Suppurative pylephlebitis with multiple liver abscesses complicating regional ileitis: review of literature--1940-1960

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.

Pylephlebitis and Crohn's disease: A rare case of septic shock

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We describe a rare case of septic shock due to mesenteric pylephlebitis in a 47 years old man affected with Crohn’s disease.

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The occurrence of mesenteric pylephlebitis in Crohn’s disease is extremely rare, but to be considered in presence of a septic shock without clinical signs of peritonitis.

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Computed tomography scan confirmed the diagnosis and medical therapy led to a complete clinical remission of the mesenteric pylephlebitis.

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Optimizing pylephlebitis management, we performed an elective surgery aiming to bowel sparing and minimizing the intra and post-operative complications.

Introduction

Troncular pylephlebitis, defined as septic thrombophlebitis of the portal vein, is usually secondary to suppurative infection from the regions drained by the portal system. Therefore, pylephlebitis can occur from the portal vein main tributaries. The occurrence of mesenteric pylephlebitis in Crohn’s disease is extremely rare.

Presentation of case

We describe a case of septic shock due to mesenteric pylephlebitis in a 47 years old male affected with Crohn’s disease. The patient was admitted to the emergency department after he had been complained from 3 h of a peri-umbilical abdominal pain associated to fever and shivering quickly followed by a severe hypotension. His medical history included histologically confirmed ileal Crohn’s disease diagnosed 4 years before and treated with mesalamine only. Computed tomography scan confirmed the mesenteric pylephlebitis diagnosis. After medical therapy with antibiotics and systemic nutrition, the patient was successfully operated to treat his ileal Crohn’s disease.

Discussion

In our case, the quick onset of a septic shock was not due to a peritonitis complicating a Crohn’s disease, but to a rare condition not needing an urgent surgical resolution. This report shows that, even in Crohn’s disease, once diagnosis is performed, antibiotic therapy associated to enteral and parenteral nutrition can lead to a complete clinical remission of mesenteric pylephlebitis, mandatory to perform an elective surgery.

Conclusion

This case highlights the importance of promptly considerate and treat mesenteric pylephlebitis in presence of a septic shock in a Crohn’s disease patient who is not showing clinical signs of peritonitis.

[Fungal liver abscesses in a patient with primary sclerosing cholangitis and Crohn's disease]

Liver abscesses are a relatively infrequent complication of inflammatory bowel disease. These abscesses are usually multiple and of polymicrobial origin. The development of primary sclerosing cholangitis in inflammatory bowel disease, although provoking alterations in biliary morphology and a higher incidence of infections, does not predispose patients to the development of liver abscesses. We describe a new case of primary sclerosing cholangitis and Crohn's disease with multiple fungal liver abscesses caused by Candida albicans. The patient had developed a duodenal-biliary fistula. Antibiotic therapy produced clinical response and surgery was performed to repair the fistula.

Percutaneous drainage for suppurative pylethrombophlebitis developing in a patient with chronic pancreatitis

Suppurative pylethrombophlebitis is an extremely rare disease with high mortality. It is difficult to diagnose this disease because its nonspecific clinical features are unfamiliar to physicians. A 64-year-old Asian man, who had undergone a longitudinal pancreaticojejunostomy for alcoholic chronic pancreatitis 7 years before, had right upper abdominal pain and high fever. Abdominal sonography and contrast-enhanced abdominal computed tomography detected thrombus and fluid collection in the portal vein. After a percutaneous needle puncture, the patient was diagnosed as having suppurative pylethrombophlebitis and treated with only drainage and antibiotics; no operation was required. This case suggests that minimally invasive percutaneous needle puncture of the intrahepatic portal vein may be an accurate procedure for the appropriate diagnosis and treatment of suppurative pylethrombophlebitis.

Staphylococcal liver abscess and acute cholecystitis in a patient with Crohn's disease receiving infliximab

We present an unusual case of empyema of the gallbladder associated with a pyogenic liver abscess in a patient with Crohn's disease on Infliximab. It manifested by weakness, weight loss, and vague abdominal pain, which eventually localized to the right upper quadrant 4 days prior to admission. Diagnostic evaluation, which included ultrasonography and computed tomography, revealed cholelithiasis, gallbladder wall thickening, and a low-attenuation, complex mass in the left hepatic lobe. Cholecystectomy and open drainage of the liver abscess were successfully performed. There are few reports of intrahepatic abscess associated with Crohn's disease. The relationship between acute cholecystitis and Crohn's disease has also been documented. However, this report documents the unusual complication of pyogenic liver abscess secondary to acute cholecystitis in the unique population of Crohn's disease patients on Infliximab.

