Positive Murphy's Sign Research Articles

Abdominal Pain: An Omental Occasion: Presidential Poster

A 45-year-old woman with no significant medical history presented with two days of right upper quadrant (RUQ) pain. The pain started as vague, diffuse abdominal discomfort but progressed to severe RUQ pain that worsened with inspiration, movement and food intake. Bowel movements were unchanged. On initial examination she was afebrile with normal vital signs. Abdominal exam revealed RUQ tenderness and positive Murphy's sign. Blood work was significant for WBC of 20,200/mm (83% neutrophil), total bilirubin 1.0mg/dL, and direct bilirubin 0.2mg/dL. Abdominal ultrasound demonstrated a mildly enlarged liver without focal masses or nodularity and normal gallbladder; CT abdomen was initially unremarkable. The severe RUQ pain persisted; MRCP revealed stranding and edema in omental fat at the dome of the liver and small right pleural effusion. The patient was treated with analgesics with subsequent resolution of her pain. Omental infarction, until recently, has been an elusive diagnosis in patients presenting with abdominal pain because of its relative rarity and nonspecific clinical presentation. A result of vascular compromise, omental infarction typically presents with sudden-onset right lower quadrant abdominal pain without fever or gastrointestinal symptoms. Secondary infarction is caused by omental torsion, thrombosis from hypercoagulopathy or vascular abnormalities. Idiopathic infarction may be related to obesity, heavy food intake, local trauma or use of laxatives. Imaging findings on ultrasound or CT include a focal area of increased echogenicity in the omental fat or as fat stranding and swirling of omental vessels. Radiographic diagnosis of omental infarction is critical as laparoscopic evaluation can be avoided. Abdominal pain from omental infarction is often managed conservatively with analgesics and anti-inflammatory drugs due to the self-limited disease course. However, a standard treatment modality has yet to be established. Rarely, persistent pain, bleeding, adhesions or abscesses may develop and require surgical intervention.Figure 1Figure 2This patient, with no known abdominal pathology or risk factors, had an atypical presentation of a rare clinical disease, in which imaging was paramount for diagnosis. There have been no reported cases of omental trapping in the liver dome and thus is a newly reported mechanism of infarction. The abdominal pain was initially attributed to hepatobiliary disease given location and thus multiple imaging modalities were utilized before a final diagnosis was made. In patients presenting with acute abdomen, regardless of location, omental infarction should remain on the differential as it may minimize diagnostic imaging and avoid surgery.

Spontaneous Rupture of an Intrahepatic Biliary Duct Causing a Right Pleural and Retroperitoneal Biloma

Bilomas are encapsulated collections of bile outside of the biliary tree and are mainly caused by iatrogenic injury or abdominal trauma. Spontaneous rupture of the biliary tree is not common. We report a case of a patient with spontaneous rupture biloma treated with percutaneous and internal-external biliary drainage. A 68-year-old man with significant history of amyloidosis and monoclonal paraproteinemia was admitted for progressively worsening right upper quadrant abdominal pain and nausea for the last week. Vital signs were unremarkable and physical exam revealed mild jaundice and a positive Murphy sign. No rebound or guarding. Laboratory results revealed total bilirubin of 1.7 mg/dL, direct bilirubin of 0.8 mg/dL, alkaline phosphatase of 328 IU/L, AST of 190 IU/L, ALT 154 IU/L. Pancreatic enzymes and Ca 19-9 were within normal limits. Right upper quadrant ultrasound showed a distended gallbladder with biliary sludge and a dilated common bile duct (CBD) measuring 11mm. MRCP suggested a pancreatic head mass. Subsequent ERCP showed narrowing at the CBD making it difficult for cannulation. However fine needle aspiration samples were obtained and came back positive for malignancy. Over the next few days, the patient became febrile, continued having the abdominal pain and developed worsening liver function tests. CT of the abdomen revealed a large retroperitoneal fluid collection, intra and extrahepatic biliary duct dilation and a right pleural effusion. Patient underwent right chest tube placement, which drained 2 L of bilious pleural fluid. She also underwent percutaneous transhepatic cholangiogram, which showed bilious leakage from third order branch of the right hepatic duct at the level of the superior aspect of the right lobe of the liver, which was causing complete obstruction of the distal CBD. Subsequent internal-external biliary drain was placed without complications, followed by resolution of the patient's jaundice over the next days. Follow up CT of the abdomen confirmed resolution of the retroperitoneal and right pleural bilomas. After discharge, patient underwent Whipple procedure for resection of what was found to be a well differentiated cholangiocarcinoma of the CBD. He has been following with general surgery and hematology/oncology since then. Spontaneous biloma is a rare occurrence which needs to be promptly assessed and treated. Percutaneous biliary drainage with placement of an internal-external drain is an effective procedure which can be used, especially if endoscopic sphincterotomy is not feasible.

