Pylephlebitis Megan Brundrett October 19, 2009

Outline Etiology Etiology Microbiology Microbiology Clinical Manifestations Clinical Manifestations Diagnosis Diagnosis Complications Complications Treatment Treatment Prognosis Prognosis Take Home Points Take Home Points

Etiology Pylephlebitis is septic thrombophlebitis of the portal venous system Pylephlebitis is septic thrombophlebitis of the portal venous system Is a rare complication of ruptured viscera – including appendicitis and diverticulitis Is a rare complication of ruptured viscera – including appendicitis and diverticulitis Much more common in early 20 th century prior to antibiotic therapy Much more common in early 20 th century prior to antibiotic therapy Most common cause is diverticulitis (about 70% of cases) Most common cause is diverticulitis (about 70% of cases) May be more common in pts with hypercoaguable states May be more common in pts with hypercoaguable states

Microbiology Common enteric organisms Common enteric organisms Most common organisms are B. fragilis, and E. coli 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 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 Proteus mirabilis, Klebsiella pneumoniae, anaerobic streptococci, Clostridium species, yeasts 80% of patients have concurrent bacteremia, oftentimes polymicrobial 80% of patients have concurrent bacteremia, oftentimes polymicrobial

Clinical Manifestations Abdominal pain, fever, nausea, vomiting, headache Abdominal pain, fever, nausea, vomiting, headache Hepatomegaly, splenomegaly, and jaundice Hepatomegaly, splenomegaly, and jaundice Leukocytosis, neutropenia, elevated GGT, and elevated alk phos Leukocytosis, neutropenia, elevated GGT, and elevated alk phos Imaging studies – CT scan, or abdominal ultrasound can demonstrate thrombus in portal vein Imaging studies – CT scan, or abdominal ultrasound can demonstrate thrombus in portal vein

Complications Liver abscesses Liver abscesses Progression of thrombus to mesenteric vein and bowel ischemia Progression of thrombus to mesenteric vein and bowel ischemia Portal hypertension Portal hypertension

Treatment Antibiotic therapy – Mainstay of therapy 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 Anticoagulation – Unsure about use in this condition 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 Prior to antibiotic era – uniformly fatal Prior to antibiotic era – uniformly fatal Still 10-30% fatal, most fatalities are from quickly progressing sepsis Still 10-30% fatal, most fatalities are from quickly progressing sepsis Long term - portal hypertension Long term - portal hypertension

Take Home Points Pylephlebitis – not common, but something to think about with fever/abdominal pain, especially in patient with diverticulitis. Pylephlebitis – not common, but something to think about with fever/abdominal pain, especially in patient with diverticulitis. Complications – liver abscess, portal HTN, bowel ischemia. Complications – liver abscess, portal HTN, bowel ischemia. Antibiotics can save a person’s life! Antibiotics can save a person’s life!

References Spelman. (2009). Pylephelbitis. UpToDate. Retrieved from Spelman. (2009). Pylephelbitis. UpToDate. Retrieved from Saxena et al, 1996 Jun;91(6): The American Journal of Gastroenterology. Saxena et al, 1996 Jun;91(6): The American Journal of Gastroenterology.