Abdominal pain secondary to pylephlebitis: an uncommon disease of the portal venous system, treated with local thrombolytic therapy.

Pylephlebitis is a rare complication of intra-abdominal inflammatory processes that carries an elevated mortality rate. Even in the modern era, diagnosis and treatment are difficult because of the nonspecific nature of clinical signs and symptoms, as well as laboratory tests. We present a patient with pylephlebitis who had rapid resolution of symptoms after administration of t-PA. With a high index of suspicion, improved imaging and interventional radiology techniques, the outcome of this uncommon entity can be improved. A 59-year-old male presented with generalized malaise, chills, 30-pound weight loss and diffuse abdominal pain. Concurrent medical problems included diabetes mellitus and hypertension that were treated with pioglitazone, metformin and atenolol. Vital signs on initial evaluation were, temperature of 100.3[degrees]F, heart rate 83, BP 116/68 and pain score of 9/10 on a 0-10 scale. The abdomen was distended, tender to deep palpation and hepatosplenomegaly was noted. Laboratory data revealed WBC of 12.900, blood glucose of 500 mg/dl, minimal elevations of AST, ALT and ALP. CT scan of abdomen with contrast showed almost complete occlusion of the portal vein with 10% forward flow; diffuse thrombosis of mesenteric veins, hepatosplenomegaly and thickening of the sigmoid colon. The patient was started on aztreonam and piperacillin/tazobactam. Blood cultures grew Bacteroides fragilis and antibiotics were changed to metronidazole. Abdominal pain continued and local thrombolytic therapy (t-PA) was initiated with 10 mg bolus followed by a tapering over the next 24 hours via the superior mesenteric artery. After the procedure his symptoms resolved. A repeat angiogram and CT scan of the abdomen showed resolution of the thrombus and recanalization of the veins. He underwent colonoscopy, which showed extensive diverticulosis and on biopsy nonspecific colitis. Pylephlebitis can complicate any intra-abdominal or pelvic infection that occurs in the region drained by the portal venous system, especially diverticulitis and appendicitis. Unfavorable outcomes from overwhelming sepsis, hepatic abscesses and portal hypertension are common. The infection is usually polymicrobial and although antibiotics constitute the major treatment modality, there is scant literature regarding use thrombolytics. Our case supports the use of t-PA in this disease. As in our patient, use of local thrombolytic therapy should be considered if there is evidence disease progression or lack of resolution despite the antibiotic treatment. In conclusion, high index of suspicion, appropriate antibiotic choice and local thrombolytic infusion may lead to improved outcomes.

Khalil A. Amir, Ravi Bobba, Ratnakara Sherigar, Narain Srinivas, and Edward Arsura. Department of Internal Medicine, University of Virginia, Roanoke-Salem Program, Veterans Affairs Medical Center, Salem, VA.