1566 Pylephlebitis and Intestinal Necrosis: An Unexpected Outcome of a Common Infection

Abstract

INTRODUCTION: Although rare, pylephlebitis should be included on the differential for any patient with CT imaging showing thrombosis in the portal vasculature, with a recent intraabdominal infection. Although there are not yet guidelines for management of this potential deadly complication, patients who received early antibiotics and anticoagulation have been associated with better outcomes. CASE DESCRIPTION/METHODS: A 59-year-old female presented with worsening abdominal pain two days after being discharged for uncomplicated diverticulitis, for which she was receiving a course of ciprofloxacin and metronidazole. Initial CBC was significant for a leukocytosis of 19.5 K/uL, and CT imaging revealed an inferior mesenteric vein (IMV) thrombosis extending up to her portal vein. She was continued on her antibiotics and started on unfractionated heparin for systemic anticoagulation. Despite these interventions, the patient continued to experience worsening abdominal pain, with physical exam revealing significant rebound tenderness. Interventional radiology (IR) guided aspiration on hospital day (HD) 6 as well as endoscopic aspiration on HD 9 were attempted. However, the location of the infectious process was prohibitively difficult to access. Repeat CT imaging done on HD 10 showed progressive septic thrombophlebitis with evidence of bowel ischemia. She underwent emergent washout with left colectomy and end colostomy. Throughout her admission, her course had been complicated by perforated diverticulitis and candida dubliniensis fungemia. The patient eventually improved and was discharged on HD 29. She was discharged to complete piperacillin-tazobactam (4 weeks of therapy), anidulafungin (6 weeks of therapy) and Coumadin (6 months of therapy). DISCUSSION: Pylephlebitis is a grave condition that can arise from common infections adjacent to the portal venous system. Diagnosis is now commonly made by imaging showing thrombosis in the portal vasculature. The mortality rate is significant, estimated to be 11-25%. Repeat imaging should be considered if there is lack of clinical improvement. Broad spectrum antibiotic therapy is a mainstay of treatment. Lower mortality rates and improved outcomes have been shown in those who were anticoagulated. Complications can be seen in up to 20% of patients, the most common of which are chronic thrombosis or extension of the thrombus, bowel ischemia and abscess formation. Surgery is not required for the initial management but can be used to obtain source control and manage complications.