Pylephlebitis due to perforated appendicitis in a teenager

Abstract

Pylephlebitis, a septic thrombophlebitis of the portal vein, is a life-threatening complication of intraabdominal infections, commonly associated with acute appendicitis in children, and diverticulitis in adults. A 13-year-old boy was admitted for high fever and jaundice. On the fifth day of hospitalization, ultrasound Doppler flow and Computer Tomography scan studies showed thrombosis of the portal vein and acute appendicitis. The patient was treated with antibiotics, anticoagulation and laparotomy with appendectomy. No thrombophilic risk factors were diagnosed. Our aim is to improve physicians' awareness of this complication and emphasize the importance of early diagnosis and appropriate therapy in children in order to reduce serious complications and long-term sequels.

Pylephlebitis: A Diagnostic Challenge

“…We can also find hepatomegaly with elevated liver enzymes and jaundice [3], when associated with liver abscess or cholangitis [2]. Laboratory tests usually demonstrate elevated markers of inflammation [2]. Despite bacteremia has been reported in 50-80% cases, in our case we did not find the etiological agent [4].…”

“…It can be asymptomatic or present with gastrointestinal symptoms (ex: abdominal pain, nausea, vomiting, and diarrhea), fever and constitutional symptoms (ex: fatigue, malaise, and anorexia/weight loss) [3]. We can also find hepatomegaly with elevated liver enzymes and jaundice [3], when associated with liver abscess or cholangitis [2]. Laboratory tests usually demonstrate elevated markers of inflammation [2].…”

“…The anticoagulation therapy is controversial, but the available data are limited. Some authors consider that it prevents thrombus propagation, reduces the risk of mesenteric ischemia, improves recanalization and reduces the risk of recurrent thrombosis [2].…”

“…It is often a complication of intra-abdominal infection such as diverticulitis (most common), acute appendicitis, necrotizing pancreatitis, acute cholecystitis, colitis, inflammatory bowel disease, viscus perforation, hemorrhoidal disease, Behcet's syndrome or amebic colitis [2]. However, we cannot identify a primary source of infection in 70% of patients [3].…”

Acute Appendicitis Complicated with Ileocolic Vein Thrombosis

“…Venous thrombosis with childhood appendicitis is relatively rare [1][2][3]. When ileocolic vein thrombosis and splenic infarction are caused by appendicitis, as in our patient, the following mechanisms of thrombogenesis are considered possible: thrombi form locally owing to a state of DIC and a hyperinflammatory condition that extends into the vascular lumens.…”