Septic Phlebitis: A Dangerous Complication of Diverticulitis

Abstract

Colonic diverticulitis is an inflammation of the colon due to microperforation of a diverticulum, a sac-like protrusion of the colonic wall. This digestive tract disease is most common among the elderly people and affects predominantly the distal portion of the colon (sigmoid and descending). Pericolonic abscess, fistula formation, perforation, luminal obstruction, and peritonitis are well-known complications of diverticulitis. One of the most rare fistulas is enterovascular, which is a communication between a blood vessel and adjacent bowel. An uncommon complication and threatening condition of perforated diverticula is septic phlebitis, in which perforation spreads to the mesentery and erodes a blood vessel. We report a case of septic phlebitis due to enterovascular fistula. This is the case of a 79 year-old female, Latin American, past medical history of diverticulosis, arterial hypertension, and lumbar disk herniation who presented with low back pain, abdominal pain, fever, and nausea; she was treated symptomatically and discharged home from a hospital of the metropolitan area. She returned due to persistence of symptoms and multiple episodes of bright red blood per rectum. On examination, patient was acutely ill with positive digital rectal exam for blood. She was admitted and placed NPO with high dose of proton pump inhibitors plus antibiotic therapy. Abdominopelvic CT scan with IV contrast was performed which showed acute sigmoid diverticulitis with abscess formation, nodular liver appearance, and left portal vein thrombosis. Blood cultures were done and showed anaerobic gram-negative bacilli consistent with Porphyromonas spp. During hospitalization, patient developed septic shock and acute respiratory failure that required vasopressor therapy and intubation, respectively. Abdominopelvic CT with PO and IV contrast was repeated which showed portal venous thrombosis with sigmoid/inferior mesenteric vein fistula. Bowel rest was given and total parenteral nutrition was started. Patient was given intravenous fluids and broadspectrum antibiotics; end colectomy with Hartmann's pouch and partial colectomy was done with significant improvement of symptoms. Patient was discharged home to complete physical therapy rehabilitation. Septic phlebitis of the inferior mesenteric vein is an unusual complication of diverticular disease. History, physical examination, and radiographic imaging are helpful in identifying this entity. Prompt radiologic imaging is detrimental to the diagnosis, treatment, and management of abdominal pathology. Surgical intervention in a rapidly manner can be lifesaving. Early diagnosis and treatment should be emergent due to high-risk mortality from this complication.Figure 1Figure 2Figure 3