ArticlePDF AvailableLiterature Review


Pylephlebitis is a condition with significant morbidity and mortality. We review herein 100 relevant case reports published since 1971. Eighty-one patients were reported with acute pylephlebitis, while the remaining patients had chronic pylephlebitis. The most common predisposing infections leading to pylephlebitis were diverticulitis and appendicitis. Cultures from blood or other tissues were positive in 77%. The infection was polymicrobial in half of the patients and the most common isolates were Bacteroides spp, Escherichia coli and Streptococcus spp. Thrombosis was extended to the superior mesenteric vein (SMV), splenic vein, and intrahepatic branches of the portal vein (PV) in 42%, 12%, and 39%, respectively. Antibiotics were administered in all and anticoagulation in 35 cases. Patients who received anticoagulation had a favourable outcome compared to those who received antibiotics alone (complete recanalization 25.7% vs 14.8% (p > 0.05), no recanalization 5.7% vs 22.2% (p < 0.05), and death 5.7% vs 22.2% (p < 0.01)). Cases with complete recanalization had prompt diagnosis and management and two-thirds were recently published. Nineteen patients died; the majority of these (73.7%) died over the period 1971-1990. In conclusion, pylephlebitis remains an entity with high morbidity and mortality, but modern imaging modalities have facilitated an earlier diagnosis and have improved the prognosis. Anticoagulation has a rather beneficial effect on patients with pylephlebitis.
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Pylephlebitis: An overview of non-cirrhotic cases and
factors related to outcome
Theoni Kanellopouloua, Alexandra Alexopouloua, George Theodossiadesb, John Koskinasa &
Athanasios J. Archimandritisa
a Second Department of Medicine, Medical School, University of Athens, Hippokration
Hospital, Athens, Greece
b First Regional Transfusion and Haemophilia Centre, Hippokration Hospital, Athens, Greece
Published online: 08 Jun 2010.
To cite this article: Theoni Kanellopoulou, Alexandra Alexopoulou, George Theodossiades, John Koskinas & Athanasios J.
Archimandritis (2010) Pylephlebitis: An overview of non-cirrhotic cases and factors related to outcome, Scandinavian Journal
of Infectious Diseases, 42:11-12, 804-811
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Correspondence: A. Alexopoulou, 40 Konstantinoupoleos St, 16342 Hilioupolis, Athens, Greece. Tel: 30 210 7774742. Fax: 30 210 7706871.
(Rece ived 30 Mar ch 2010; ac cepted 27 J une 2010)
Pylephlebitis begins with thrombophlebitis of small
veins draining an area of any intra-abdominal or pel-
vic infection [1]. Thrombophlebitis may extend into
larger veins leading to septic thrombophlebitis of the
portal vein (PV) and occasionally extending further
to involve the superior mesenteric vein (SMV). The
risk of thrombosis is particularly high when patients
develop sepsis leading to disseminated intravascular
coagulation (DIC) [2]. The appropriate diagnosis and
management of pylephlebitis depends on a high
degree of clinical suspicion, the use of imaging stud-
ies, and early initiation of empiric antibacterial ther-
apy combined with anticoagulant therapy [1]. PV
thrombosis (PVT) is an increasingly recognized dis-
order, due to an increased use of and improvements
in non-invasive imaging techniques for the diagnostic
evaluation of abdominal pain [3,4].
Literature review
We identifi ed all relevant English language case
reports by a MEDLINE search for the period July
1971 to December 2009 using the terms pylephle-
bitis , septic thrombosis of the PV , septic throm-
bophlebitis of the PV , pylethrombosis , infectious
thrombosis of the PV and suppurative thrombosis
of the PV . We also reviewed the reference lists of
original articles. We did not include cases that had
inadequate clinical or laboratory/microbiological
information for the diagnosis and course of pyl-
ephlebitis. In addition, cases of pylephlebitis with a
cirrhotic background were excluded. We did not
include any case series of PVT of various aetiologies,
where individual data of cases with pylephlebitis
were not available. We abstracted patient demograph-
ics, predisposing factors, microbiological studies,
the method of diagnosis, treatment, and outcome.
Pylephlebitis: An overview of non-cirrhotic cases and factors
related to outcome
1 ,
1 &
From the
1 Second Department of Medicine, Medical School, University of Athens, Hippokration Hospital, Athens, Greece, and
2 First Regional Transfusion and Haemophilia Centre, Hippokration Hospital, Athens, Greece
Pylephlebitis is a condition with signifi cant morbidity and mortality. We review herein 100 relevant case reports published
since 1971. Eighty-one patients were reported with acute pylephlebitis, while the remaining patients had chronic pylephle-
bitis. The most common predisposing infections leading to pylephlebitis were diverticulitis and appendicitis. Cultures from
blood or other tissues were positive in 77%. The infection was polymicrobial in half of the patients and the most common
isolates were Bacteroides spp, Escherichia coli and Streptococcus spp. Thrombosis was extended to the superior mesenteric
vein (SMV), splenic vein, and intrahepatic branches of the portal vein (PV) in 42%, 12%, and 39%, respectively. Antibiot-
ics were administered in all and anticoagulation in 35 cases. Patients who received anticoagulation had a favourable outcome
compared to those who received antibiotics alone (complete recanalization 25.7% vs 14.8% ( p 0.05), no recanalization
5.7% vs 22.2% ( p 0.05), and death 5.7% vs 22.2% ( p 0.01)). Cases with complete recanalization had prompt diag-
nosis and management and two-thirds were recently published. Nineteen patients died; the majority of these (73.7%) died
over the period 1971 1990. In conclusion, pylephlebitis remains an entity with high morbidity and mortality, but modern
imaging modalities have facilitated an earlier diagnosis and have improved the prognosis. Anticoagulation has a rather
benefi cial effect on patients with pylephlebitis.