Clinical Presentation, Imaging, and Management of Acute Cholecystitis

Acute cholecystitis (AC) is a life-threatening emergency that commonly occurs as a complication of gallstones. Severe right upper quadrant pain, abdominal guarding, fever, and a positive Murphy's sign with an elevated white blood cell count are the classical clinical manifestations of AC. Although ultrasonography is typically the initial diagnostic examination in patients with suspected AC, computed tomography and magnetic resonance imaging are commonly performed to identify complications; cholescintigraphy is recommended in patients with equivocal findings on the other imaging modalities, as this technique has the highest diagnostic accuracy in the diagnosis of AC. Imaging studies are also helpful in the timely detection of complications associated with AC. Although laparoscopic cholecystectomy is considered the gold-standard treatment for AC, percutaneous gallbladder drainage with or without cholecystostomy tube placement is a safe, effective management technique for surgically high-risk patients with multiple medical conditions. This treatment can be used as either a bridging therapy, with elective cholecystectomy performed at a later time after improvement of the patient's condition, or as definitive treatment in surgically unfit patients. Radiologists play a pivotal role in the initial diagnosis and management of patients with AC.

Drainage of amoebic liver abscess by single incision laparoscopic surgery. Report of a case

Abstract Background Single incision laparoscopic surgery has increased recently due to successful results, achieved in several procedures. The aim of the present work is to present the first case in which single incision laparoscopy is used for the drainage of an amoebic liver abscess. Clinical case A 44-year-old man presented with intense right upper quadrant pain, generalised jaundice, tachycardia, fever, hepatomegaly and a positive Murphy's sign. Laboratory results revealed an increased plasma bilirubin, elevated alkaline phosphatase and transaminases, leucocytosis, negative viral panel for hepatitis, and positive antibodies against Entamoeba histolytica . On an abdominal computed tomography a 15 cm × 12.1 cm hypodense lesion was observed in the patient's liver, identified as an amoebic liver abscess. Analgesics and antibiotics were started and subsequently the patient was submitted to laparoscopic drainage of the abscess using a single port approach. Drainage and irrigation of the abscess was performed. Four days later the patient was discharged without complications. Conclusion Management of amoebic liver abscess is focused on the elimination of the infectious agent and obliteration of the abscess cavity in order to prevent its complications, especially rupture. Laparoscopic surgery has proved to be a safe and effective way to manage this entity.

The Surgical Clerkship and Medical Student Performance in a Standardized Patient Case of Acute Cholecystitis

