on the topic.

An unusual complication of acute appendicitis: isolated superior mesenteric venous pylephlebitis

Septic thrombophlebitis of the portal vein or one of its tributaries is referred to as pylephlebitis. It is unusual to have superior mesenteric venous thrombophlebitis. It frequently arises as a result of an infection in the portal venous system's drainage area, such as appendicitis or diverticulitis. Preoperative diagnostic imaging can help in the early diagnosis of acute phase pylephlebitis. A case of acute appendicitis complicated by an intra-abdominal abscess and superior mesenteric venous pylephlebitis is presented. Appendicectomy, abscess drainage, and antibiotic and anticoagulant treatment resulted in a full recovery. After two months, follow-up imaging revealed that the superior mesentric vein had been completely canalised.

Acute Appendicitis Complicated by Septic Thrombophlebitis of the Portal Vein Shown by 18 F-FDG and 68 Ga-FAPI-46 PET/CT

ABSTRACT

Septic thrombophlebitis of the portal vein is a serious infectious disorder and is difficult to be diagnosed at an early stage. In this case, we presented 18 F-FDG and 68 Ga-FAPI-46 PET/CT findings in a 45-year-old man with acute appendicitis complicated by septic thrombophlebitis of the portal vein. 68 Ga-FAPI-46 PET/CT showed intense radiotracer uptake in the thrombosis of the portal vein, with higher SUV max and larger disease extent than 18 F-FDG PET/CT. This case demonstrated that 68 Ga-FAPI PET/CT may be a useful imaging modality for the diagnosis of this infectious condition.

Decoding pylephlebitis: Tracing the path of infected thrombosis and liver abscesses

Pylephlebitis, a septic thrombophlebitis of the portal vein, is an uncommon but serious complication following an abdominal site of infection, most frequently diverticulitis or appendicitis. It has a high mortality rate, yet it commonly presents with unspecific abdominal complaints and fever, making diagnosis by clinical and laboratory examinations alone, impossible. This report highlights the extensive computed tomography (CT) findings of pylephlebitis with multiple hepatic abscesses thought to be secondary to diverticulitis, in a patient presenting with septic shock. Radiological characteristics differentiating the liver lesions from malignancy, and showing the ascending pathway of vascular involvement from the inferior mesenteric vein to portal veins is presented, as well as the search for the primary site of infection. Recognizing and understanding the imaging findings in pylephlebitis is crucial for diagnosis and avoiding delay of appropriate treatment for this otherwise often fatal condition.

A case report of acute appendicitis complicated by pylephlebitis: medical and surgical management

Pylephlebitis is a suppurative thrombus of the portal vein and/or its branches secondary to an intra-abdominal infection. Acute appendicitis is the most common cause of emergency operation in general surgery and is typically treated with antibiotics and timely appendectomy with minimal adverse outcomes (Ferris M, Quan S, Kaplan BS, et al. The global incidence of appendicitis: a systematic review of population-based studies. Ann Surg 2017;266:237-41 and Poon S, Lee J, NG KM, Chiu GWY, et al. The current management of acute uncomplicated appendicitis: should there be a change in paradigm? A systematic review of the literatures and analysis of treatment performance. WJES 2017;12:46). Unfortunately, the identification of pyelephlebitis is difficult to make due to its nonspecific clinical presentation and can result in significant morbidity or mortality if not appropriately treated. Certain laboratory derangements and positive intra-abdominal imaging combined with a high index of suspicion can make the diagnosis. Treatment involves broad-spectrum antibiotics, anticoagulation, and source control of the primary nidus of infection. Our case presentation follows the successful clinical course of a young male diagnosed with acute appendicitis complicated by pylephlebitis. He was treated with antibiotics and anticoagulation followed by interval laparoscopic appendectomy with consequential resolution of thrombus on subsequent cross-sectional imaging.

[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.

Severe Typhoid Fever Complicated by Superior Mesenteric and Splenic Vein Thrombosis

Typhoid fever (Typhoid or enteric fever) is still the most common bacterial bloodstream infection worldwide, caused by Salmonella typhi. The transmission route is indirect through passive vehicles such as contaminated water or food. Main clinical findings are a fever lasting more than three days, abdominal symptoms, leukocytosis, and anemia. Typhoid can cause a wide range of multi-organ complications. We report a particularly severe form of this infection complicated by superior mesenteric vein and splenic vein thrombosis, an extremely uncommon manifestation.

