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Pylephlebitis

Pylephlebitis. Megan Brundrett October 19, 2009. Outline. Etiology Microbiology Clinical Manifestations Diagnosis Complications Treatment Prognosis Take Home Points. Etiology. Pylephlebitis is septic thrombophlebitis of the portal venous system

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Pylephlebitis

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  1. Pylephlebitis Megan Brundrett October 19, 2009

  2. Outline • Etiology • Microbiology • Clinical Manifestations • Diagnosis • Complications • Treatment • Prognosis • Take Home Points

  3. Etiology • Pylephlebitis is septic thrombophlebitis of the portal venous system • Is a rare complication of ruptured viscera – including appendicitis and diverticulitis • Much more common in early 20th century prior to antibiotic therapy • Most common cause is diverticulitis (about 70% of cases) • May be more common in pts with hypercoaguable states

  4. Microbiology • Common enteric organisms • Most common organisms are B. fragilis, and E. coli • Bacteroides species have pro-coagulant properties – have enzyme that breaks down heparin and have surface components that promote fibrin clotting • Proteus mirabilis, Klebsiella pneumoniae, anaerobic streptococci, Clostridium species, yeasts • 80% of patients have concurrent bacteremia, oftentimes polymicrobial

  5. Clinical Manifestations • Abdominal pain, fever, nausea, vomiting, headache • Hepatomegaly, splenomegaly, and jaundice • Leukocytosis, neutropenia, elevated GGT, and elevated alk phos • Imaging studies – CT scan, or abdominal ultrasound can demonstrate thrombus in portal vein

  6. Complications • Liver abscesses • Progression of thrombus to mesenteric vein and bowel ischemia • Portal hypertension

  7. Treatment • Antibiotic therapy – Mainstay of therapy - Metronidazole/Flouroquinolone - Zosyn, Unasyn, or Ertapenem No accepted regimen because of the rarity of the condition. Length of treatment – 4 to 6 weeks • Anticoagulation – Unsure about use in this condition - Help prevent clot extension or if clot is extending - If patient has hypercoaguable state - If Bacteroides is isolated

  8. Prognosis • Prior to antibiotic era – uniformly fatal • Still 10-30% fatal, most fatalities are from quickly progressing sepsis • Long term - portal hypertension

  9. Take Home Points • Pylephlebitis – not common, but something to think about with fever/abdominal pain, especially in patient with diverticulitis. • Complications – liver abscess, portal HTN, bowel ischemia. • Antibiotics can save a person’s life!

  10. References • Spelman. (2009). Pylephelbitis. UpToDate. Retrieved from http://www.uptodate.com • Saxena et al, 1996 Jun;91(6):1251-3. The American Journal of Gastroenterology.

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