Although an Observed Structured Clinical Examination (OSCE) has been used to evaluate patient interaction and general knowledge competencies of third-year students during their required surgical clerkships, whether surgical clerkship experience predicts satisfactory performance with a surgical patient in an OSCE environment has not been investigated. We hypothesized that completion of the third-year surgery clerkship would improve student ability to diagnose acute cholecystitis and recognize the further need for hospital admission and treatment. An observational study design was used to determine student skills in evaluating a simulated surgical patient with abdominal pain from acute cholecystitis. The skills included key data gathering, physical examination, and information-sharing tasks. Tertiary care academic medical center. Performance was compared between a cohort of 101 medical students who had completed the third-year surgical clerkship and 72 who had not. A secondary analysis compared performance for 91 students who had completed their third-year clerkship in sites near the University of California, San Francisco School of Medicine, and 10 who did so at a regional campus geographically distant from the medical school. Of the 173 students who participated in the OSCE, only 42% correctly identified the diagnosis of acute cholecystitis, though 71% did suggest the possibility of a biliary process to the standardized patient. Most of the students who identified the condition as acute cholecystitis or gallbladder-related process had completed their third-year surgical clerkship (odds ratio [OR] = 3.26). Students who completed their surgical clerkship were also better able to recommend appropriate treatment for the patient (OR = 2.35), and recommend admission to the hospital or emergency department (OR = 2.00). Approximately one-third (35.3%) of all students documented a positive Murphy's sign, but only 6.4% identified the triad of leukocytosis, fever, and a Murphy's sign as diagnostic of acute cholecystitis and the need for surgical intervention. Student performance on the clinical examination did not differ depending on whether the students completed their clerkship at a Bay Area or regional hospital. Student recognition of the key physical examination and laboratory findings diagnostic of acute cholecystitis was low, but students were better able to recommend further treatment for a patient with acute cholecystitis after completing the third-year surgical clerkship. Our study reveals areas where surgical educators can improve medical student ability to accurately diagnose acute cholecystitis and evaluate acute abdominal processes.

Extremely rare case of acute edematous pancreatitis associated with an incidental pancreatic lipoma

Case report: A 60-year-old woman was admitted to the Hospital because of intense epigastric pain, nausea and vomiting. Her previous medical history was negative. The physical examination revealed epigastric tenderness and positive Murphy's sign. Laboratory tests showed neutrophilic leukocytosis, high ESR, amylase and lipase. Gamma-GT, alkaline phosphatase, total and direct bilirurbin were in the normal range. Ultrasound showed an oval shape and hypoechoic lesion with maximum size of 2.5 cm, located in the head of pancreas; the organ had blurred margins and was increased in size. Color Doppler sonogram did not reveal vascularity inside the lesion. Neoplastic markers, such as CEA and CA 19.9, were negative. Further investigation was mandatory. On Computer Tomography (CT), the lipoma appeared as a well-circumscribed lesion with density values characteristic for adipose tissue, while on Magnetic Resonance Imaging (MRI) it demonstrated high and decreased signal intensity on T1- and T2-weighted images, respectively. The diagnosis of acute pancreatitis associated with an incidental pancreatic lipoma was made. The patient underwent conservative treatment with benefit.

A case of acute cholecystitis in Henoch–Schönlein purpura

A case of acute cholecystitis in Henoch–Schönlein purpura

English

OBJECTIVE- To determine the prevalence of carcinoma of the gallbladder in the specimens following routine cholecystectomy. STUDY DESIGN- Observational case series study Place & Duration of study- Department of Surgery, Rama Medical college Hospital and Research center, from April 2009 to March 2013. MATERIALS AND METHOD-All patients with symptomatic gallstone disease of both sex having age range between 15 to 70 year were included. Patients with pre diagnosed Gallbladder malignancy, Gallbladder mass, Empyema Gallbladder and Gallstones associated with obstructive jaundice were excluded. All cholecystectomized gall bladder specimens were sent for histopathological examination. RESULTS-Five hundred and twenty patients (520) including 104 males and 416females (M: F ratio 1:4) aged15-70 year and having a mean age of 41.7 year (± SD 2.4), were included in this retrospective study. Commonest presentations were pain in the right hypochondrium and a positive Murphy's sign (87.71%) followed by dyspepsia (55%), nausea, vomiting (40%), pyrexia (31.92%) and weight loss (05%). Twenty two (4.23%) patients had a diagnosis of malignancy of gallbladder at histopathology examination. Mean age for patients with malignancy was 55.25 year with a male to female ratio of 01:10. Well differentiated adenocarcinoma was reported in 45.45% cases, moderately differentiated in 36.36%, poorly differentiated in 09.09% and undifferentiated in 09.09%patients CONCLUSION-Though early detection and treatment has declined the incidental Gall Bladder carcinoma occurrence, but routine histopathology of cholecystectomized Gall Bladder is necessary for early detection of Gall Bladder Cancer. KEY WORDS-Cholecystectomy, Gallstones, Histopathology.

