History

Fact Explanation
Fever Phlebitis of portal vein is almost always results from inflamed thrombosis of the portal vein (Pylephlebitis). It usually occurs as a complication of intra-abdominal infection in a region drained by the portal vein. The most common etiology is diverticulitis. Other causes are perforated appendicitis or peritonitis. Patients present with very non specific symptoms. Still the mortality is very high. So, there should be a high clinical suspicion. High degree of fever is a common , but nonspecific finding of Pylephlebitis. Fever is accompanied with chills and rigors. [1,2,3,4]
Abdominal pain This can present in some patients. Right upper quadrant abdominal pain can be severe and depends on the patency of the portal vein. Causative intra-abdominal foci of infection can result in right lower quadrant pain (appendicitis) or generalized abdominal pain (peritonitis) may also be evident in some cases. [2,3,4,5]
Vomiting Additionally, patient may have several other non specific complaints such as nausea, vomiting, fatigue, diarrhea, and anorexia/weight loss. [1,3,5]
Complications Hepatic abscess is most commonly reported. Rarely, progression of the thrombus may result in portal hypertension. [3,5,6]
At risk population Patient may have a past history of diverticulitis, perforated appendicitis, or peritonitis which act as common etiologies for the development of phlebitis of the portal vein. A recent abdominal surgery can also predispose to pylephlebitis. [1,2,4,6]
References
  1. WONG K, WEISMAN DS, PATRICE KA. Pylephlebitis: a rare complication of an intra-abdominal infection. J Community Hosp Intern Med Perspect [online] 2013 [viewed 02 September 2014] Available from: doi:10.3402/jchimp.v3i2.20732
  2. CASTRO R, FERNANDES T, OLIVEIRA MI, CASTRO M. Acute appendicitis complicated by pylephlebitis: a case report. Case Rep Radiol [online] 2013:627521 [viewed 02 September 2014] Available from: doi:10.1155/2013/627521
  3. SHIN AR, LEE CK, KIM HJ, SHIM JJ, JANG JY, DONG SH, KIM BH, CHANG YW. Septic pylephlebitis as a rare complication of Crohn's disease. Korean J Gastroenterol [online] 2013 Apr, 61(4):219-24 [viewed 02 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/23624737
  4. COYNE CJ, JAIN A. Pylephlebitis in a previously healthy emergency department patient with appendicitis. West J Emerg Med [online] 2013 Sep, 14(5):428-30 [viewed 02 September 2014] Available from: doi:10.5811/westjem.2013.1.15353
  5. HAGOPIAN T, ZUNIGA F, SURANI SR. Pylephlebitis: an uncommon complication of intra-abdominal infection. West J Emerg Med [online] 2011 Nov, 12(4):575-6 [viewed 02 September 2014] Available from: doi:10.5811/westjem.2011.1.2197
  6. GAJENDRAN M, MUNIRAJ T, YASSIN M. Diverticulitis complicated by pylephlebitis: a case report. J Med Case Rep [online] 2011 Oct 10:514 [viewed 02 September 2014] Available from: doi:10.1186/1752-1947-5-514

Examination

Fact Explanation
Fever Almost all the patients are febrile. [1,2,3]
Abdominal tenderness Right upper quadrant abdominal tenderness is present in many patients. Rebound tenderness in the right iliac fossa is probably due to causative appendicitis. Generalized abdominal tenderness is indicative of abdominal peritonitis. [1,2,3,4]
References
  1. WONG K, WEISMAN DS, PATRICE KA. Pylephlebitis: a rare complication of an intra-abdominal infection. J Community Hosp Intern Med Perspect [online] 2013 [viewed 02 September 2014] Available from: doi:10.3402/jchimp.v3i2.20732
  2. COYNE CJ, JAIN A. Pylephlebitis in a previously healthy emergency department patient with appendicitis. West J Emerg Med [online] 2013 Sep, 14(5):428-30 [viewed 02 September 2014] Available from: doi:10.5811/westjem.2013.1.15353
  3. CASTRO R, FERNANDES T, OLIVEIRA MI, CASTRO M. Acute appendicitis complicated by pylephlebitis: a case report. Case Rep Radiol [online] 2013:627521 [viewed 02 September 2014] Available from: doi:10.1155/2013/627521
  4. SHIN AR, LEE CK, KIM HJ, SHIM JJ, JANG JY, DONG SH, KIM BH, CHANG YW. Septic pylephlebitis as a rare complication of Crohn's disease. Korean J Gastroenterol [online] 2013 Apr, 61(4):219-24 [viewed 02 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/23624737

