Pylephlebitis Complicating Acute Appendicitis: Prompt Diagnosis with Contrast-Enhanced Computed Tomography

[Multi-Detector CT Findings of Typical and Atypical Appendicitis: A Pictorial Essay]

Multi-detector CT (MDCT) is a highly accurate diagnostic tool that is commonly used to evaluate appendicitis and its complications. The diagnosis of appendicitis based on MDCT findings can be difficult and challenging when the observed findings are inconsistent with the typical features. Atypical appendicitis includes a wide spectrum of features, such as variable positions of the appendix and cecum, complications, and unusual pathological findings of secondary appendicitis that mimic or induce appendicitis. Our pictorial essay describes the diverse spectrum of atypical appendicitis and appendicitis-like conditions in terms of location abnormalities, complications, and uncommon pathologies, including related tumors, reactive appendicitis, appendiceal diverticulitis, and IgG4-related disease. Through this essay, the readers can become more familiar with MDCT findings of atypical appendicitis.

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%.

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).

Superior Mesenteric Venous (SMV) Thrombosis Accompanied with Appendicitis in a Patient with Primary Diagnosis of Typhoid Fever

BACKGROUND

Septic thrombophlebitis of the Superior Mesenteric Venous (SMV) is rarely accompanied by appendicitis, and symptoms are atypical, so the diagnosis is commonly delayed, resulting in it is associated with high mortality.

CASE PRESENTATION

We report a case of neglected SMV septic thrombophlebitis is caused by appendicitis. The patient represented with fever, vague abdominal pain without rebound tenderness, and history of the consumption of contaminated water. Antibiotic initiated due to suspicious typhoid fever. Then typhoid fever was ruled out. Computed tomography (CT) scans revealed micro-abscess forming complicated appendicitis and the thrombus in SMV.

DISCUSSION AND CONCLUSION

The patient underwent a laparoscopic appendectomy, during which retrocecal gangrened perforated appendix with a 2×2 cm abscess was drained. Based on positive culture with ESBL organism meropenem was initiated. Appendectomy and treatment with broad- -spectrum antibiotics and anticoagulation led to a full recovery.

Mesenteric venous thrombosis complicating acute appendicitis: A case series

INTRODUCTION

Acute appendicitis is one of the most common surgical conditions. In the current era it rarely presents in association with mesenteric venous thrombosis. We present 4 cases of mesenteric venous thrombosis occurring in the setting of acute appendicitis.

METHODS

We performed a retrospective review of Mayo Enterprise clinical database for inpatients with a diagnosis of acute appendicitis and venous thrombosis related ICD-10 codes. Charts for patients with a diagnosis of mesenteric venous thrombosis and acute appendicitis were reviewed to identify demographic data, findings at presentation, and management patterns.

RESULTS

A total of 1,615 inpatients were identified with a principle diagnosis of acute appendicitis across the Mayo Enterprise from October 1st, 2015- March 31st, 2019. Four inpatients with a diagnosis of acute appendicitis were also noted to have a mesenteric venous thrombosis at presentation resulting in an incidence of 0.25 %. Mean duration of symptoms at presentation was 12.25 days. All patients with acute appendicitis and mesenteric venous thrombosis were initially managed with a heparin drip, antibiotics, and intravenous fluids. Ultimately, 3 of 4 patients underwent appendectomy.

CONCLUSION

Mesenteric venous thrombosis complicating acute appendicitis is rare and typically presents in a delayed fashion. Patients without evidence of non-viable bowel are typically treated initially with intravenous fluid resuscitation, antibiotics, bowel rest, and anticoagulation with a heparin drip.

Clues to vascular disorders at non-contrast CT of the chest, abdomen, and pelvis

Non-contrast chest CT scans are commonly performed while CT scans of the abdomen and pelvis are performed in a select subset of patients; those with limited renal function, an allergy to iodinated contrast, in the setting of suspected renal calculus, retroperitoneal hematoma, common duct calculus, abdominal aortic aneurysm with or without rupture, and in patients undergoing a PET-CT scan. In the absence of intravenous contrast, vascular structures may prove challenging to evaluate, yet their assessment is an important component of every non-contrast CT examination. We describe the key imaging features of both arterial and venous pathology, and review clues and common associated non-vascular findings, which can help the radiologist identify vascular disorders at non-contrast CT. Briefly, alternative imaging options are discussed.