A Rare Etiology of Acute Abdomen Syndrome: Gallbladder Torsion

Acute abdomen syndrome is a frequently encountered clinical condition in emergency departments and includes a wide spectrum of surgical diagnoses. On the other hand, gallbladder torsion is a very rarely seen cause of the acute abdomen syndrome. A 74-year-old male patient admitted to the emergency department with abdominal pain present for two days, with gradually increasing intensity. Diffuse tenderness and guarding was present in the abdominal examination with positive Murphy sign. According to the radiologic evaluation, the patient was taken to the operation room under emergency condition with the preliminary diagnosis of gallbladder perforation. Total gallbladder necrosis due to torsion was detected in operation and cholecystectomy was performed. This case has been presented because of its rare incidence and emphasize that its preoperative diagnosis is very difficult. doi: http://dx.doi.org/10.4021/jmc1293e

Gallbladder perforation: the hole sign

We report a case of gallbladder perforation (GBP) in a patient with right upper quadrant pain and a positive Murphy's sign, a previous history of cholelithiasis and co-morbidities. We compare the diagnosis of GBP using the ‘hole-sign’ on ultrasound with the literature for contrast-enhanced ultrasound, computed tomography and magnetic resonance imaging.

Preoperative factors predicting conversion from laparoscopic to open cholecystectomy

Background: Laparoscopic cholecystectomy (LC) has replaced open cholecystectomy (OC) for the treatment of gallbladder disease. However, certain cases still require conversion to open procedures. Conversion to OC can be predicted based on parameters available preoperatively. This study identified risk factors that may predict conversion from a laparoscopic to an open procedure. Patients and methods: From January 2007 to January 2010, a total of 130 laparoscopic cholecystectomies performed in our list were included in this prospective clinical study at Suez Canal University Hospitals. Patients were mostly females (71.5%) and age ranged from 23ys- 69ys with symptomatic GB stone disease. Analysis of many predictive parameters including; history, laboratory data, ultrasound results, and intraoperative details were performed. Multivariate logistic regression was used to determine those variables predicting conversion of LC to open OC during the procedure. Results: Laparoscopic cholecystectomy was converted into OC in 12.3% of the patients.The cause of conversion in this group was uncontrollable bleeding from injured cystic artery during difficult dissection in (37.5%), marked adhesions due to previous upper abdominal surgery (31.3%), inflamed thick GB wall (18.7%) and marked obesity (12.5%). Preoperative factors that can predict conversion from laparoscopic to OC are (in descending sort) elevated total leucocytic count (TLC) andfever(acute inflammation), pericholecysticfluid collection by US, elevated bilirubin, BMI > 35 Kgfm2, thickened GB wall, US positive Murphy's sign , previous upper abdominal surgery, low albumin, age >60years and ascites. Conclusion: In feverish morbidly obese patients with elevated TLC, thickened GB wall and/or pericholecystic fluid collection on US assessment with or without previous upper abdominal surgery, or low plasma albumin or mild jaundice (patients with one or more predictive factors), these patients should be subjected to LC by highly expert skillful team or may be the option of open cholecystectomy is the preferable from the start to lessen morbidity.

Selective Internal Radiotherapy (SIRT) of Hepatic Tumors: How to Deal with the Cystic Artery

Selective internal radiotherapy (SIRT) with the beta emitter yttrium-90 (Y90) is a rapidly developing therapy option for unresectable liver malignancies. Nontarget irradiation of the gallbladder is a complication of SIRT. Thus, we aimed to assess different strategies to avoid infusion of Y90 into the cystic artery (CA). After hepatic digital subtraction angiography and administration of technetium-99m-labeled human serum albumin ((99)mTc-HSA), 295 patients with primary or secondary liver tumors underwent single-photon emission computed tomography/computed tomography (SPECT/CT). Different measures were taken before repeated Y90 mapping and SIRT to avoid unintended influx into the CA where necessary. Clinical symptoms, including pain, fever, or a positive Murphy sign, were assessed during patient follow-up. A significant (99)mTc-HSA accumulation in the gallbladder wall (higher (99)mTc-HSA uptake than in normal liver tissue) was seen in 20 patients. The following measures were taken to avoid unintended influx into the CA: temporary/permanent occlusion of the CA with gelfoam (n=5)/microcoil (n=1), induction of vasospasm with a microwire (n=4), or altering catheter position (n=10). Clinical signs of cholecystitis were observed in only one patient after temporary CA occlusion with gelfoam and were successfully treated by antibiotics. Cholecystectomy was not required for any patient. It is important to identify possible nontarget irradiation of the gallbladder. The risk for radiation-induced cholecystitis can be easily minimized by temporary or permanent CA embolization, vasospasm induction, or altering the catheter position.

