- Denis Spelman, MBBS, FRACP, FRCPA, MPH
Denis Spelman, MBBS, FRACP, FRCPA, MPH
- Adjunct Professor, Monash University
- Alfred Hospital, Victoria, Australia
Pylephlebitis, or infective suppurative thrombosis of the portal vein, is a serious condition with significant morbidity and mortality, which can complicate intraabdominal sepsis of any etiology. Although universally fatal in the preantibiotic era , the outcome of this infection has improved somewhat with modern diagnostic and therapeutic modalities. Curiously, however, reports of the diagnosis have increased in the last 15 years, possibly as a result of newer, more sensitive imaging techniques .
The portal vein is formed by the union of the superior mesenteric vein with the splenic veins. The portal system drains blood from the abdominal section of the gastrointestinal tract, with the exception of the lower part of the rectum.
Pylephlebitis begins with thrombophlebitis of small veins draining an area of infection. Extension of the thrombophlebitis into larger veins leads to septic thrombophlebitis of the portal vein, which can extend further to involve the mesenteric veins . In a review of case reports, the superior mesenteric vein was involved in 42 percent . Thrombus involved the splenic vein and intrahepatic branches of the portal vein in 12 and 39 percent of cases, respectively. Mesenteric vein involvement can lead to bowel ischemia, infarction and death.
An associated hypercoagulable state is found in some cases of pylephlebitis . As an example, in one series of 44 cases, 18 were hypercoagulable due to clotting factor deficiencies, malignant conditions, or AIDS .
Pylephlebitis can complicate any intraabdominal or pelvic infection that occurs in the region drained by the portal venous system, especially diverticulitis and appendicitis (figure 1) [2,6-8]. In a 1948 report, the most common inciting infection was appendicitis, accounting for all 21 cases . However, the incidence of pylephlebitis following appendicitis significantly decreased with the introduction of antibiotics . One of the most frequent foci is diverticulitis, which accounted for 6 of 18 cases in one series . Although diverticulitis is a common cause of pylephlebitis, pylephlebitis remains a rare complication of diverticulitis .
- Saxena R, Adolph M, Ziegler JR, et al. Pylephlebitis: a case report and review of outcome in the antibiotic era. Am J Gastroenterol 1996; 91:1251.
- Plemmons RM, Dooley DP, Longfield RN. Septic thrombophlebitis of the portal vein (pylephlebitis): diagnosis and management in the modern era. Clin Infect Dis 1995; 21:1114.
- Kasper DL, Sahani D, Misdraji J. Case records of the Massachusetts General Hospital. Case 25-2005. A 40-year-old man with prolonged fever and weight loss. N Engl J Med 2005; 353:713.
- Kanellopoulou T, Alexopoulou A, Theodossiades G, et al. Pylephlebitis: an overview of non-cirrhotic cases and factors related to outcome. Scand J Infect Dis 2010; 42:804.
- Pradka SP, Trankiem CT, Ricotta JJ. Pylephlebitis and acute mesenteric ischemia in a young man with inherited thrombophilia and suspected foodborne illness. J Vasc Surg 2012; 55:1769.
- Baril N, Wren S, Radin R, et al. The role of anticoagulation in pylephlebitis. Am J Surg 1996; 172:449.
- Duffy FJ Jr, Millan MT, Schoetz DJ Jr, Larsen CR. Suppurative pylephlebitis and pylethrombosis: the role of anticoagulation. Am Surg 1995; 61:1041.
- Joly V, Belmatoug N, Sibert A, et al. Septic thrombophlebitis of the portal vein. Clin Infect Dis 1996; 23:417.
- SORO Y. Pylephlebitis and liver abscesses due to appendicitis. J Int Coll Surg 1948; 11:464.
- Tsao YT, Lin SH, Cheng CJ, Chang FY. Pylephlebitis associated with acute infected choledocholithiasis. Am J Med Sci 2006; 332:85.
- Tung JY, Johnson JL, Liacouras CA. Portal-mesenteric pylephlebitis with hepatic abscesses in a patient with Crohn's disease treated successfully with anticoagulation and antibiotics. J Pediatr Gastroenterol Nutr 1996; 23:474.
