Pyleflebitis met ongebruikelijke etiologie

Casuïstiek
22-09-2014
Josine Eising, Matthijs R. Douma en Wim G. Meijer

Pylephlebitis with an uncommon aetiology

This supplementary information is presented as submitted by the corresponding author. It has not been copy-edited by NTvG.

Background

Pylephlebitis is a septic thrombophlebitis of the portal and/or mesenteric veins. It is caused by an abdominal infection in the drainage area of the portal vein. Diverticulitis is the main underlying condition, whereas appendicitis was the most prevalent cause in earlier days. Clinical features depend on the aetiology of the abdominal infection, but presenting symptoms on the emergency department often are fever, cold chills and abdominal pain. Computerized tomography (CT) scanning of the abdomen is the preferred method of radiologic imaging. Blood cultures are often positive with mixed anaerobic species, E. coli or Steptococcus species, but other bacteria are also commonly found.Pylephlebitis has significant morbidity and mortality. Complications are liver abscesses and bowel ischemia.Treatment consist of intravenously administered antibiotics and treatment of the causative abdominal infection. Antibiotics should be adjusted based on the results of the blood cultures. Treatment with anticoagulation remains controversial.

Case description

We describe the case of a 77 year old women, who presented to the emergency department (ED) with peeking fever and cold chills. She had recently been analyzed for right upper quadrant abdominal pain existing since two months. With physical examination no abnormalities were found, besides mild pain in de right upper quadrant. Laboratory findings at the ED showedelevated levels of CRP 347 mg/l, leukocytes of 14.4 10e9/l, AF 126 U/l, gamma-GT 149 U/l, total bilirubin 24 µmol/l, conjugated bilirubin 15 µmol/l, ASAT 76 U/l, ALAT 57 U/l. Urine analysis and chest x-ray showed no abnormalities. Abdominal sonography showed some widening of the ductuscholedochus, without evidence for choledocholithiasis. Abdominal CT scan showed partial thrombosis of the portal vein and the superior mesenteric vein. The wall of the proximal part of the colon seemed to be mildly thickened. No diverticula were seen. The patient was admitted and treated with intravenous antibiotics (piperacilline/tazobactam) and anticoagulation, with suspected cholangitis.Bloodcultures were positive forStaphylococcus Hominisand Streptococcus Milleri.Later on the diagnosis pylephlebitiswas made. After recovering to good health she was discharged. Two months later the patient presented again to the ED, this time with rectal blood loss. Endoscopy showed a cocktail stick stuck in a diverticulum, the cocktail stick was removed during the endoscopy. In hindsight the cocktail stick was visible in the caecum on the earlier made abdominal CT scan. In hindsight the patient remembered to have choked when eating something from a cocktail stick, after which the right upper quadrant abdominal pain started. The cocktail stick probably caused a covered perforation of the caecum, which resulted in the pylephlebitis.

Conclusion

In this case report we describe a patient with septic thrombophlebitis of the portal and/or mesenteric veins (pylephlebitis) caused by a covered perforation of the caecum due to an ingested cocktail stick.