Pylephlebitis Secondary to a Gangrenous Appendicitis a Forgotten Complication. Case Report and a Review of the Literature

Abstract

Introduction: Pylephlebitis is an uncommon condition with a significant mortality which can complicate intrabdominal sepsis of any etiology. (1) Case presentation: A 22-year-old male with 2 weeks of epigastric and right upper quadrant pain with associated fever and chills, nausea and vomiting, hyperbilirubinemia and leukocytosis in blood test was documented. An acute cholangitis was the first diagnosis. Abdominal ultrasound described multiple abscesses and gallbladder wall thickening, and inflammatory changes around the gallbladder. CT scan was performed and revealed a case of acute appendicitis complicated with a thrombosis of the portal vein. Diagnostic laparoscopy was performed, here we observed an inflammatory process in the right lower quadrant, cholecystectomy with cholangiography was done with no complications, and then appendicectomy was performed. Broad-spectrum antibiotic and anticoagulation treatment led to full recovery. Follow-up after 12 months showed a full recovery and no signs of thrombosis in the serial CT scans for follow-up. Discussion: Pylephlebitis can present as a clinical cholangitis-like scenario with hyperbilirubinemia with liver abscess formation. (2) CT scan seems to be the most sensitive diagnostic test because it can identify the underlying infection foci, it also can show the extension of the thrombosis and other complications like liver abscesses (3). Surgical removal of the source of infection and adequate antibiotic treatment adjusted by culture should be initiated promptly (4). Anticoagulant treatment should be considered in the case of poor clinical outcome or thrombosis progression (5). Conclusion: Pylephlebitis should be considered in the case of poor clinical outcome of intrabdominal infections, a properly diagnosis with imaging tests and multimodal management can reduce the morbidity and mortality, and also short- and long-term complications of this pathology (6).