Right Upper Quadrant Pain With Mild Jaundice: Is It Always What It Looks Like?

Right Upper Quadrant Pain With Mild Jaundice: Is It Always What It Looks Like?

A Patient With Recurrent Pancreatitis

Question: A 63-year-old African-American woman with a history of recurrent pancreatitis was admitted with severe right upper quadrant pain radiating to the back. Her medical history was notable for 3 prior episodes of pancreatitis that required hospitalization in 2000, 2006, and 2007. On the day of admission, physical examination revealed a soft abdomen that was tender to palpation in the right upper quadrant with a positive Murphy's sign. Laboratory data were notable for an amylase of 1203 and a lipase of 2091 in the setting of normal liver function tests (LFTs) and a normal leukocyte count.

Gallbladder Dysfunction Diagnosed by Cholescintigraphy with a Fatty Meal

To the editor, The pathogenesis of gallbladder dysfunction is not fully understood and functional assessment of gallbladder emptying cholescintigraphy is widely used as a diagnostic tool. We present a case of gallbladder dysfunction diagnosed by cholescintigraphy with fatty meal. A 36-year-old woman with Behcet's disease presented with frequent postprandial right upper quadrant pain of three weeks' duration. Each episode lasted more than 30 minutes, resulting in interruption of daily activities. On examination, she was afebrile with positive Murphy's sign. Routine blood tests were within normal limits. Abdominal ultrasonography, computed tomography scan, upper gastrointestinal endoscopy, and colonoscopy yielded negative findings. Endoscopic retrograde cholangiopancreatography showed no structural pancreatobiliary diseases or delayed contrast drainage. Then gallbladder dysfunction was suspected, we performed cholescintigraphy (CS). Gallbladder filling was noted at 60 minutes after injection of 99mTc-pyridoxyl-5-methyl-tryptophan (Fig. 1A, arrow). Then 58 g chocolate (energy 324 kcal, fat 20 g) was given to her. She developed mild right upper quadrant pain and the gallbladder was still detected 30 minutes later (Fig. 1B, arrow). Fatty meal stimulated CS disclosed a decreased gallbladder ejection fraction (GBEF) of 25%, indicating a diagnosis of gallbladder dysfunction. The patient was initially treated conservatively with motility agents, which did not improve her symptom. She underwent laparoscopic cholecystectomy, which completely resolved her symptom. She has remained well for 6 years. Fig. 1 (A) Cholescintigraphy showing gallbladder filling at 60 minutes after injecting 99mTc-pyridoxyl-5-methyl-tryptophan (arrow). (B) The gallbladder was still detectable 30 minutes after ingesting chocolate (arrow), indicating gallbladder dysfunction. Gallbladder dysfunction, also known as biliary dyskinesia, is characterized by functional alterations without structural biliary abnormalities. Although measurement of GBEF by cholecystokinin (CCK)-CS has been well established for the diagnostic criteria, the dose, dose rate, and duration of infusion of CCK has not been standardized. Recently, oral fatty meal including half-and-half milk, yolk and chocolate, which release endogenous CCK and are more physiologic cholagogue stimulants than exogenous CCK, can serve as alternative stimulants to CCK.1,2 As there are many countries where CCK is not available, CS with fatty meal has become common practice. In this case, the GBEF was calculated at 30 minutes after having fatty meal. Although the GBEF has been generally calculated at 60 minutes after having fatty meal and its normal value has been established as over 33%,3 recent studies have indicated that the GBEF at 30 minutes is also regarded as a reliable value by using percentile methodology as well as an absolute cut-off.4,5 In addition, sphincter of Oddi manometry was not performed to rule out sphincter of Oddi dysfunction (SOD) in this case, it was unlikely based on the long and unremarkable post-cholecystectomy course. In conclusion, it is emphasized that CS with fatty meal is useful in order to interpret the subgroup that will benefit from cholecystectomy. Further studies are needed to establish the utility of CS with fatty meal.