Scandinavian Journal of Infectious Diseases, 2010; 42: 804–811
ISSN 0 036-5548 pri nt/ ISSN 1651-1980 onli ne © 2010 Infor ma Hea lthca re
DOI : 10.3109 / 003655 48 .2010.50 84 64
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Pylephlebitis: A literature review 805
One hundred cases of pylephlebitis were found: 9
cases from 1971 to 1980, 18 cases from 1981 to
1990, 22 cases from 1991 to 2000, and 51 cases from
2001 to date. The Chi-square test was used to com-
pare categorical data.
Clinical presentation
The age range was 20 days to 77 y (mean 42.3 y)
and 24% of the cases were paediatric ( 18 y) [5 24].
Most of the affected individuals (68%) were males.
The condition was considered acute if symptoms
developed less than 60 days prior to hospital assess-
ment and there was no evidence of porto-systemic
collaterals and cavernomatous formation of the por-
tal vein [25]. Eighty-one patients (81%) presented
with acute pylephlebitis.
The most common presenting symptoms were
fever in 86% and abdominal pain in 82%. Symptoms
on admission are shown in Table I. Physical fi ndings
disclosed splenomegaly in 23% [5,17,20,23,26 34],
hepatomegaly in 42% [5,11,13,14,20,24,26,28,31,
32,34 42], and transient or persistent ascites in 20.5%
of instances [7,10,14,15,17,24,32,33,39,42 48].
Regarding laboratory tests, leukocytosis was a
common fi nding (80% of cases). Liver enzyme values
were stated in 67 cases and disclosed an elevation
of aspartate aminotransferase (AST) and/or alanine
aminotransferase (ALT) levels in 69%, an increase
of alkaline phosphatase (ALP) and/or gamma-
glutamyl transpeptidase (GGT) levels in 40%, an
increase of total bilirubin in 55%, and anaemia in
55% of cases.
The most common intra-abdominal infl ammatory
conditions leading to pylephlebitis were diverticulitis
(30%) [26 28,30,33,34,37,38,42,43,45,47 62] and
appendicitis (19%) [5,6,8,10,12,14 17,22,23,31,40,
41,46,60,63 65], followed by infl ammatory bowel
disease (6%) [20,21,39,44,66,67] and pancreatitis
(5%) [60,68 71] (Table II). Past or concomitant
medical conditions possibly related to the develop-
ment of pylephlebitis are shown in Table III. Remote
abdominal surgery (performed beyond 6 months
prior to reported admission) was reported in 18%
[11,28,30,31,35,38,42,53,66,67,69,72 77], whereas
a recent abdominal procedure (performed within
30 days prior to the diagnosis of pylephlebitis) was
reported in 19% of patients [22,31,33,36,41,42,
51,56,60,61,63,65,75,77 81]. In neonates, pyle-
phlebitis was attributed to umbilical vein cannu-
lation or umbilical sepsis in 80% of reported cases
A thrombophilic disorder was searched for in
30 patients only and was identifi ed in 11 [9,22,23,
29,34 36,40,54,74,80]. Malignancy possibly related
to thrombophilia was present in 6 cases [22,34 36,
74,80] (Table IV) and none had a medical history
of myeloproliferative disease.
A microorganism was yielded from blood culture
exclusively in 36 cases (42%) [10,11,15,16,23,26
29,31,35,37,40,41,43,46 50,52,56,58,62,64,
73 75,77,80 85], both from blood and other tissue
samples in 22 (26%) [7,30,33,34,36,38,44,48,54,
57,58,61,66,71,72,77,87 89], from liver abscesses or
portal vein aspiration in 13 (16%) [9,18,32,34,42,53,
59,68,69,90], and from samples other than blood in 6
patients (7%) [11,20,39,67,76,78]. No microorgan-
ism was yielded in 8 (9%) [6,9,21,24,45,63,70,91]
and there was no information about microbiological
studies for the remaining 15 subjects [5,8,12,19,22,
Table II. Aetiology of pylephlebitis.
Local cause n (%)
Diverticulitis 30 (30%)
Appendicitis 19 (19%)
Infl ammatory bowel disease 6 (6%)
Pancreatitis 5 (5%)
Gastroenteritis 4 (4%)
Umbilical vein catheter 3 (3%)
Cholangitis 3 (3%)
Gastric/duodenal ulcer 2 (2%)
Liver abscesses 2 (2%)
Amoebiasis 2 (2%)
Evidence of intra-abdominal sepsis 3 (15%)
Aetiologies with only 1 observation
a 15 (15%)
Unrecognized cause 6 (6%)
Total 100
a Aetiologies with only 1 obser vation: umbilical sepsis; emphy-
sematous gastritis; intragastric migration of an adjustable gastric
band; percutaneous liver biopsy; acute or chronic hepatic artery
obstruction; subcapsular haematoma of the liver; toothpick
perforation and migration; necrotic segment of distal small bowel;
necrotic splenic fl exure carcinoma; incarcerated incisional
abdominal hernia; intestinal ischemia; peripancreatic ligamental
abscess; Fusobacterium necrophorum septicaemia; urinary
infection; Beh ç et s disease (underlying arteritis).
Table I. Symptoms on admission.
Symptom n (%)
Fatigue/exhaustion/malaise 95 (95%)
Fever 86 (86%)
Abdominal pain 82 (82%)
Vomiting/nausea 28 (28%)
Diarrhoea 27 (27%)
Anorexia/weight loss 19 (19%)
Lethargy/confusion 8 (8%)
Apnoea/wheezing 4 (4%)
Myalgia/arthralgia 4 (4%)
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806 T. K a n ellop o u lou et al.
( n 1) [31], and endoscopic ultrasonography
( n 1) [45]. The mode of diagnosis was not stated
in 1 case [58].