Fusobacterium bacteremia presenting with inferior mesenteric vein thrombosis

Isolated mesenteric vein thrombosis associated with Fusobacterium is rare. Physicians should be aware regarding the association of Fusobacterium with thrombosis at various sites.

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.

Hepatic Vein Pylephlebitis as a Cause of Bilateral Pyopneumothorax

Pylephlebitis is a rare complication of intra-abdominal infections and has a significant mortality rate, necessitating early recognition for optimal treatment. Here, we present the case of a 36-year-old male with fever, shortness of breath, cough, and epigastric pain. He was ultimately diagnosed with hepatic vein pylephlebitis along with multiple pulmonary and hepatic lesions believed to be septic emboli and hepatic abscess. He developed recurrent bilateral pyopneumothorax which required drainage by interventional radiology multiple times. The patient improved and was discharged on intravenous antibiotics for four weeks. While hepatic abscesses are a known complication of pylephlebitis, pyopneumothorax is a rare, unreported complication. Recognition of this potential complication is important for clinicians when treating patients with hepatic vein pylephlebitis.

Case report: Concurrent pylephlebitis and subarachnoid hemorrhage in an octogenarian patient with Escherichia coli sepsis

Background

Pylephlebitis refers to an infective suppurative thrombosis that occurs in the portal vein and its branches. Concurrent pylephlebitis and subarachnoid hemorrhage (SAH) are rare but fatal for patients with sepsis. This scenario drives the clinicians into a dilemma of how to deal with coagulation and bleeding simultaneously.

Case summary

An 86-year-old man was admitted to hospital for chills and fever. After admission, he developed headache and abdominal distension. Neck stiffness, Kernig's and Brudzinski's sign were present. Laboratory tests discovered decreased platelet count, elevated inflammatory parameters, aggravated transaminitis, and acute kidney injury. Escherichia coli (E. coli) were identified in blood culture. Computed tomography (CT) revealed thrombosis in the superior mesenteric vein and portal veins. Lumbar puncture and Brain CT indicated SAH. The patient had eaten cooked oysters prior to illness. It was speculated that the debris from oyster shell might have injured his intestinal mucosa and resulted in bacterial embolus and secondary thrombosis in portal veins. The patient was treated with effective antibiotics, fluid resuscitation, and anticoagulation. The dose titration of low molecular weight heparin (LMWH) under close monitoring attributed to diminution of the thrombosis and absorption of SAH. He recovered and was discharged after 33-day treatment. One-year follow-up indicated that the post-discharge course was uneventful.

Conclusion

This report describes a case of an octogenarian with E. coli septicemia who survived from concurrent pylephlebitis and SAH along with multiple organ dysfunction syndrome. For such patients with life-threatening complications, even in the acute stage of SAH, decisive employment of LMWH is essential to resolve thrombosis and confers a favorable prognosis.

Pylephlebitis Complicated by Hepatic Abscesses due to Fusobacterium Nucleatum: A Case of Lemierre's Syndrome Variant and Literature Review

In gastrointestinal-variant Lemierre syndrome, Fusobacterium nucleatum can cause pylephlebitis and liver abscesses. We report a 62-year-old woman presenting with abdominal pain and altered mental status. Abdominal computed tomography showed hepatic lesions and thrombosis in the superior mesenteric and portal veins. Magnetic resonance cholangiopancreatography showed multiple cystic hepatic masses suspicious for abscess vs metastases. Malignancy workup was unrevealing. F. nucleatum grew on both blood and ultrasound-guided liver aspirate cultures. Twelve weeks of antibiotics and anticoagulants resolved her condition. Given the high mortality rates, prompt detection and treatment of gastrointestinal-variant Lemierre syndrome is critical to delivering quality, patient-centered care.