Differential Diagnoses

Fact Explanation
Cholangitis Cholangitis is an infection of the common bile duct. A history of biliary stones or recent biliary tract manipulation associated with fever, right upper quadrant pain, and jaundice is highly suggestive of cholangitis. [1]
Cholecystitis Acute cholecystitis follows a stone impaction in the neck of the gall bladder which may cause continuous epigastric or right upper quadrant pain, vomiting, fever, local peritonism, or a gall bladder mass. Jaundice may present sometimes. [2]
Appendicitis Appendicitis is inflammation of the appendix and is a surgical emergency. The classic symptoms of appendicitis include dull pain in the peri umbilical area that becomes sharp as it moves to the lower right abdomen, loss of appetite, nausea and/or vomiting. [3]
References
  1. ARRIVĂ© L, RUIZ A, EL MOUHADI S, AZIZI L, MONNIER-CHOLLEY L, MENU Y. MRI of cholangitis: traps and tips. Diagn Interv Imaging [online] 2013 Jul-Aug, 94(7-8):757-70 [viewed 02 September 2014] Available from: doi:10.1016/j.diii.2013.03.006
  2. GNASSINGBĂ© K, KATAKOA G, KANASSOUA KK, ADABRA K, MAMA WA, SIMLAWO K, ETEH K, TEKOU H. Acute cholecystitis from typhic origin in children. Afr J Paediatr Surg [online] 2013 Apr-Jun, 10(2):108-11 [viewed 27 July 2014] Available from: doi:10.4103/0189-6725.115033
  3. KARUL M, BERLINER C, KELLER S, TSUI TY, YAMAMURA J. Imaging of appendicitis in adults. Rofo [online] 2014 Jun, 186(6):551-8 [viewed 02 September 2014] Available from: doi:10.1055/s-0034-1366074

Investigations - for Diagnosis

Fact Explanation
Full blood count Leukocytosis is evident owing to the causative bacterial infection of the abdomen. Some patients may show anemia. [1,2,3,4]
Blood culture All febrile patients with suspected septic phlebitis should undergo blood culture. It helps in effective antibiotic therapy. Samples should be taken before the empirical antibiotic therapy is started. Positive blood cultures are found in majority of patients. [2,3,4,5]
Liver profile Liver enzymes such as ALT and AST may be normal or high.[3,5,6]
Ultrasound scan Pylephlebitis can be diagnosed via abdominal ultrasonography showing a thrombus in the portal vein. [1,4,5]
CT scan CT scan is the investigation of choice in detecting phlebitis in portal vein more accurately. Nonocclusive or occlusive thrombus may be shown in the scan. In addition to that, the causative focus of infection can also be identified such as diverticulitis, appendicitis or diverticulitis. Complications such as liver abscesses can also be detected. [2,3,5,6]
References
  1. WONG K, WEISMAN DS, PATRICE KA. Pylephlebitis: a rare complication of an intra-abdominal infection. J Community Hosp Intern Med Perspect [online] 2013 [viewed 02 September 2014] Available from: doi:10.3402/jchimp.v3i2.20732
  2. HAGOPIAN T, ZUNIGA F, SURANI SR. Pylephlebitis: an uncommon complication of intra-abdominal infection. West J Emerg Med [online] 2011 Nov, 12(4):575-6 [viewed 02 September 2014] Available from: doi:10.5811/westjem.2011.1.2197
  3. SHIN AR, LEE CK, KIM HJ, SHIM JJ, JANG JY, DONG SH, KIM BH, CHANG YW. Septic pylephlebitis as a rare complication of Crohn's disease. Korean J Gastroenterol [online] 2013 Apr, 61(4):219-24 [viewed 02 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/23624737
  4. CASTRO R, FERNANDES T, OLIVEIRA MI, CASTRO M. Acute appendicitis complicated by pylephlebitis: a case report. Case Rep Radiol [online] 2013:627521 [viewed 02 September 2014] Available from: doi:10.1155/2013/627521
  5. GAJENDRAN M, MUNIRAJ T, YASSIN M. Diverticulitis complicated by pylephlebitis: a case report. J Med Case Rep [online] 2011 Oct 10:514 [viewed 02 September 2014] Available from: doi:10.1186/1752-1947-5-514
  6. COYNE CJ, JAIN A. Pylephlebitis in a previously healthy emergency department patient with appendicitis. West J Emerg Med [online] 2013 Sep, 14(5):428-30 [viewed 02 September 2014] Available from: doi:10.5811/westjem.2013.1.15353

