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Surgical Drainage for Idiopathic Suppurative Pylephlebitis
Surgical Drainage for Idiopathic Suppurative Pylephlebitis Hiroshi Ohtake, MD, Hiroshi Urayama, MD, Zensei Nozaki, MD, Takeshi Harada, MD, Michio Kawasuji, MD, and Yoh Wantanabe, MD, Kanazawa, Japan
Idiopathic suppurative pylephlebitis is quite rare and only a few cases have been reported. Conservative systemic administration of antibiotics and urokinase is reported to be effective. In this report, surgical drainage was performed on an 18-year-old man who complained of fever and abdominal pain. He had no past history of abdominal inflammatory disease or abdominal surgery. Ultrasonography and computed tomography showed wide spread thrombosis of the portal vein. Laparotomy was performed and the occluded superior mesenteric vein was incised. Massive pus was removed. Thereafter, a drain was placed at the opened mesenteric vein. Drainage resulted in a dramatic decrease in fever. Postoperative radiographic studies of the colon, the small intestine, and other organs did not show any abnormalities. Emergency surgical drainage was performed successfully, instead of systemic administration of antibiotics and urokinase. Surgical drainage may be useful for wide spread pylephlebitis and pylethrombosis. (Ann Vasc Surg 1998; 12:83-85.)
Suppurative pylephlebitis is a rare but severe complication of intraabdominal infections.1,2 Liver abscesses, diverticulitis, appendicitis, and various inflammatory bowel diseases have been reported as underlying diseases.3-5 Pylephlebitis following the detection of intraabdominal inflammation can be diagnosed and treated immediately. However, the idiopathic form pylephlebitis is quite rate and shows non-specific abdominal pain. In this report, we described a patient with idiopathic suppurative pylephlebitis complaining of severe abdominal pain who was treated by surgical drainage.
CASE REPORT An 18-year-old man was admitted to our hospital with a 10-day history of fever, chills, and abdominal pain. He From Department of Surgery (1), Kanazawa University School of Medicine, Kanazawa, Japan. Correspondence to: H. Ohtake, MD, Department of Surgery (1), Kanazawa University School of Medicine, Takara-machi 13-1, Kanazawa, 920, Japan.
had no past history of abdominal inflammatory disease or abdominal surgery. At admission, physical examination revealed rebound tenderness of the abdomen. The white blood cell (WBC) count and C reactive protein (CRP) increased. Ultrasonography of the abdomen showed thrombosis of the portal vein (Fig. 1A). Computed tomography showed wide spread occlusion of the superior mesenteric vein and portal vein (Fig. 1B). Emergency laparotomy was performed. Intraoperative findings showed that the small intestine was edematous and not necrotic. All organs showed an absence of inflammatory change. The occluded superior mesenteric vein was incised. Massive pus was removed. Thrombectomy by Fogarty catheter was tried, but no thrombus was removed and the blood flow did not recover. After a drain was placed at the opened mesenteric vein, the wound was closed. Wide broad spectrum antibiotics were administered postoperatively. His general condition recovered rapidly. Drainage resulted in a dramatic decrease in fever, WBC, and CRP (Fig. 2). Postoperative radiographic studies of the colon, the small intestine, and other organs did not show any abnormalities. He was anticoagulated postoperatively. Pus culture grew Bacteroides fragilis. One month later, postoperative ultrasonography showed cavernomatous transformation of the portal vein. 83
84
Case reports
Annals of Vascular Surgery
Fig. 2. Postoperative clinical course: (—) WBC, white blood cell count; (– – –) CRP, C reactive protein; (– - –) body temperature; shaded area shows the duration of anitbiotics administration.
Fig. 1. Preoperative abdominal imaging: A ultrasonography of the liver by right intercostal scan (arrow shows the thrombosis in the portal vein); B computed tomography (arrow shows the thrombosis in the superior mesenteric vein).