Pylephlebitis Complicated by Bacteremia: A Rare Complication Following Laparoscopic Cholecystectomy

Pylephlebitis is a rare but serious condition caused by intra-abdominal or pelvic infections that can lead to septic thrombophlebitis of the portal veins. While laparoscopic cholecystectomy is considered a safe and effective treatment option, it is not without its risks, and pylephlebitis following this procedure is an extremely rare occurrence. Here, we present the case of a 73-year-old male who presented with lower abdominal pain for the last two weeks. He had undergone laparoscopic cholecystectomy for symptomatic cholelithiasis four weeks prior with an unremarkable follow-up. Laboratory tests revealed leukocytosis and blood culture showed Streptococcus constellatus. A CT scan revealed portal vein thrombosis causing diffuse periportal edema throughout the liver. The patient was treated with antibiotics and anticoagulation for pylephlebitis.

Pylephlebitis complicating acute calculous cholecystitis: A case report

Pylephlebitis is a complication of intra-abdominal infections. Its occurrence during cholecystitis is a rare situation. We report the case of a 43-year-old female patient who presented with septic thrombosis of the right portal branch following acute calculous cholecystitis diagnosed on abdominal CT. The clinical evolution was favorable under antibiotic therapy and a cholecystectomy was scheduled.

Inferior mesenteric vein thrombophlebitis secondary to acute diverticulitis

Inferior mesenteric vein thrombophlebitis is an uncommon condition. Most cases of portal-mesenteric thrombophlebitis affect either the portal vein or superior mesenteric vein; it is not known why the inferior mesenteric vein is less affected. Thrombophlebitis typically occurs following inflammatory intra-abdominal processes, such as diverticulitis. Diverticulitis is a common condition in the Western world, with several common complications, such as fistula formation and bowel wall perforation. However, although diverticulitis is a common cause of portal-mesenteric thrombophlebitis, thrombophlebitis is still a rare complication of diverticulitis. We present a case of diverticulitis complicated with interior mesenteric vein thrombophlebitis with gas extension into the portal vein.

Pylephlebitis: An uncommon complication of sigmoid diverticulitis

Pylephlebitis is defined as a septic thrombophlebitis of the portal vein, usually secondary to infection in regions contiguous to or drained by the portal system. Although extremely uncommon in the modern era, pylephlebitis still carries an appreciable risk of severe morbidity and mortality, if unrecognized and left untreated. Herein we report the case of severe pylephlebitis in a patient with acute sigmoid diverticulitis. Although highly elusive, prompt diagnosis is crucial to ensure appropriate management and limit associated morbidity.

Superior Mesenteric Vein Thrombosis as a Rare Complication of Appendicitis: A Report of Two Cases

Intra-abdominal inflammatory conditions, including acute appendicitis, are a common occurrence in the emergency department. In addition to employing various imaging modalities to determine the underlying cause, the consequences of these inflammatory diseases must be assessed. Thrombosis of the superior mesenteric vein is a rare complication of acute appendicitis. It is essential to be aware of this complication as early diagnosis may improve patient prognosis given that this consequence has a high mortality rate.

Evaluation of Low-Molecular-Weight Heparin for Treatment of Portal Vein Thrombosis in Liver Cirrhosis Patients

Background and Objectives: Even though low-molecular-weight heparin (LMWH), including dalteparin, has a critical role in portal vein thrombosis (PVT) treatment in liver cirrhosis (LC) patients, the predictive factors and the proper dose of dalteparin for PVT treatment and relapse have not yet been investigated. Materials and Methods: This retrospective study evaluated the records of LC patients receiving dalteparin from July 2013 to June 2019. The odds ratio (OR) and adjusted OR were calculated from univariate and multivariable analyses, respectively. Results: Among data from 121 patients, the overall recanalization rate of all patients was 66.1% (80 patients). No history of variceal bleeding (OR 4.6, 95% CI: 1.88-11.43) and the case of newly developed thrombus before dalteparin treatment (OR 3.2, 95% CI: 1.24-8.08) were predictive factors associated with increased treatment response. Relapse of PVT occurred in 32 out of 80 patients (40%) who showed a recanalization. The risk of relapse was 3.1-3.9 times higher in those who took more than three months or more than six months from the diagnosis of PVT to dalteparin treatment compared to those who took less than these durations, respectively. In the dosing regimen, patients with the kg-based dosing regimen showed 2.6 times better response than those with the fixed dosing regimen. However, no difference in bleeding complications was observed. Conclusion: In the dosing regimen, the kg-based regimen that was the same as the venous thromboembolism regimen was a better option for the efficacy and safety of dalteparin therapy. Additionally, when treating PVT in LC patients, careful monitoring is recommended for patients with predictive factors for treatment response and relapse of PVT.