Liver abscess in inflammatory bowel disease: report of two cases and review of the literature

Hepatic abscesses are a rare complication of inflammatory bowel disease (IBD). Despite the fact that certain hepatobiliary complications of IBD, including cholelithiasis, primary sclerosing cholangitis (PSC) and cholangiocarcinoma predispose patients with IBD to ascending cholangitis, previously published data does not demonstrate that biliary infection is an important mechanism underlying liver abscess development in these patients. We describe two patients with inflammatory bowel disease, both with PSC, who developed multiple liver abscesses, and review the literature on liver abscesses in association with inflammatory bowel disease.

Management of suppurative pylephlebitis by percutaneous drainage: placing a drainage catheter into the portal vein

Persistent infection of the portal vein is a rare entity with significant mortality. We present two cases of infected thombis of the portal vein, one infected with fungus and the other with bacteria, both requiring percutaneous drainage to allow a response to antibiotics. The distinction between bland thrombis, infected thrombis, portal venous air, and pneumobilia will be discussed so that suppurative pylephlebitis can be recognized more easily as drain placement appears to affect a more prompt degree of improvement than antibiotics alone.

Crohn's disease presenting as septic thrombophlebitis of the portal vein (pylephlebitis): case report and review of the literature

Septic thrombophlebitis of the portal vein, or pylephlebitis, is an extremely rare complication of intraabdominal infection, most commonly caused by diverticulitis (1). The following case report describes a patient without previous significant medical history presenting with painless jaundice and presumed malignancy. Workup revealed pylephlebitis due to an ileal abscess secondary to Crohn's disease. The patient was successfully treated with broad spectrum antibiotics and terminal small bowel and right colon resection. To our knowledge, this is the first reported case of Crohn's disease diagnosed after presentation with pylephlebitis.

Pylephlebitis associated with appendicitis

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.

Liver abscess as the initial manifestation of colonic Crohn's disease: report of a case

Liver abscess is a rare complication of Crohn's disease and in most of the reported cases, the diagnosis of Crohn's disease preceded that of liver abscess. We report herein a case in which a liver abscess was the initial clinical manifestation of Crohn's disease in a 36 year old man who presented with high fever and weakness. The diagnosis of liver abscess was established by abdominal ultrasonography, computed tomography and an arterial blood culture. The abscess was resolved with antibiotic therapy alone and during the drug therapy, a barium enema examination was performed which revealed a stricture at the transverse colon. Resection of the transverse colon was performed and macroscopic and microscopic examination of the resected specimen established the diagnosis of Crohn's disease. The liver abscess was thus speculated to be secondary to the inflamed bowel. Although rare, Crohn's disease should be included in the differential diagnosis of diseases causing liver abscess.

Liver abscess complicating Crohn's disease presenting as thoracic empyema. Case report and review of the literature

A 28-year-old man with a history of Crohn's disease presented with right pleuritic pain and dyspnea. Chest radiography showed a right pleural effusion. Thoracocentesis yielded purulent fluid that subsequently grew Enterobacter aerogenes. Computed axial tomography of the abdomen revealed right subphrenic abscess and right hepatic lobe abscess. Antibiotic therapy and surgical drainage resulted in complete recovery. A review of the English literature produced 18 cases of liver abscess complicating Crohn's disease. Details of 14 of these cases are summarized.

The diagnosis and treatment of pyogenic liver abscesses

Pyogenic liver abscesses in 106 adult patients at The New York Hospital were reviewed to define optimum treatment. Mortality in the surgically treated patients was 26% (17/65), while those treated nonsurgically had a fatality rate of 95% (39/41). Multiple abscesses treated surgically had a surprisingly low mortality of 29% (5/17). Modern noninvasive tests are highly sensitive in diagnosing liver lesions greater than 2 cm. Difficulty remains in identifying small hepatic abscesses and differentiating large abscesses from tumor. Most liver abscesses have an identifiable source outside the liver. The most common source (31%) was cholangitis secondary to extrahepatic biliary obstruction. Multiple abscesses, mixed organisms, hyperbilirubinemia, and abscess complications are all associated with a significantly increased mortality. However, the lethality of the primary disease process was the most important factor determining survival. Most patients who have the underlying pathogenesis of the abscess controlled will survive surgical treatment. Transperitoneal surgical drainage and antibiotics remain the mainstay of treatment. Percutaneous drainage is recommended for high risk patients only.

Anaerobic liver abscess complicating radiation enteritis

Multifocal liver abscess developed in a 68-year-old woman with radiation enteritis. Two strains of Bacteroides fragilis were cultured from the liver and blood. Surgical drainage was not possible, and in spite of appropriate antibiotic therapy the patient died.