Portal vein thrombosis and pylephlebitis following laparoscopic appendectomy in a patient with esophageal varices

Abstract

Pylephlebitis is defined as infectious suppurative thrombosis of the portal vein. The etiologies of pylephlebitis are variable, however, nearly all cases represent a rare albeit serious complication of an intraabdominal infectious process due to the regional portal venous system drainage. Appendicitis is a well-documented cause of pylephlebitis. A 1995 review of 19 cases of reported pylephlebitis demonstrated appendicitis as the second most common pre-disposing etiology in the development of pylephlebitis, with Bacteroides and E. coli being the most commonly cultured organisms. The utility of therapeutic anticoagulation following diagnosis is presently undetermined. We describe a case of pylephlebitis presenting 5 days status post laparoscopic appendectomy for uncomplicated acute appendicitis in a 62-year-old adult male with a history of cirrhosis and esophageal varices. Considering the patient’s history of cirrhosis and resultant esophageal varices, this uncertainty regarding the use of anticoagulation was particularly problematic. Given the lack evidence-based guidelines, a multidisciplinary approach weighing the risks and benefits of systemic anticoagulation was employed. Ultimately, the decision was made to proceed with therapeutic anticoagulation under close supervision with serial imaging to identify thrombus propagation and/or recanalization. While the patient did not demonstrate evidence of recanalization after 58 days of therapy, the throm-bus did indeed fail to propagate further. Clarification regarding the utility of anticoagulation in the setting of pylephlebitis in conjunction with risk stratification based on individual patient factors is certainly warranted to optimize future clinical outcomes.