In 56 (56%) subjects, the diagnosis of PVT was
made during the fi rst 7 days following admission,
while in the remaining subjects the diagnosis was
Extension of thrombosis to the SMV was described
in 42% [5,7,8,10,14 18,20,21,23,26 30,33,37,39,
43,45 48,53,54,57,58,62 64,66,67,70,71,83 87,93]
and to the splenic vein in 12% [14,17,23,27,31,3
4,47,68,69,71,85,88]. Thrombosis of the intrahe-
patic branches of the PV was disclosed in 39% [6 8,
11,14 24, 30,33,34,36,38,42,43,45,48,52,53,55,58,59,
61,67 70,74,76,78,80 82,85,87,89] and thrombosis
of the inferior mesenteric vein in 2% [34,49]. Intra-
portal gas was visualized in 18% [35,37,43,44,48,
50,51,56 58,62,67 70,75,80,86] and there was co-
existence of liver abscesses in 37% [6,9,10,12 14,
20,22,24,28,30 32,34,41,42,45,46,48,53,54,
57,58,60,61,66,68,69,72,81,87,89] of subjects. Ten
patients had evidence of bowel ischemia on CT
scans, all of whom had thrombosis of the SMV [15,
Table IV. Thrombophilic disorders possibly related to pylephlebitis.
Thrombophilic disorder n
a 6
Protein S defi ciency 1
Anti-thrombin III and protein C defi ciency 1
Factor XII defi ciency 1
Transient positivity of anti-cardiolipin antibodies 1
Oral contraceptives 1
No thrombotic predisposing disorder found 19
No data 70
a Colon cancer (1); acute lymphocytic leukaemia (1); adeno-
carcinoma (1), VIPoma (1); hepatocellular carcinoma (1); breast
cancer (1).
Table III. Conditions possibly related to pylephlebitis.
Medical condition n
Recent abdominal surgical procedure 19
Remote abdominal surgery 18
Immunosuppression (immunosuppressive drugs,
rheumatological conditions, other) 14
Chronic pancreatitis 5
Malignancy (solid tumours/haematological
malignancies) 6
Infl ammatory bowel disease 6
Alcoholism 8
Viral hepatitis 3
Other 3
A single microorganism was recovered in 40
(47%) [9 11,13,18,23,26 31,33,37,40,42,46,48,49,
52,53,56,64,67,68,71,73 77,81 83,85,88], 2 3 bac-
teria in 26 (31%) [7,15 17,32,34,36,38,39,43,44,
48,50,54,58,59,62,66,69,72,79,80,84,89], and more
than 3 in 11 (13%) [14,25,34,35,41,47,57,58,61,
78,86,87,90] instances. Table V shows the microor-
ganisms involved in pylephlebitis. The most common
was Bacteroides fragilis, following by Escherichia
coli and Streptococcus spp.
The diagnosis of PVT was made exclusively by ultra-
sonography (US) in 12 and by computed tomogra-
phy (CT) scan in 28 cases. In 23 further cases both
methods were used for diagnosis. The diagnosis was
made by autopsy study in 16 cases (16%) [30,32,
34,42,48,59 61,68,75,81,90,92], 11 of which were
reported over the period 1971 1985 [30,32,34,42,
59 61,81]. The remaining were diagnosed during a
surgical procedure ( n 8) [22,41,56,62,64,65,68,80],
by angiography ( n 4) [33,60,71,87], magnetic
resonance imaging of the abdomen ( n 3) [6,51,77],
positron emission tomography/CT scan ( n 2)
[35,90], liver biopsy confi rmed later by autopsy
( n 1) [78], Tc-99m confi rmed later by angiography
Table V. Microorganisms involved in pylephlebitis.
Type of microorganism n
Bacteroides spp. 27
Clostridium spp. 11
Fusobacterium spp. 7
Peptostreptococcus spp. 5
Lactobacillus spp. 1
Propionibacterium acnes 1
Eubacterium spp. 2
Bifi dobacterium spp. 1
Aerobic bacteria
Gram-positive cocci
Streptococcus spp. 17
Staphylococcus spp. 5
Enterococcus spp. 2
Gram-negative bacilli
Escherichia coli 22
Pseudomonas aeruginosa 4
Klebsiella spp. 5
Proteus spp. 5
Eikenella corrodens 1
Acinetobacter spp. 1
Campylobacter jejuni 1
Shigella spp. 1
Corynebacterium spp. 1
Aeromonas hydrophila 1
Aerobacter aerogenes 1
Candida spp. 7
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Pylephlebitis: A literature review 807
The mortality rate was high since 19 patients died
(19%) [30,32,34,42,48,50,59 61,67,75,78,81,90,93].
Fourteen patients (73.7%) died over the period
1971 1990 and 5 patients (26.3%) over 1991 2009.
The average age was 60.1 y, and all were adults. Their
concomitant medical conditions included diabetes
mellitus [30,34,48], liver transplantation [75],
chronic renal failure [50], severe burn [91], breast
cancer [34], Crohn s disease [67], alcohol abuse
[30,32,61,78], and remote abdominal operation
[30,42,67,75]. Seven patients died during the fi rst
week of hospitalization [30,32,34,48,75,92]. All the
patients who died were diagnosed to have acute
PVT. The cause of pylephlebitis was diverticulitis in
47% of cases (9 patients) [30,34,42,48,50,59 61].
Imaging studies and autopsy revealed SMV in
2 (10.5%) [30,67] and extension of thrombosis to
intrahepatic branches in 8 (42%) [30,34,42,59,61,
67 78,81] and to the splenic vein in 1 case [34].
Intraportal gas was observed in 3 (16%) [50,67,75],
liver abscesses in 8 (42%) [30,32,34,42,48,61,81],
and bowel ischemia in 2 cases (10.5%) [60,81].
