Pylephlebitis Complicating Concurrent Sigmoid Endometriosis and Diverticulosis: A Case Report

Abstract

Purpose To explain an unusually severe presentation of concurrent sigmoid diverticulosis and endometriosis. Intestinal endometriosis can be complicated by colonic obstruction, perforation, fistula formation, and sepsis. Suppurative thrombosis of the portal system (pylephlebitis) complicating intestinal endometriosis has not been previously reported. Methods A previously fit and well 44-year-old woman presented with a two-day history of severe, intermittent left iliac fossa pain and loose, brown stools. CT scan revealed thickening of the sigmoid colon and inferior mesenteric and intra-hepatic vein thrombosis with patchy liver perfusion. Conservative management failed and an exploratory laparotomy showed a sigmoid inflammatory phlegmon. The inferior mesenteric vein containing pus and thrombus was excised together with the sigmoid mass. Results Histology revealed sigmoid colonic diverticulosis and endometriosis associated with extensive subserosal abscess formation. Widespread suppurative necrotizing venulitis with partial thrombosis of mesenteric veins was found. Literature review revealed that endometriotic cells produce a variety of pro-inflammatory mediators. Conclusions We postulate that endometriotic tissue within the diverticular sigmoid colon triggered an inflammatory cascade, leading to bacterial translocation and pylephlebitis.