Transcript Pylephlebitis - University of North Carolina at Chapel Hill

Pylephlebitis
Megan Brundrett
October 19, 2009
Outline
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Etiology
Microbiology
Clinical Manifestations
Diagnosis
Complications
Treatment
Prognosis
Take Home Points
Etiology
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Pylephlebitis is septic thrombophlebitis of the portal
venous system
Is a rare complication of ruptured viscera – including
appendicitis and diverticulitis
Much more common in early 20th century prior to
antibiotic therapy
Most common cause is diverticulitis (about 70% of
cases)
May be more common in pts with hypercoaguable
states
Microbiology
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Common enteric organisms
Most common organisms are B. fragilis, and E. coli
Bacteroides species have pro-coagulant properties –
have enzyme that breaks down heparin and have
surface components that promote fibrin clotting
Proteus mirabilis, Klebsiella pneumoniae, anaerobic
streptococci, Clostridium species, yeasts
80% of patients have concurrent bacteremia,
oftentimes polymicrobial
Clinical Manifestations
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Abdominal pain, fever, nausea, vomiting,
headache
Hepatomegaly, splenomegaly, and jaundice
Leukocytosis, neutropenia, elevated GGT, and
elevated alk phos
Imaging studies – CT scan, or abdominal
ultrasound can demonstrate thrombus in portal
vein
Complications
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Liver abscesses
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Progression of thrombus to mesenteric vein
and bowel ischemia
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Portal hypertension
Treatment
Antibiotic therapy – Mainstay of therapy
- Metronidazole/Flouroquinolone
- Zosyn, Unasyn, or Ertapenem
No accepted regimen because of the rarity of the condition.
Length of treatment – 4 to 6 weeks
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Anticoagulation – Unsure about use in this condition
- Help prevent clot extension or if clot is extending
- If patient has hypercoaguable state
- If Bacteroides is isolated
Prognosis
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Prior to antibiotic era – uniformly fatal
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Still 10-30% fatal, most fatalities are from
quickly progressing sepsis
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Long term - portal hypertension
Take Home Points
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Pylephlebitis – not common, but something to
think about with fever/abdominal pain,
especially in patient with diverticulitis.
Complications – liver abscess, portal HTN,
bowel ischemia.
Antibiotics can save a person’s life!
References
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Spelman. (2009). Pylephelbitis. UpToDate.
Retrieved from http://www.uptodate.com
Saxena et al, 1996 Jun;91(6):1251-3. The
American Journal of Gastroenterology.