Sepsis was the cause of death in most of the cases
[30,34,48,50,59,61,67,75,78], followed by peritoni-
tis [34,42,60], liver failure [32,90], bowel ischemia
[60,81], intestinal bleeding [78], and rupture of the
PV [92].
Outcome in relation to anticoagulation treatment
In the group of patients with a fatal outcome, 1
patient died at admission without any treatment [92]
and 11 were treated with antibiotics alone [30,32,
34,42,48,59,61,75,78,81,90,92], while anticoagula-
tion plus antibiotics was administered in 2 patients
[34,50]. For 5 patients who died there was no infor-
mation on whether anticoagulation was administered
or not [60,67].
Thirty-fi ve patients were treated with anticoagu-
lation and antibiotics (Table VI) [5,7,8,10,12,14 17,
19,20,27,28,37,38,40,43,45,47,48,50,52 55,58,
63,66,73,74,77,83,84]. Six (17.1%) patients had
chronic PVT at presentation [7,14,17,20,64,77]. On
admission, thrombosis of the SMV was observed in
23 (65.7%) [5,7,8,10,14 17,20,27,37,43,45,47,53,
54,58,63,64,66,77,83,84], and 2 of them (5.7%)
also had bowel ischemia [15,54]. Complete resolu-
tion of the thrombus was observed in 9 cases (25.7%)
[5,10,12,15,37,52,54,55,84]. No resolution was
observed in 2 patients who later died [34,50] and
improvement was observed in 23 cases (65.7%) [7,8,
63,64,66,73,74,77,84,86]. Two patients (5.7%)
developed portal hypertension.
During hospitalization, 47 patients underwent an
open surgical procedure due to the disease causing
pylephlebitis (appendicitis, diverticulitis, etc.). Nine-
teen were operated on prior to the diagnosis of
pylephlebitis and 28 following the diagnosis.
Antibiotics were used in all cases. Usually a com-
bination of antibiotics was used on admission as
empirical therapy, followed by a change in antibiotic
scheme targeted to the microorganism isolated from
culture. Intraportal antibiotics were administered in
2 patients [33,38]. Aspiration and drainage of pus
was performed in 6 patients [18,24,38,68,69,71],
whereas an interventional procedure (thrombectomy
in 3, aorta superior mesenteric artery bypass in 1)
was attempted in 4 patients [10,19,87,93]. Systemic
brinolytic drugs were administered in 5 cases [7,18,
26,38,89] and in 1 further case intraportal fi brin-
olysis was performed [87]. Anticoagulation treat-
ment was administered after fi brinolytic treatment
in 2 patients [7,38] and aspirin in 1 [26].
Anticoagulation treatment was administered in
35 cases [5,7,8,10,12,14 17,19,20,27,28,34,37,38,
40,43,45,47,49,50,52 55,58,63,64,66,73,74,
77,83,84]. Parenteral treatment (unfractionated hep-
arin or low molecular weight heparin) was given ini-
tially to 29 patients [5,7,8,10,14,17,19,20,34,37,
38,40,43,47,49,52 55,63,64,66,73,74,77,82,84],
followed by oral treatment with vitamin K antago-
nists in 20 cases [5,8,10,14,17,20,34,37,47,49,52 54,
63,64,73,74,77,82,84], while in the remaining 6 (out
of 35) only oral anticoagulation treatment was
administered [12,15,16,45,50,86]. The course of the
disease (recanalization, improvement or no recana-
lization) was available for 89 patients who were
followed-up (Table VI).
Table VI. Outcome in patients who received anticoagulation
compared to those who did not.
Yes ( n 35) No ( n 54) p -Value
Acute pylephlebitis 29 (88.9%) 50 (92.5%) NS
Chronic pylephlebitis 6 (17.1%) 4 (7.4%) NS
Superior mesenteric vein
thrombosis 23 (65.7%)
a 16 (29.6%)
b p 0.01
Complete recanalization 9 (25.7%) 8 (14.8%) NS
No recanalization 2 (5.7%) 12 (22.2%) p 0.05
Development of portal
hypertension 2 (5.7%) 6 (11.1%)
c NS
Death 2 (5.7%) 12 (22.2%) p 0.01
Improvement 23 (65.7%) 34 (62.9%) NS
NS, not signifi cant.
a Two patients experienced bowel ischemia.
b Five patients experienced bowel ischemia.
c Three patients already had gastric/oesophageal varices on
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808 T. K a n ellop o u l ou et al.
imaging methods demonstrating thrombus in the
PV with or without associated mesenteric vein
thrombus. Intraportal gas was not rare, occurring in
about a sixth of instances. In more than half of cases
(56%) the diagnosis was made during the fi rst week
of hospitalization. In the remaining cases, the diag-
nosis was delayed. Diagnosis was usually delayed
because pylephlebitis, as an uncommon condition,
was not considered a possible diagnosis and therefore
was not thoroughly investigated; or probably because
clinical signs and symptoms of portal vein thrombo-
sis were not specifi c and the portal vein was poorly
Regarding aetiology, the most common inciting
infection associated with pylephlebitis was diverticu-
litis, which occurred in one third of the cases. Appen-
dicitis, cholecystitis and cholangitis, which were the
most common foci in some case series in the litera-
ture [94], were less frequent. Infl ammatory bowel
disease was revealed to be the predisposing factor in
a small proportion of cases. Bacteraemia occurred in
about 60% of cases, while cultures from blood or
other tissue samples were positive in 77%. The infec-
tion was polymicrobial in half of the instances and
the most common isolates were B. fragilis, E. coli and
Streptococcus spp. These fi ndings of the polymicro-
bial nature of infection and the isolated bacteria
Bacteroides spp. and E. coli are similar to those
reported in other series [84]. However, it is impor-
tant to note that Gram-positive bacteria, and par-
ticularly Streptococcus spp., were demonstrated to
be among the most common isolates.