- Baddley JW, Singh D, Correa P, Persich NJ. Crohn's disease presenting as septic thrombophlebitis of the portal vein (pylephlebitis): case report and review of the literature. Am J Gastroenterol 1999; 94:847.
- Shin AR, Lee CK, Kim HJ, et al. Septic pylephlebitis as a rare complication of Crohn's disease. Korean J Gastroenterol 2013; 61:219.
- Chau NG, Bhatia S, Raman M. Pylephlebitis and pyogenic liver abscesses: a complication of hemorrhoidal banding. Can J Gastroenterol 2007; 21:601.
- De Roover A, Detry O, Coimbra C, et al. Pylephlebitis of the portal vein complicating intragastric migration of an adjustable gastric band. Obes Surg 2006; 16:369.
- Tandon R, Davidoff A, Worthington MG, Ross JJ. Pylephlebitis after CT-guided percutaneous liver biopsy. AJR Am J Roentgenol 2005; 184:S70.
- Wang YF, Chang CC, Lee TC, et al. Recent trend of pylephlebitis in Taiwan: Klebsiella pneumoniae liver abscess as an emerging etiology. Infection 2013; 41:1137.
- Sakamoto H, Suga M, Ozeki I, et al. Subcapsular hematoma of the liver and pylethrombosis in the setting of cholestatic liver injury. J Gastroenterol 1996; 31:880.
- Farin P, Paajanen H, Miettinen P. Intraoperative US diagnosis of pylephlebitis (portal vein thrombosis) as a complication of appendicitis: a case report. Abdom Imaging 1997; 22:401.
- Wireko M, Berry PA, Brennan J, Aga R. Unrecognized pylephlebitis causing life-threatening septic shock: a case report. World J Gastroenterol 2005; 11:614.
- Dean JW, Trerotola SO, Harris VJ, et al. Percutaneous management of suppurative pylephlebitis. J Vasc Interv Radiol 1995; 6:585.
- Nishimori H, Ezoe E, Ura H, et al. Septic thrombophlebitis of the portal and superior mesenteric veins as a complication of appendicitis: report of a case. Surg Today 2004; 34:173.
- Brown KT, Gandhi RT, Covey AM, et al. Pylephlebitis and liver abscess mimicking hepatocellular carcinoma. Hepatobiliary Pancreat Dis Int 2003; 2:221.
- Chang TN, Tang L, Keller K, et al. Pylephlebitis, portal-mesenteric thrombosis, and multiple liver abscesses owing to perforated appendicitis. J Pediatr Surg 2001; 36:E19.
- Balthazar EJ, Gollapudi P. Septic thrombophlebitis of the mesenteric and portal veins: CT imaging. J Comput Assist Tomogr 2000; 24:755.
- Bleeker-Rovers CP, Jager G, Tack CJ, et al. F-18-fluorodeoxyglucose positron emission tomography leading to a diagnosis of septic thrombophlebitis of the portal vein: description of a case history and review of the literature. J Intern Med 2004; 255:419.
- Perez-Cruet MJ, Grable E, Drapkin MS, et al. Pylephlebitis associated with diverticulitis. South Med J 1993; 86:578.
- Condat B, Pessione F, Helene Denninger M, et al. Recent portal or mesenteric venous thrombosis: increased recognition and frequent recanalization on anticoagulant therapy. Hepatology 2000; 32:466.
- Sherigar R, Amir KA, Bobba RK, et al. Abdominal pain secondary to pylephlebitis: an uncommon disease of the portal venous system, treated with local thrombolytic therapy. Dig Dis Sci 2005; 50:983.
- Vivas I, Bilbao JI, Martínez-Cuesta A, et al. Combination of various percutaneous techniques in the treatment of pylephlebitis. J Vasc Interv Radiol 2000; 11:777.
- Pelsang RE, Johlin F, Dhadha R, et al. Management of suppurative pylephlebitis by percutaneous drainage: placing a drainage catheter into the portal vein. Am J Gastroenterol 2001; 96:3192.
- CLINICAL MANIFESTATIONS
- Laboratory findings
- Blood cultures
- Imaging studies
- - Computerized tomography
- - Ultrasound
- - Other studies
- - Recommended regimens
- - Duration of therapy
- Percutaneous techniques
- FOLLOW UP
- SUMMARY AND RECOMMENDATIONS