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%.

Clostridium difficile Bacteremia as a Rare Presentation of Polymicrobial Pyogenic Liver Abscesses and Its Management Challenges

Extracolonic manifestations of Clostridium difficile have been rarely reported. We herein report a case of a 60-year-old immunocompetent man presenting with fever, nausea, abdominal pain, and loose stools for 2 weeks. Triple-phase liver computed tomography demonstrated pyogenic liver abscesses and portal pylephlebitis. Blood cultures grew C. difficile and Bacteroides fragilis, and liver abscess cultures grew Proteus mirabilis, Escherichia coli, and the viridans group Streptococci. Antibiotics coverage was selected to direct at all identified organisms. This demonstrates an unusual case of C. difficile bacteremia in a patient with polymicrobial pyogenic liver abscesses and pylephlebitis.

Pylephlebitis after sigmoid colonic polypectomy

A man in his 40s presented with a 7-day history of fever and abdominal pain after polypectomy of the sigmoid colon. On physical examination, he had mild tenderness on deep palpation of the left lower abdominal quadrants without guarding, rigidity or rebound tenderness. Contrast-enhanced CT revealed the thrombosis of the inferior mesenteric vein and the portal vein. Blood cultures were positive for Escherichia coli We diagnosed him with pylephlebitis after colonic polypectomy, as a rare complication. He was started on cefmetazole and heparin. Antibiotic and anticoagulation therapy were initiated. He had a complete recovery within 17 days. The patient had no evidence of underlying hypercoagulable condition, and no signs of recurrence at a 3-month follow-up. Pylephlebitis after colonic polypectomy is extremely rare. Although bacteraemia after colonoscopy was a rare complication, phlebitis should be considered in the differential diagnosis of patients who present with persisted fever and abdominal pain after polypectomy.

Pylephlebitis secondary to inflammatory colitis: A case report

Pylephlebitis is a thrombotic occlusion of the portal vein or its branches secondary to infection in regions that drain to the portal venous system. Clinical presentation is often atypical, and patients may initially present with non-specific abdominal symptoms. We report a case of pylephlebitis secondary to inflammatory colitis depicted by CT scan in a 35-year-old female admitted for acute abdominal pain associated with vomiting and fever.

Pylephlebitis: A Rare Complication of Acute Appendicitis

Pylephlebitis is defined as an infective suppurative thrombosis of the portal vein and its tributaries - a rare complication of intra-abdominal infections. It is most commonly seen in patients with diverticulitis and appendicitis. Prompt diagnosis with abdominal ultrasound and computerized tomography (CT) scan along with early and aggressive treatment with broad-spectrum antibiotics is crucial because of its high mortality rates. However, this diagnosis is often missed due to the nature of its nonspecific clinical symptoms. We discuss a case of a 22-year-old male who presented with pylephlebitis as a complication of acute gangrenous appendicitis. The patient was treated successfully with appropriate surgical intervention, antibiotics, and anticoagulation.

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

Introduction

Pylephlebitis represents an uncommon but serious condition with significant mortality which can complicate intrabdominal sepsis of any etiology. One of the most common predisposing infections is appendicitis.

Presentation of case

A 21-year-old male with 4 days of epigastric and right upper quadrant pain with associated fever and chills with hyperbilirubinemia and leukocytosis in blood test was orientated as cholangitis at first diagnostic. Poor response to antibiotic treatment with persistent fever and bacteriemia with E. coli and S. constellatus isolated in blood cultures led to complete the study with a CT scan which revealed an acute appendicitis complicated with thrombosis of the superior mesenteric vein (SMV) up to the splenoportal confluence. Appendectomy, treatment with broad-spectrum antibiotic and anticoagulation treatment led to full recovery. Follow-up after 6 months showed almost complete SMV patency.