There is a potential pathogenetic role of pro-
thrombotic alterations during invasive bacterial
infections [2]. A complication such as DIC has been
observed in patients with bacteraemia from Gram-
positive cocci and recent studies have indicated
platelets to play an important role in endotoxin-
induced DIC releasing antimicrobial proteins [2]. A
strong link between B. fragilis infection and PVT has
been demonstrated possibly because of the transient
development of anti-cardiolipin antibodies [54,77,95].
A more thorough study of the pathogenetic role of
bacteria in PVT is needed.
A possible underlying thrombophilic disorder
was not investigated in two thirds of case reports.
Bone marrow aspiration was not performed in most
of the patients to exclude underlying myeloprolifera-
tive disease, and the presence of the JAK2V617F
mutation was not tested. These results probably
underestimate the prevalence of an underlying
thrombophilic disorder [96].
Pylephlebitis is an entity with high morbidity
and mortality. We have shown that about one fi fth
of patients described in case reports had a fatal
outcome. The most common complications were
Fifty-four patients were treated with antibiotics
without anticoagulation. Chronic PVT at presenta-
tion occurred in 4 cases (7.4%) [9,13,31,71,87,88].
On admission, thrombosis of the SMV was observed
in 16 cases (29.6%) [18,21,26,29,30,33,39,46,48,
57,58,70,71,85,87] and bowel ischemia in 2 (9.3%)
[88]. During follow-up, complete recanalization
was reported in 8 patients (14.8%) [6,21,22,26,35,
48,77,85], whereas there was no recanalization
in 12 (22.2%) [30,32,34,42,48,59,61,75,78,80,90].
However, improvement was recognized in 34 cases
(62.9%) [9,11,13,18,29,31,33,36,41,44,46,51,56 58,
68 72,77,79,82,87 90]. Portal cavernoma forma-
tion was stated in 9 patients (16.7%) [11,13,18,
24,29,68,69,87] (2 had carvernoma on admission
[13,87]). Portal hypertension was stated in 6 patients
(11.1%) [9,11,24,31,71] (3 already had gastric/
oesophageal varices on admission [9,31,71]). No
patient with endoscopic fi ndings of varices had any
episode of bleeding. Comparison of the 2 groups,
with and without anticoagulation, showed a favour-
able outcome for the former (Table VI).
Analysis of the cases with complete recanalization
(18 cases) [5 6,10,12,15,21 23,26,35,37,48,52,54,
55,76,84,85] showed that all cases were reported
after 1986 and that 66.7% were from 2001 onwards
[5,6,10,12,15,26,35,37,52,54,55]. Ten patients were
adults and 8 were children [5,6,10,12,15,21 23].
The disease was diagnosed promptly following
admission (mean time to diagnosis 2.8 days). Seven
patients had appendicitis as the underlying focus
of infection [5,6,10,12,15,22,23], 6 diverticulitis
[26,37,48,52,54,55], 2 gastric ulcers [35,85], and
the remaining 3 various aetiologies. The disease was
rather severe, since 11 of them had thrombosis of the
SMV (61%) [5,10,15,21,23,26,37,48,54,84,85] and
7 had liver abscesses (39%) [6,10,12,22,48,54].
Analysis of 100 case reports in the literature demon-
strated that pylephlebitis may present at any age,
from neonates to adults. The clinical manifestations
of pylephlebitis were non-specifi c and most patients
experienced abdominal pain and fever. Laboratory
tests were also non-specifi c and the most common
ndings were leukocytosis, anaemia and abnormal
liver function tests.
Most of the case reports described patients
diagnosed in recent years as a result of newer more
sensitive imaging techniques. It is of note that the
number of cases reported during the last decade was
equal to that reported in the previous 3 decades.
In addition, it is evident that before 1985, an impor-
tant number of cases were diagnosed by autopsy.
Ultrasound and CT were the most frequently used
Downloaded by [Alexandra Alexopoulou] at 09:06 15 August 2015
Pylephlebitis: A literature review 809
Declaration of interest: No confl ict of interest.
No fi nancial support was received.
Chirinos JA, Garcia J, Alcaide ML, Toledo G, Baracco GJ, [1]
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27:584 8.
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extension of thrombosis involving the SMV, the
intrahepatic branches of the PV and the splenic
vein, and the formation of liver abscesses. The most
common causes of death were sepsis and/or perito-
nitis. The majority of patients with the worst out-
come had a severe underlying condition such as
diabetes mellitus or immunosuppression. The pre-
cipitating focus of infection did not appear to play
a role in the disease severity, since almost half of
the patients who died had diverticulitis, which was
found to be the most common aetiology in the total
cases studied. All of the patients who died were
considered to have acute pylephlebitis. However, the
outcome of this condition has improved recently
since the majority of cases (75%) died before 1990,
while only 25% died following that date [48,50,
75,90,92]. Modern imaging techniques may facili-
tate an early diagnosis and have the ability to identify
the underlying focus of infection in the abdomen or
pelvis. In addition, the wide use of broad-spectrum
antibiotics and early anticoagulant therapy may
account for the improved outcome.
The aim of anticoagulant treatment is to reverse
or prevent progression of thrombosis and treat com-
plications of established PVT. Early anticoagulation
in mesenteric and portal vein thrombosis is consid-
ered to minimize serious complications such as
bowel ischemia and infarction. A rather benefi cial
effect of anticoagulation therapy was observed in
the cases studied. Although more severe disease
with a high rate of SMV thrombosis was evident in
cases who received anticoagulation treatment, an
improved outcome was observed with a higher reca-
nalization rate, lower mortality and lower rate of
development of portal hypertension or cavernoma
formation. On the other hand, cases treated with
antibiotics alone, without coagulation, experienced
a higher rate of failure of recanalization and mortal-
ity. Finally, surgical thrombectomy was associated
with recurrence of thrombosis, surgical morbidity
and mortality and was ineffective in cases presented
in this review [10,19,87].