Investigations - Followup

Fact Explanation
Abdominal ultrasound scans This should be done to assess the resolution of the phlebitis after the acute stage and later on to early identification of possible secondary outcomes and recurrences. [1,2,3]
Echo cardiogram Patients should be followed up as the possibility of the development of endocarditis is not uncommon. [1,3]
References
  1. CASTRO R, FERNANDES T, OLIVEIRA MI, CASTRO M. Acute appendicitis complicated by pylephlebitis: a case report. Case Rep Radiol [online] 2013:627521 [viewed 02 September 2014] Available from: doi:10.1155/2013/627521
  2. COYNE CJ, JAIN A. Pylephlebitis in a previously healthy emergency department patient with appendicitis. West J Emerg Med [online] 2013 Sep, 14(5):428-30 [viewed 02 September 2014] Available from: doi:10.5811/westjem.2013.1.15353
  3. GAJENDRAN M, MUNIRAJ T, YASSIN M. Diverticulitis complicated by pylephlebitis: a case report. J Med Case Rep [online] 2011 Oct 10:514 [viewed 02 September 2014] Available from: doi:10.1186/1752-1947-5-514

Management - Specific Treatments

Fact Explanation
Antibiotic treatment Empirical antibiotic therapy should be commenced until the blood culture and antibiotic sensitivity test reports are received. The therapy should cover both aerobic gram-negatives and anaerobic organisms. The usual drugs of choices are metronidazole, gentamicin, piperacillin, ceftizoxime, imipenem, and ampicillin intravenously. An exact duration has not been established. Antibiotics should be administered for a minimum of 4 weeks. It is sufficient to prevent hepatic abscesses, which is a common complication of Pylephlebitis. [1,2,3,4,5]
Anticoagulation Administration of anticoagulant is debatable. Most patients are not anticoagulated unless there is evidence of progression despite appropriate antibiotic therapy. This includes the likelihood of development of bowel ischemia and infarction secondary to extension of the thrombus. [2,3,5,6]
Surgical thrombectomy Surgical removal of the thrombosis is reserved for those who do not respond to medical management. [1,3,5]
References
  1. WONG K, WEISMAN DS, PATRICE KA. Pylephlebitis: a rare complication of an intra-abdominal infection. J Community Hosp Intern Med Perspect [online] 2013 [viewed 02 September 2014] Available from: doi:10.3402/jchimp.v3i2.20732
  2. COYNE CJ, JAIN A. Pylephlebitis in a previously healthy emergency department patient with appendicitis. West J Emerg Med [online] 2013 Sep, 14(5):428-30 [viewed 02 September 2014] Available from: doi:10.5811/westjem.2013.1.15353
  3. SHIN AR, LEE CK, KIM HJ, SHIM JJ, JANG JY, DONG SH, KIM BH, CHANG YW. Septic pylephlebitis as a rare complication of Crohn's disease. Korean J Gastroenterol [online] 2013 Apr, 61(4):219-24 [viewed 02 September 2014] Available from: http://www.ncbi.nlm.nih.gov/pubmed/23624737
  4. GAJENDRAN M, MUNIRAJ T, YASSIN M. Diverticulitis complicated by pylephlebitis: a case report. J Med Case Rep [online] 2011 Oct 10:514 [viewed 02 September 2014] Available from: doi:10.1186/1752-1947-5-514
  5. HAGOPIAN T, ZUNIGA F, SURANI SR. Pylephlebitis: an uncommon complication of intra-abdominal infection. West J Emerg Med [online] 2011 Nov, 12(4):575-6 [viewed 02 September 2014] Available from: doi:10.5811/westjem.2011.1.2197
  6. CASTRO R, FERNANDES T, OLIVEIRA MI, CASTRO M. Acute appendicitis complicated by pylephlebitis: a case report. Case Rep Radiol [online] 2013:627521 [viewed 02 September 2014] Available from: doi:10.1155/2013/627521