Successful Mechanical Lithotripsy in Bouveretʼs Syndrome

Purpose: Bouveret's syndrome is rare complication of cholelithiasis. It is characterized by gastric outlet obstruction caused by duodenal impaction of a large gallstone that passed into the duodenal bulb through a cholecystoduodenal fistula. It is critical to establish the diagnosis in order to perform an urgent therapeutic intervention. This is a case presentation of a patient with Bouveret's syndrome that was treated endoscopically with mechanical lithotripsy. A 93 year old female presented with abdominal pain, nausea, and vomiting for 1 week. Her past medical history was remarkable for coronary artery disease and hypertension. She was on Aspirin and Toprol®. On exam, she appeared confused, was febrile, and had a positive Murphy's sign. Laboratory data revealed leukocytosis, alkaline phosphatase of 152 U/l, alanine aminotransferase of 287 U/l, and total bilirubin of 3.3 mg/dl. Ultrasound of the abdomen showed dilated common bile duct and cholelithiasis. She was started on intravenous antibiotics. She underwent an urgent ERCP for suspected choledocholithiasis and cholangitis that revealed a 5 cm stone impacting the duodenal bulb. Gallbladder mucosa was fused with the duodenal bulb mucosa. The patient was a poor surgical candidate. Initial attempt to remove the stone endoscopically using a snare, rat tooth, and roth net failed. A percutaneous biliary drainage was placed by interventional radiology. An EGD was carried out on the subsequent day. Using a snare, the stone was broken into 2 pieces which were pulled back to the stomach. Then a mechanical lithotripter was used to break the stones into smaller pieces, all pieces were retrieved using a roth net. The patient recovered completely in 5 days and was discharged. The complication and mortality rates of surgical treatment can be substantial in patients with Bouveret's syndrome who are poor surgical candidates. In these patients endoscopic modalities can be carried out. This case illustrates a successful endoscopic treatment of Bouveret's syndrome using a combination of mechanical lithotripsy, a snare, and roth net. Mechanical lithotripsy is a safe approach and carries no additional significant risks.

A cheesy diagnosis

In September, 2009, a 31-year-old woman presented to our emergency room with a 3-day history of severe abdominal pain. 3 weeks before admission she had undergone a caesarean section to deliver her second child. She had no nausea, anorexia, vomiting, or fever. Examination was normal apart from a positive Murphy's sign. C reactive protein (CRP) concentrations were raised at 9·7 mg/L, but numbers of neutrophils were normal. We suspected acute cholecystitis and started antibiotic treatment with amoxicillin; however, ultrasonography showed no signs of an inflamed gallbladder, and a CT scan of the abdomen showed signs only of peritonitis and postoperative changes.

Endoscopic transpapillary gallbladder drainage for Mirizzi syndrome accompanied with obstructive suppurative cholecystitis

Objective To evaluate endoscopic transpapillary gallbladder drainage （ETGD） for Mirizzi syndrome accompanied with acute obstructive suppurative cholecystitis. Methods Data of 8 cases, who presented with acute right upper quadrant abdominal pain and positive Murphy sign and were diagnosed by imaging and endoscopic retrograde cholangiopancreatography （ERCP） as having Csendes type Ⅰ of Mirizzi syndrome, were retrospectively studied. The cholelithiasis with obstructive suppurative cholecystitis were treated with stone removal via ERCP and subsequent ETGD. Results ETGD was successfully performed in all patients, and no complications or death occurred. The symptoms relieved after the procedure, and body temperature and white blood cells gradually decreased to normal level. Imaging findings one week after ETGD showed subsidence of gallbladder inflammation. All patients remained symptom free at follow-up of 6 months, except occasional discomfort in gallbladder area in 2 patients. Conclusion Endoscopic treatment is safe and effective in patients with Mirizzi syndrome. ETGD is able to relieve infection and clinical symptoms in such patients accompanied with acute suppurative cholecystitis. Key words: Cholecystitis ; Cholangiopancreatography, endoscopic retrograde ; Mirizzi syndrome ; Endoscopic transpapillary gallbladder drainage

