- 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 .
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- CLINICAL MANIFESTATIONS
- Laboratory findings
- Blood cultures
- Imaging studies
- - Computed tomography
- - Ultrasound
- - Other studies
- - Recommended regimens
- - Duration of therapy
- Percutaneous techniques
- FOLLOW UP
- SUMMARY AND RECOMMENDATIONS