The
n e w e ng l a n d j o u r na l
of
m e dic i n e
Images in Clinical Medicine Lindsey R. Baden, M.D., Editor
Pylephlebitis as a Complication of Diverticulitis A
B
Fernando Bazan, M.D. Marcos Busto, M.D. Hospital del Mar Barcelona, Spain [email protected]
A
45-year-old man presented to the emergency department with a 4-day history of fever and jaundice. Initial workup revealed leukocytosis and elevated aminotransferase levels that indicated possible cholangitis. Despite broad-spectrum antibiotic therapy, the patient did not have clinical improvement. A computed tomographic scan showed acute perforated sigmoid diverticulitis (Panels A and B, arrow) and gas in the mesentery (Panels A and B, white arrowheads). In addition, there was gas in the inferior mesenteric vein extending to the splenic vein up to the origin of the portal vein (Panel A, red arrowheads), a finding that was consistent with pylephlebitis. Fat stranding around the inferior mesenteric vein, indicating inflammation, was also noted, and there were peripheral linear collections of gas in the liver. An emergency Hartmann’s procedure was performed, and the patient received antibiotic therapy against Escherichia coli, which grew on culture, with no anticoagulation therapy. He had clinical improvement and was discharged 18 days after surgery. Pylephlebitis is an infective suppurative thrombosis of the portal vein, its branches, or both and is typically associated with intraabdominal infections, such as diverticulitis, appendicitis, necrotizing pancreatitis, and inflammatory bowel diseases. Bacteroides fragilis and E. coli are the most common pathogens.
DOI: 10.1056/NEJMicm1501584 Copyright © 2015 Massachusetts Medical Society.
2270
n engl j med 373;23
nejm.org
December 3, 2015
The New England Journal of Medicine Downloaded from nejm.org on December 5, 2015. For personal use only. No other uses without permission. Copyright © 2015 Massachusetts Medical Society. All rights reserved.
n e w e ng l a n d j o u r na l
of
m e dic i n e
Images in Clinical Medicine Lindsey R. Baden, M.D., Editor
Pylephlebitis as a Complication of Diverticulitis A
B
Fernando Bazan, M.D. Marcos Busto, M.D. Hospital del Mar Barcelona, Spain [email protected]
A
45-year-old man presented to the emergency department with a 4-day history of fever and jaundice. Initial workup revealed leukocytosis and elevated aminotransferase levels that indicated possible cholangitis. Despite broad-spectrum antibiotic therapy, the patient did not have clinical improvement. A computed tomographic scan showed acute perforated sigmoid diverticulitis (Panels A and B, arrow) and gas in the mesentery (Panels A and B, white arrowheads). In addition, there was gas in the inferior mesenteric vein extending to the splenic vein up to the origin of the portal vein (Panel A, red arrowheads), a finding that was consistent with pylephlebitis. Fat stranding around the inferior mesenteric vein, indicating inflammation, was also noted, and there were peripheral linear collections of gas in the liver. An emergency Hartmann’s procedure was performed, and the patient received antibiotic therapy against Escherichia coli, which grew on culture, with no anticoagulation therapy. He had clinical improvement and was discharged 18 days after surgery. Pylephlebitis is an infective suppurative thrombosis of the portal vein, its branches, or both and is typically associated with intraabdominal infections, such as diverticulitis, appendicitis, necrotizing pancreatitis, and inflammatory bowel diseases. Bacteroides fragilis and E. coli are the most common pathogens.
DOI: 10.1056/NEJMicm1501584 Copyright © 2015 Massachusetts Medical Society.
2270
n engl j med 373;23
nejm.org
December 3, 2015
The New England Journal of Medicine Downloaded from nejm.org on December 5, 2015. For personal use only. No other uses without permission. Copyright © 2015 Massachusetts Medical Society. All rights reserved.