Aetiology and severity of the disease did not
appear to play any role in the rate of recanalization,
since recanalization occurred in cases with any kind
of local aetiology and in rather severe disease. How-
ever, the vast majority of recanalization cases were
the most recently reported and the most promptly
diagnosed and treated.
In conclusion, pylephlebitis is a serious condition
with signifi cant morbidity and mortality that can
complicate intra-abdominal sepsis of any aetiology.
Early diagnosis of pylephlebitis and management of
predisposing intra-abdominal infections followed by
combined antibiotic and anticoagulant therapy are
the most important factors for recanalization.
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... Blood cultures are useful, as the infection is often complicated by bacteremia (1,2). Several case series have reported that the causative organisms commonly implicated were Escherichia coli, Bacteroides spp., and viridans streptococci (1,2,7). To our knowledge, however, there have been no reports of pylephlebitis caused by Bacillus species. ...
... A recent retrospective-observational study reported that anticoagulation was associated with thrombus resolution and a lower complication rate of chronic portal hypertension but not with a reduced mortality rate (10). A few reports showed that early anticoagulation was associated with a reduction in mortality (3,7), while another showed no particular benefit (1). No study has examined the duration of anticoagulation. ...
... In our case, based on blood cultures, the causative organisms were B. subtilis and F. nucleatum. There have been several reports of cases with pylephlebitis caused by Fusobacterium species (7,11). To our knowledge, however, there have been no reports of a case caused by B. subtilis or other Bacillus species. ...
A 90-year-old man presented with a 3-day history of general malaise. He was febrile (39.3°C) but the initial evaluation did not reveal the cause of the fever. After admission, Bacillus subtilis and Fusobacterium nucleatum were grown from multiple sets of blood cultures. In addition, contrast-enhanced computed tomography revealed thrombi in the portal vein and superior mesenteric vein; he was diagnosed with pylephlebitis. After receiving antimicrobial treatment and anticoagulation, the patient was cured. Pylephlebitis is a rare condition and may be the cause of unknown fevers. This is the first reported case of pylephlebitis caused by Bacillus subtilis.
... Common causes include diverticulitis, appendicitis, pancreatitis, inflammatory bowel disease, and other abdominal infections. Certain procedures and risk factors such as hypercoagulable states or clotting factor deficiencies, recent abdominal surgery, malignancy, smoking, steroid use, and immobility can also trigger the condition [6]. ...
... The results of the same study revealed that bacteremia affected 88% of the patients and that Bacteroides, Gram-negative bacilli, and Streptococci were the most frequently identified microorganisms. In a retrospective assessment of the English-language literature from 1971 to 2009, 100 cases of pylephlebitis were found to have been documented [6]. ...
... Appendicitis (19%), inflammatory bowel disease (6%), and pancreatitis (5%) were also identified as frequent causes. Bacteremia was present in 60% of cases, with a single microbe found in 47% of cases and multiple bacterial organisms found in the rest [6]. No patients contained Actinomyces; the most prevalent pathogens were Bacteroides, E. coli, and Streptococci. ...
Full-text available
Pylephlebitis is a rare but serious condition caused by intra-abdominal or pelvic infections that can lead to septic thrombophlebitis of the portal veins. While laparoscopic cholecystectomy is considered a safe and effective treatment option, it is not without its risks, and pylephlebitis following this procedure is an extremely rare occurrence. Here, we present the case of a 73-year-old male who presented with lower abdominal pain for the last two weeks. He had undergone laparoscopic cholecystectomy for symptomatic cholelithiasis four weeks prior with an unremarkable follow-up. Laboratory tests revealed leukocytosis and blood culture showed Streptococcus constellatus. A CT scan revealed portal vein thrombosis causing diffuse periportal edema throughout the liver. The patient was treated with antibiotics and anticoagulation for pylephlebitis.
... We propose the most likely source of the patient's infection was his recent appendectomy. Kanellopoulou, et al. found that appendicitis is the most common cause of pylephlebitis, or infectious suppurative thrombophlebitis of the portal venous system, 14 In 2017, Jayasimhan et al. 16 conducted a systematic review finding 48 cases of hepatic abscesses associated with Fusobacterium. Ten of these cases were either confirmed or suspected to be due to a lower gastrointestinal infection. ...
... A systematic review found similar mortality rates in the "antibiotic alone" and "antibiotic plus anticoagulation" groups. 14 The same review found the mortality rate to be zero for the "anticoagulation alone" group. 14 However, the number of cases in this review is too small to make definitive recommendations. ...
Lemierre's syndrome is a rare condition characterized by Fusobacterium bacteremia from an oropharyngeal source with septic emboli causing internal jugular vein (IVJ) thrombophlebitis in an otherwise young and healthy host. Rare variants of this rare disease have been described impacting the gastrointestinal, pulmonary, neurologic, musculoskeletal, soft tissue, and genitourinary systems. We discuss a case of an abdominal variant of Lemierre's syndrome. An otherwise young and healthy male presented with two pyogenic hepatic abscesses, Fusobacterium necrophorum bacteremia, and local hepatic venous thrombosis. The hepatic abscesses were percutaneously drained, he received broad-spectrum antibiotics and therapeutic-level anticoagulation, and he showed marked clinical improvement over a six-day hospital course. He was discharged with four weeks of daily oral and intravenous (IV) antibiotics, six months of direct oral anticoagulation, and close follow up. Clinicians should consider thrombophlebitis in more anatomical locations than the IVJ which is found classically in Lemierre’s syndrome in the setting of Fusobacterium bacteremia.
... On an intravenously contrasted CT scan, thrombus involvement of the portal system can be assessed, as well as the underlying abdominal pathology [3][4][5]. If pyelephebitis is suspected radiographically, the initiation of IV antibiotics and anticoagulation should be immediate [6][7][8]. The patient should be supported with IV f luid resuscitation as needed. ...