Discussion

Pylephlebitis can present as a clinical cholangitis-like picture with hyperbilirubinemia with or without liver abscess formation. CT scan seems to be the most sensitive diagnostic test as it identifies the underlying focus of infection, the extension of the thrombosis and detects liver abscesses. Surgical removal of the source of infection as appendectomy and adequate antibiotic treatment adjusted by culture should be initiated promptly. Anticoagulant treatment should be considered in the case of poor clinical outcome or thrombosis progression.

Conclusion

Pylephlebitis should be suspected mainly in patients with appendicitis and diverticulitis with erratic behavior despite surgical removal and/or antibiotic treatment with abnormal liver tests and persistent bacteriemia. CT scan is the preferred image study.

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Pylephlebitis represents an uncommon but serious condition.

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Main cause has to be extensively investigated.

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Appendicitis is a potential cause of pylephlebitis.

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Pylephlebitis should be suspected mainly in patients with appendicitis and diverticulitis with erratic behavior.

Venous Thrombosis Has a Constellation of Different Risk Factors: A Case Report and State-of-the-Art Review

Splanchnic venous thrombosis and cerebral venous thrombosis are uncommon manifestations of venous thromboembolism (VTE) that have been associated with inherited thrombophilias. Hyperhomocysteinemia is an established risk factor for thrombosis, and methylenetetrahydrofolate reductase (MTHFR) mutation is the most common genetic alteration in this condition. The association between MTHFR mutations, mild to moderate elevations in homocysteine, and the risk for thrombosis is controversial. Pylephlebitis, also known as suppurative portal vein thrombophlebitis, usually originates from an intra-abdominal infectious process. It is a condition with high morbidity and mortality, partly due to its late diagnosis, and antibiotics are the gold standard treatment. The purpose of anticoagulation is dubious. We describe the case of a 60-year-old male with a previous history of venous sinus thrombosis and MTHFR A1298C mutation with mild homocysteine ​​elevation who presented with signs and symptoms of intra-abdominal infection and whose abdominopelvic computed tomography (CT) with intravenous contrast showed splanchnic-vein thrombosis. Through this complex case, the authors present a review of the current state of the art on VTE, hyperhomocysteinemia, and pylephlebitis, emphasizing the need for a holistic view of the patient in the decision-making process.

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).

Portal Vein Thrombosis Associated With Fusobacterium nucleatum Bacteremia: A Rare Abdominal Variant of Lemierre’s Syndrome

Lemierre's syndrome is a rare but potentially severe complication of bacterial infections that usually affects previously healthy adolescents and young adults. It commonly presents as septic thrombophlebitis of the internal jugular vein and bacteremia following a recent oropharyngeal infection. The most commonly isolated organisms are Fusobacterium necrophorum, followed by Fusobacterium nucleatum and other anaerobes. Atypical Lemierre's syndrome is characterized by thrombophlebitis at sites distant from the head and neck veins and is far less encountered than typical Lemierre's syndrome. Here, we present a case of an elderly African American female with pylephlebitis, a rare abdominal variant of Lemierre's syndrome with extensive portal vein, splenic vein, and mesenteric vein thrombosis following perforated diverticulitis and resultant F. nucleatum bacteremia. She demonstrated complete recovery following appropriate long-term intravenous antibiotics and anticoagulation. This case calls attention to the re-emergence of the rare manifestation of this forgotten disease and highlights improved outcomes with prompt recognition and early treatment.

Venous thromboembolism in chronic gastrointestinal disorders

INTRODUCTION

Chronic gastrointestinal disorders (including autoimmune gastritis, celiac disease, inflammatory bowel disease, and diverticular disease) are highly prevalent disorders, that may be associated with unpredictable, life-threatening complications, such as thromboembolic events. Venous thromboembolism (VTE) is one of the major causes of morbidity and mortality worldwide. Several conditions, including cancer, major trauma, surgery, prolonged immobilization, are well-established risk factors for VTE. Over the past decade, chronic inflammation has also been identified as an independent risk factor for VTE due to the prothrombotic effects of inflammatory cytokines and oxidative stress on the coagulation cascade. Other several mechanisms were shown to be associated with a higher incidence of VTE in patients with gastrointestinal disorders.