DISCUSSION Pylephlebitis occurs under various conditions causing intraperitoneal infection. In the past, pylethrombosis due to pylephlebitis was usually a complication of uncontrolled appendiceal sepsis.1 Many other abdominal inflammations can also cause pylephlebitis.3,4,5 High fever, sepsis and liver abscess following the abdominal infection are signs of pylephlebitis.2 Recently, ultrasonography and contrast-enhanced CT are reported to be useful for early diagnosing thrombosis of the portal vein. Pylephlebitis following the detection of intraabdominal inflammation can be diagnosed and treated immediately. However, the idiopathic form of pylephlebitis is quite rare and shows non-specific abdominal pain. The differential diagnosis is difficult, and there ia a strong possibility of a delay in adequate treatment. Treatment of pylephlebitis involves treating in-
fection and thrombosis of the portal vein. Conservative systemic administration of antibiotics and urokinase is reported to be effective and recommened.1,2 For more direct and invasive procedures, continuous antibiotics, heparin, and urokinase infusion through a percutaneous transhepatic catheter has been performed.6 However, idiopathic pylethrombosis is quite rare, and the mortality rate after conventional therapy has not been reported. Harch reported that surgery is indicated for patients with signs of peritonitis, enteric ischemia, or unresolved sepsis. In this case, massive pus occluded the portal vein and was difficult to remove by antibiotics. Furthermore, if conservative treatment is ineffective, fatal complications such as multiple liver abscess or wide spread intestinal necrosis may occur. We recomment radical surgical drainage for patients demonstrating only peritoneal signs, but also massive pus on CT or ultrasonography. In our case, though drainage was clinically effective, a few days were required for normalization of WBC, CRP, and body temperature. Idiopathic intestional inflammation, which was not detected on pre-or intraoperative findings, might have been present, causing this pylephlebitis. Intraoperative findings showed old thrombus, which could not be removed by Fogarty catheter. Portal vein occlusion is thought to progress gradually. This pylephlebitis might have been caused by infection subsequent to portal vein thrombosis. We think that postoperative antibiotics and anticoagulation is very important. In conclusion, the idiopathic form of pylephlebitis is quite rare and a delay in the final diagnosis and treatment can cause fatal complications. We successfully performed emergency surgical drainage, instead of conservative systemic administration of antibiotics and urokinase. Radical surgical drainage
Vol. 12, No. 1, 1998
postoperative antibiotics and anticoagulation are recommended for wide spread pylephlebitis and pylethrombosis. REFERENCES 1. Harch JM, Radin RD, Yellin AE, Donovan AJ. Pylethrombosis. Arch Surg 1987;122:1116-1119. 2. Knowkaert DC, Robaeys GK, Cox EJ, Marchal GJ. Supprurative pylethrombosis: A changing clinical picture. Gastroenterology 1989;97:28-30.
Case reports
85
3. Perex CMJ, Grable E, Drapkin MS, Jablons DM, Cano G. Pylephlebitis associated with diverticulitis. South Med J 1993; 86:578-580. 4. Slovis TL, Haller JO, Cohen HL, Berdon WE, Watts FB. Complicated appendiceal inflammatory disease in children: Pylephlebitis and liver abscess. Radiology 1989;171:823825. 5. Shen C. Suppurative pylephlebitis and liver abscess complicating colonic diverticulitis. 6. Ibuki Y, Hirasa H, Takakuwa H, et al. A case of suppurative pylephlebitis with development of hepatopetal collaterals. Nippon Shoukakibyou Gakkai Zasshi 1985;82:1406-1411.
Idiopathic suppurative pylephlebitis is quite rare and only a few cases have been reported. Conservative systemic administration of antibiotics and urokinase is reported to be effective. In this report, surgical drainage was performed on an 18-year-old man who complained of fever and abdominal pain. He had no past history of abdominal inflammatory disease or abdominal surgery. Ultrasonography and computed tomography showed wide spread thrombosis of the portal vein. Laparotomy was performed and the occluded superior mesenteric vein was incised. Massive pus was removed. Thereafter, a drain was placed at the opened mesenteric vein. Drainage resulted in a dramatic decrease in fever. Postoperative radiographic studies of the colon, the small intestine, and other organs did not show any abnormalities. Emergency surgical drainage was performed successfully, instead of systemic administration of antibiotics and urokinase. Surgical drainage may be useful for wide spread pylephlebitis and pylethrombosis. (Ann Vasc Surg 1998; 12:83-85.)
Suppurative pylephlebitis is a rare but severe complication of intraabdominal infections.1,2 Liver abscesses, diverticulitis, appendicitis, and various inflammatory bowel diseases have been reported as underlying diseases.3-5 Pylephlebitis following the detection of intraabdominal inflammation can be diagnosed and treated immediately. However, the idiopathic form pylephlebitis is quite rate and shows non-specific abdominal pain. In this report, we described a patient with idiopathic suppurative pylephlebitis complaining of severe abdominal pain who was treated by surgical drainage.
CASE REPORT An 18-year-old man was admitted to our hospital with a 10-day history of fever, chills, and abdominal pain. He From Department of Surgery (1), Kanazawa University School of Medicine, Kanazawa, Japan. Correspondence to: H. Ohtake, MD, Department of Surgery (1), Kanazawa University School of Medicine, Takara-machi 13-1, Kanazawa, 920, Japan.