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Pylephlebitis is a suppurative thrombus of the portal vein and/or its branches secondary to an intra-abdominal infection. Acute appendicitis is the most common cause of emergency operation in general surgery and is typically treated with antibiotics and timely appendectomy with minimal adverse outcomes (Ferris M, Quan S, Kaplan BS, et al. The global incidence of appendicitis: a systematic review of population-based studies. Ann Surg 2017;266:237–41 and Poon S, Lee J, NG KM, Chiu GWY, et al. The current management of acute uncomplicated appendicitis: should there be a change in paradigm? A systematic review of the literatures and analysis of treatment performance. WJES 2017;12:46). Unfortunately, the identification of pyelephlebitis is difficult to make due to its nonspecific clinical presentation and can result in significant morbidity or mortality if not appropriately treated. Certain laboratory derangements and positive intra-abdominal imaging combined with a high index of suspicion can make the diagnosis. Treatment involves broad-spectrum antibiotics, anticoagulation, and source control of the primary nidus of infection. Our case presentation follows the successful clinical course of a young male diagnosed with acute appendicitis complicated by pylephlebitis. He was treated with antibiotics and anticoagulation followed by interval laparoscopic appendectomy with consequential resolution of thrombus on subsequent cross-sectional imaging.
... In their series of 95 cases, the most common germ involved was Streptococcus viridans, E. coli, Bacteroides fragilis, and Streptococcus anginosus [11]. Kanellopoulou et al. also found S. viridans in their patients [19]. ...
Suppurative thrombophlebitis of the portal-mesenteric venous system occurring in the setting of abdominal inflammatory and infectious processes is a serious condition that can lead to septic shock, bowel ischemia, hepatic abscess, and death if unrecognized. Diagnosis is often delayed because symptoms are aspecific and pain at the primary site of infection may be mild. Contrast-enhanced CT scans can diagnose both portal thrombosis and a primary infection site. Treatment may include early resective surgery in case of appendicitis or diverticulitis, in association with large-spectrum antibiotics and possibly anticoagulation. A characteristic of suppurative thrombophlebitis, whether splanchnic or systemic, is the latency before the effects of antibiotic therapy are seen. Anticoagulation can be administered to avoid extension to the superior mesenteric vein. We presented a critically ill 53-year-old man with chronic colonic diverticulitis complicated by suppurative emphysematous portal-mesenteric thrombophlebitis with only a slow response to large-spectrum antibiotics.
... A review of 91 cases conducted by Choudry et al. found a lower mortality rate in patients treated with anticoagulation compared to antimicrobial therapy alone [2]. Similar findings were observed by Kanellopoulou et al. wherein on reviewing 81 cases, anticoagulation was associated with a higher rate of complete vein recanalization and a lower mortality rate [7]. ...
Pylephlebitis is a rare complication of intra-abdominal infections and has a significant mortality rate, necessitating early recognition for optimal treatment. Here, we present the case of a 36-year-old male with fever, shortness of breath, cough, and epigastric pain. He was ultimately diagnosed with hepatic vein pylephlebitis along with multiple pulmonary and hepatic lesions believed to be septic emboli and hepatic abscess. He developed recurrent bilateral pyopneumothorax which required drainage by interventional radiology multiple times. The patient improved and was discharged on intravenous antibiotics for four weeks. While hepatic abscesses are a known complication of pylephlebitis, pyopneumothorax is a rare, unreported complication. Recognition of this potential complication is important for clinicians when treating patients with hepatic vein pylephlebitis.
Pylephlebitis, a septic thrombophlebitis of the portal vein, is an uncommon but serious complication following an abdominal site of infection, most frequently diverticulitis or appendicitis. It has a high mortality rate, yet it commonly presents with unspecific abdominal complaints and fever, making diagnosis by clinical and laboratory examinations alone, impossible. This report highlights the extensive computed tomography (CT) findings of pylephlebitis with multiple hepatic abscesses thought to be secondary to diverticulitis, in a patient presenting with septic shock. Radiological characteristics differentiating the liver lesions from malignancy, and showing the ascending pathway of vascular involvement from the inferior mesenteric vein to portal veins is presented, as well as the search for the primary site of infection. Recognizing and understanding the imaging findings in pylephlebitis is crucial for diagnosis and avoiding delay of appropriate treatment for this otherwise often fatal condition.
Background: The pilephlebitis is the septic thrombophlebitis of the portal venous system ranging from asymptomatic to severe complications. Diagnosed based on imaging tests, and their treatment is based on antibiotics and anticoagulant therapy. Clinic case: 24 years male, appendectomy 12 days before. Readmission for 3 days with fever, jaundice and choluria; hyperbilirrubinemia. Intravenous contrast CT is performed, showed thrombus in portal, splenic and mesenteric vein system. Diagnosis of pylephlebitis is established, initiating managed with antibiotics and anticoagulant, with favorable clinical outcome. The pylephlebitis has an estimated incidence of 2.7 cases per year, with an unspecified clinical picture ranging from asymptomatic to severe cases with septic shock and hepatic failure. There may be accompanying fever and abdominal pain in more than 80% of the cases and presenting in some cases with leukocytosis and hyperbilirrubinemia. Intravenous contrast CT is the gold standard. The treatment is based on 4 points: Septic focus control, antibiotics, early anticoagulant and resolution of complications. Conclusions: The pylephlebitis should be taken into consideration as a possible secondary complication of intraabdominal infections. A timely diagnosis with a imaging tests and apply treatment reduce their morbidity and mortality.