Image of the Month—Quiz Case

A 70-YEAR-OLD MAN VISITED THE EMERgency department with a 3-day history of right upper quadrant pain. He was febrile (temperature, 37.6°C) and his white blood cell count was 19 10/μL. His abdomen was soft and tender at the right upper quadrant with a positive Murphy sign. He had a history of splenectomy for hereditary spherocytosis at age 40 years and a history of upper gastrointestinal tract bleeding from a gastric ulcer 7 years prior to admission. He had a gallstone disease for the last 12 years. The abdominal ultrasonographic scan showed acute cholecystitis with gallbladder wall thickening and pericholecystic fluid collection, and chest radiography revealed a mass of the right lower lobe (Figure 1). The patient underwent a cholecystectomy and had an eventful postoperative recovery. He was then referred to the chest physicians and had further investigation with a biopsy guided by magnetic resonance imaging (Figure 2) and computed tomography. Unfortunately, the histopathologic examination results of the biopsy specimen were inconclusive; thus, the patient underwent a right thoracotomy.

Early Enteral Feeding and Anticoagulation in Pylephlebitis with Hepatic Dysfunction

Purpose: Pylephlebitis is a rare complication of certain inflammatory processes in the gastrointestinal tract and often pose many challenges for gastroenterologists. Methods: A 54 year-old man presented with a 1 week history of epigastric pain, fevers, and decreased appetite. He had a history of diabetes mellitus, hypertension, hyperlipidemia, peripheral vascular disease and moderate alcohol use in the past. Admission vitals were BP 114/71 mmHg, pulse of 133/min and temperature of 101F. Exam revealed jaundice, distended and diffuse abdominal tenderness with a positive Murphy's sign. Labs included wbc 17.6 K/uL, albumin 4.2 gm/dL, INR 1.35, total/direct bilirubin 5.7/4.3 mg/dL, alkaline phosphatase 154 IU/L, with normal transaminases. HIDA scan showed decreased hepatic uptake consistent with hepatic dysfunction without cystic duct obstruction. Abdominal CT scan showed sigmoid diverticulitis with a pericolic collection and thrombosis of the left portal vein. No thrombosis was seen in the mesenteric veins. The diverticulitis was treated with meropenem. The total bilirubin increased to a peak of 9.7 mg/dL and INR at 1.57 over the next 3 days. Anticoagulation therapy was initiated on day 3. Leukocytosis and fevers resolved by day 4 and oral feeding was started on day 5. Results: Based on clinical symptoms and radiologic findings of sigmoid diverticulitis and portal vein thrombosis (PVT), pylephlebitis was diagnosed. Pylephlebitis, also known as infective suppurative thrombosis of the portal system, is a rare complication of intra-abdominal processes such as diverticulitis, appendicitis or inflammatory bowel disease. Significant controversy surrounds the benefit of anticoagulating these patients. Literature suggests that only patients with a malignancy, clotting factor deficiencies, or mesenteric vein involvement should be anticoagulated. We initiated heparin because of worsening hyperbilirubinemia and witnessed gradual hepatic function normalization. Another challenge was the timing of initiating oral nutrition since enteral nutrition may stimulate portal vein flow, further exacerbating the PVT. Oral feedings were started on day 5 without any complications. To the best of our knowledge, there is no previously published data on the issue of feeding in patients with pylephlebitis. Our patient's favorable course and prompt recovery provides anectodal evidence that enteral feeding is not contraindicated in this condition. Conclusion: We present a rare case of pylephlebitis in which diverticulitis caused significant hepatic dysfunction due to a left portal vein thrombus. The issues of anticoagulation and enteral feeding are addressed. We believe that given the right clinical setting, enteral feeding can be started early with favorable results.