had no past history of abdominal inflammatory disease or abdominal surgery. At admission, physical examination revealed rebound tenderness of the abdomen. The white blood cell (WBC) count and C reactive protein (CRP) increased. Ultrasonography of the abdomen showed thrombosis of the portal vein (Fig. 1A). Computed tomography showed wide spread occlusion of the superior mesenteric vein and portal vein (Fig. 1B). Emergency laparotomy was performed. Intraoperative findings showed that the small intestine was edematous and not necrotic. All organs showed an absence of inflammatory change. The occluded superior mesenteric vein was incised. Massive pus was removed. Thrombectomy by Fogarty catheter was tried, but no thrombus was removed and the blood flow did not recover. After a drain was placed at the opened mesenteric vein, the wound was closed. Wide broad spectrum antibiotics were administered postoperatively. His general condition recovered rapidly. Drainage resulted in a dramatic decrease in fever, WBC, and CRP (Fig. 2). Postoperative radiographic studies of the colon, the small intestine, and other organs did not show any abnormalities. He was anticoagulated postoperatively. Pus culture grew Bacteroides fragilis. One month later, postoperative ultrasonography showed cavernomatous transformation of the portal vein. 83
84
Case reports
Annals of Vascular Surgery
Fig. 2. Postoperative clinical course: (—) WBC, white blood cell count; (– – –) CRP, C reactive protein; (– - –) body temperature; shaded area shows the duration of anitbiotics administration.
Fig. 1. Preoperative abdominal imaging: A ultrasonography of the liver by right intercostal scan (arrow shows the thrombosis in the portal vein); B computed tomography (arrow shows the thrombosis in the superior mesenteric vein).
DISCUSSION Pylephlebitis occurs under various conditions causing intraperitoneal infection. In the past, pylethrombosis due to pylephlebitis was usually a complication of uncontrolled appendiceal sepsis.1 Many other abdominal inflammations can also cause pylephlebitis.3,4,5 High fever, sepsis and liver abscess following the abdominal infection are signs of pylephlebitis.2 Recently, ultrasonography and contrast-enhanced CT are reported to be useful for early diagnosing thrombosis of the portal vein. Pylephlebitis following the detection of intraabdominal inflammation can be diagnosed and treated immediately. However, the idiopathic form of pylephlebitis is quite rare and shows non-specific abdominal pain. The differential diagnosis is difficult, and there ia a strong possibility of a delay in adequate treatment. Treatment of pylephlebitis involves treating in-
fection and thrombosis of the portal vein. Conservative systemic administration of antibiotics and urokinase is reported to be effective and recommened.1,2 For more direct and invasive procedures, continuous antibiotics, heparin, and urokinase infusion through a percutaneous transhepatic catheter has been performed.6 However, idiopathic pylethrombosis is quite rare, and the mortality rate after conventional therapy has not been reported. Harch reported that surgery is indicated for patients with signs of peritonitis, enteric ischemia, or unresolved sepsis. In this case, massive pus occluded the portal vein and was difficult to remove by antibiotics. Furthermore, if conservative treatment is ineffective, fatal complications such as multiple liver abscess or wide spread intestinal necrosis may occur. We recomment radical surgical drainage for patients demonstrating only peritoneal signs, but also massive pus on CT or ultrasonography. In our case, though drainage was clinically effective, a few days were required for normalization of WBC, CRP, and body temperature. Idiopathic intestional inflammation, which was not detected on pre-or intraoperative findings, might have been present, causing this pylephlebitis. Intraoperative findings showed old thrombus, which could not be removed by Fogarty catheter. Portal vein occlusion is thought to progress gradually. This pylephlebitis might have been caused by infection subsequent to portal vein thrombosis. We think that postoperative antibiotics and anticoagulation is very important. In conclusion, the idiopathic form of pylephlebitis is quite rare and a delay in the final diagnosis and treatment can cause fatal complications. We successfully performed emergency surgical drainage, instead of conservative systemic administration of antibiotics and urokinase. Radical surgical drainage
Vol. 12, No. 1, 1998
postoperative antibiotics and anticoagulation are recommended for wide spread pylephlebitis and pylethrombosis. REFERENCES 1. Harch JM, Radin RD, Yellin AE, Donovan AJ. Pylethrombosis. Arch Surg 1987;122:1116-1119. 2. Knowkaert DC, Robaeys GK, Cox EJ, Marchal GJ. Supprurative pylethrombosis: A changing clinical picture. Gastroenterology 1989;97:28-30.
Case reports
85
3. Perex CMJ, Grable E, Drapkin MS, Jablons DM, Cano G. Pylephlebitis associated with diverticulitis. South Med J 1993; 86:578-580. 4. Slovis TL, Haller JO, Cohen HL, Berdon WE, Watts FB. Complicated appendiceal inflammatory disease in children: Pylephlebitis and liver abscess. Radiology 1989;171:823825. 5. Shen C. Suppurative pylephlebitis and liver abscess complicating colonic diverticulitis. 6. Ibuki Y, Hirasa H, Takakuwa H, et al. A case of suppurative pylephlebitis with development of hepatopetal collaterals. Nippon Shoukakibyou Gakkai Zasshi 1985;82:1406-1411.