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A 77-year-old male patient presented to our hospital with a chief complaint of lower abdominal pain. Plain CT on admission demonstrated peri-appendiceal and intrapelvic fluid collections with multiple diverticula in the right colon, without an identified appendix, suggesting peri-appendiceal and intrapelvic abscesses caused by appendicitis or diverticulitis. Due to the general condition being impaired, conservative antimicrobial treatment was initiated. Portal vein thrombosis was subsequently diagnosed by contrast-enhanced CT on hospital day 4, and treated with heparin and antithrombin III. The patient resumed an oral diet on hospital day 14, and anticoagulation therapy was switched to edoxaban per-oral. He was discharged on hospital day 29. Post-discharge close examination revealed no abnormality in the appendix, leading to a diagnosis of portal vein thrombosis complicating an intra-abdominal abscess caused by diverticulitis. Laparoscopic right hemicolectomy was performed 3.5 months after initial discharge, after which the patient was discharged uneventfully. There has been no evidence of exacerbation of portal vein thrombosis or any symptoms attributed to the diverticulum for 1 year after surgery. We herein present a rare case of portal vein thrombosis associated with colonic diverticulitis, for which there are limited reports of conservative treatment followed by elective surgery.
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We report a male neonate who had liver abscess that resolved with intravenous antibiotics and surgical drainage. However, the child developed complete thrombosis of portal vein with cavernous formation within 16 days of therapy and portal hypertension subsequently. The child is now 2 1/2 years and has extra hepatic portal hypertension but is otherwise asymptomatic.
Thirty-four adult patients with portomesenteric venous occlusion (PVO) were reviewed. In 11 with hepatic cirrhosis, PVO was usually heralded by worsening ascites often with varix hemorrhage; mortality was high. Four with isolated portal block had varix hemorrhage without ascites. All of these patients survived despite recurrent hematemesis when portal decompression was not feasible in two patients. Eight others (5 agnogenic and 3 with hypercoagulability), experienced sudden abdominal pain with a clot typically propagated into mesenteric tributaries with ileojejunal infarction; survival was related to the promptness of operation and the extent of bowel ischemia. Of five patients with intraabdominal sepsis and pylephlebitis, only one survived. In the final six patients, PVO occurred with intraabdominal carcinoma. Five had progressive ascites, cachexia, and an early death. Imaging techniques included plain and contrast roentgenograms, ultrasonography, and for definitive diagnosis direct portography (operative or splenoportogram), indirect portography (splanchnic arteriovenogram), and computed tomography. Thirteen of 34 patients had ascites, and in nine of 11 patients examined, protein concentration of ascitic fluid was extremely low (less than 0.6 g/dl). Clinical presentation of PVO varies, depending on acuteness and extent of visceral venous blockade, severity of portal hypertension, auxiliary venous collateralization, and regional lymph flow. Inciting factors include endothelial damage and blood hypercoagulability from trauma, infection, stagnant circulation, blood dyscrasia, and malignancy. Improved imaging now allows early diagnosis.
Septic thrombophlebitis, as a result of invasion from adjacent nonvascular infections, includes conditions such as Lemierre syndrome (internal jugular vein septic thrombophlebitis), pylephlebitis (portal vein septic thrombophlebitis), and septic thrombophlebitis of the dural sinuses and the pelvic veins. All of these conditions are associated with a very high mortality if untreated. Appropriate antibacterial therapy dramatically improves the outcome of these infections and results in a low mortality rate, with the notable exception of septic thrombophlebitis of the durai sinuses. The endovascular nature of these infections results in secondary metastatic disease, including pneumonia, endocarditis, and arthritis due to septic embolization and/or hematogenous bacterial spread. The appropriate diagnosis and management of these infections depends on a high degree of clinical suspicion, the use of imaging studies, and early initiation of empiric antibacterial therapy. In this article, we review the diagnosis and management of septic thrombophlebitis, focusing on Lemierre syndrome, pylephlebitis, and septic thrombophlebitis of the pelvic veins.
• Hepatic portal venous gas (HPVG) in the adult is usually associated with bowel necrosis. Together these have an 80% mortality. However, HPVG may occur as a result of a variety of other pathologic conditions. We studied what we believe is the second known case resulting from sigmoid diverticulitis. This patient's survival was unexpected, because bowel perforation and pathologically demonstrated septic phlebitis occurred during the patient's long-term corticosteroid therapy. (Arch Surg 1982;117:834-835)
Idiopathic pylephlebitis and primary sclerosing peritonitis are two highly unusual entities. To our knowledge, the association of the two diseases has not been described previously. We report a 42-year-old patient with a protein S deficiency who presented with fever and chills, in whom idiopathic pylephlebitis was diagnosed. A year later, the patient was readmitted because of recurrent vomiting and weight loss. An exploratory laparotomy yielded diagnosis of sclerosing peritonitis, which resolved after surgery. The short time interval between the processes suggests that they were related to each other, and also to the protein S deficiency.
Inflammatory involvement of the inferior mesenteric vein complicating sigmoid diverticulitis resulted in septic thrombophlebitis and the presence of gas within the inferior mesenteric vein. Gas within the mesenteric and portal veins is an infrequent and relatively nonfatal complication of diverticulitis and can be recognized readily on CT scan.
We describe the case of a 58-year-old man who presented to the hospital with central abdominal pain, nausea, fever, chills, and dyspnea. While in the hospital, jaundice appeared and the liver function tests revealed features of both cholestasis and hepatocellular injury. He developed gram-negative septicemia and died on the sixth hospital day. Autopsy disclosed a perforated terminal ileal diverticulum and a contiguous mesenteric abscess. These was also severe phlebitis of mesenteric venous radicles which extended superiorly to the intrahepatic portal venules and veins. The portal veins were surrounded by multiple hepatic abscesses that varied in size from microscopic to 2.5 cm. This appears to be the first report in the world literature of suppurative pylephlebitis and hepatic abscesses resulting from a perforated ileal diverticulum. The subject of small bowel non-meckelian diverticulosis is reviewed because of the rarity of this condition and the diagnostic challenges it poses.