ABSTRACT

Introduction: Pylephlebitis is a septic thrombophlebitis of the portal vein that is caused by intra-abdominal infection, most commonly diverticulitis. If the diagnosis is missed, the mortality can be high.

Case Report: A 49-year-old Caucasian man with past medical history (PMH) of gastroesophageal reflux disease (GERD), multiple episodes of diverticulitis, and alcoholism who presented to the emergency department (ED) with a three-week history of nausea, vomiting, and abdominal pain that had worsened over the last 24 hours. Baseline labs and vitals indicated severe sepsis and noncontrast computed tomography (CT) showed sigmoid diverticulitis with air within the mesenteric and portal veins. Clinically, the patient had exam findings consistent with localized peritonitis. The patient underwent exploratory laparotomy and Hartmann’s procedure for perforated diverticulitis and drainage of abscess. Concerns for pylephlebitis were suspected on postoperative day (POD) 7 due to patient’s increasing abdominal pain and large volume, serous Jackson–Pratt (JP) drainage. Thrombosis of superior mesenteric vein, main portal vein, right portal vein, and to lesser extent left portal vein was found on CT scan, suggestive of pylephlebitis. The patient was continued on intravenous (IV) antibiotics and started on systemic anticoagulation with improvement in his clinical condition.

Conclusion: Pylephlebitis is a suppurative thrombosis involving the veins that drain the abdomen and the portal venous system. It is most commonly a result of diverticulitis due to an increase inflammatory process and causes death in about 25% of patients. It is best diagnosed using CT with oral and IV contrast, and can be associated with portal venous gas. The mainstay of treatment is antibiotics, selection depending on the suspected source. The role of systemic anticoagulation is somewhat controversial as there is limited data to support its use.