AREAS COVERED

We critically discuss the latest insights into the mechanisms responsible for thromboembolic manifestations in chronic gastrointestinal disorders, also focusing on the recognition of risk factors and treatment.

EXPERT OPINION

The occurrence of thrombotic complications is underestimated in patients with chronic gastrointestinal disorders. Identifying potential risk factors and concomitant predisposing conditions and to prevent VTE and guide treatment require a multidisciplinary approach, and this is critically important for clinicians, in order to provide the best care for such patients.

Portal Vein Thrombosis and Pyogenic Liver Abscess With Concomitant Bacteroides Bacteremia in a Patient With COVID-19 Infection: A Case Report and Brief Review

The 2019 coronavirus disease (COVID-19) can present with a wide variety of clinical manifestations, including a hypercoagulable state leading to both arterial and venous thrombosis. Portal vein thrombosis (PVT) in the setting of COVID-19 has rarely been reported in the medical literature. Pylephlebitis with concomitant liver abscess is a rare complication of intra-abdominal infection. Here, we present the case of a 49-year-old man who initially presented with intermittent fevers and generalized weakness of 1-month duration and was subsequently found to have COVID-19 infection, PVT, and Bacteroides fragilis bacteremia with associated pyogenic liver abscess. The patient was treated with intravenous antibiotics and oral anticoagulation with plan to follow up outpatient with gastroenterology in 3 months to ensure resolution of PVT and liver abscess.

Use of intravascular hypo- and hyper-attenuation on non-contrast-enhanced computed tomography in diagnosing acute septic thrombophlebitis

Septic thrombi, such as those observed in pylephlebitis and Lemierre's syndrome, are characterized by portal vein thrombosis and venous thrombosis with bacterial infection. Although radiographic findings of septic thrombus on contrast-enhanced computed tomography have been well described, no report has described the characteristics of non-contrast-enhanced computed tomography. We describe a case series of septic thrombophlebitis exhibiting intravascular hypo- and hyper-attenuation on non-contrast-enhanced computed tomography. These radiographic features reflect the pathophysiology of septic thrombus, and therefore, it is important and useful to evaluate thrombus attenuation on non-contrast-enhanced computed tomography.

Pylephlebitis Caused by Fusobacterium nucleatum in a Septuagenarian Healthy Caucasian Male: Atypical Presentation of Lemierre’s Syndrome

Lemierre's syndrome (LS) is characterized by thrombophlebitis of the internal jugular vein caused primarily by Fusobacterium necrophorum. LS is usually suspected in fit young adults with prolonged or prior pharyngeal infection. Atypical Lemierre's syndrome is commonly defined as Fusobacterium-associated thrombophlebitis outside the head-neck veins and usually occurs in older patients than typical Lemierre's syndrome. Here we present a case of atypical LS in a septuagenarian healthy Caucasian male with no prior history of pharyngitis and in whom both computed tomography (CT) and magnetic resonance imaging (MRI) demonstrated partial portal vein thrombosis associated with Fusobacterium nucleatum. This case report confirms previous reports of Fusobacterium nucleatum-associated LS variants presenting with abdominal vein thrombosis and illustrates clinical recovery after a combination of anticoagulation and antibiotic therapy.

Pylephlebitis With Hepatic Abscess Complicating a Case of Acute Pancreatitis in a Young Male: Startling Complication of Intra-Abdominal Sepsis

The thrombophlebitis of the portal vein and or its hepatic branches accompanied with a positive blood culture is known as pylephlebitis, with the most common cause as sepsis. Liver abscess formation resulting from pylephlebitis is a rare but potentially lethal complication. We report a case of a 30-year-old male who presented with acute pain in the abdomen along with nausea and vomiting for two days with a history of alcohol dependence. Upon investigation, it was revealed to be a case of acute pancreatitis with hepatic abscess with superior mesenteric and portal vein thrombosis. The patient was managed conservatively with antibiotics and anticoagulants successfully. This case highlights the importance of keeping pylephlebitis with a hepatic abscess as a crucial potential complication of acute pancreatitis as its management promptly prevents mortality.