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Pylephlebitis: Single Institutional Retrospective Review Identifies Gaps in Traditional Approach to Diagnosis and Treatment
Mohammad Alzghari*, Mahmoud Amr, Martin D. Zielinski, Donald Jenkins
Mayo Clinic, Rochester, MN
Introduction:
Pylephlebitis, a suppurative infection of the portovenous system, has traditionally been thought to be a rare (largest case series reported has fewer than 40 patients), but highly mortal (20% or greater in most studies). The diagnosis is non-specific but inferred from the combination of acute portovenous thrombosis and an inflammatory abdominal process. Literature review identified diverticulitis as the most typical inciting event and Bacteroides sp. being the most prevalent organism. We aimed to identify the characteristics of patients with symptoms consistent with the diagnosis of pylephlebitis in our institution.
Methods:
Review of patients at our institution who developed portovenous thrombosis within 30 days of an associated intra-abdominal inflammatory process from 2002 to 2012. Patients were excluded if they were less than 18 years old, or had a histories of primary/secondary hepatobiliary malignancies, splenectomy, transjugular intrahepatic portosystemic shunt (TIPS), hepatic transplant, and chronic portovenous thrombosis. Data is presented as percentages or means ± standard deviation, as appropriate.
Results:
There were 93 patients identified (60% men) with a mean age of 57±16 years. The most common associated inflammatory processes were pancreatitis (32%), diverticulitis (18 %) and peritonitis (14%). 28 patients underwent recent abdominal exploration (30%) a mean of 29±38 days prior to diagnosis. The most commonly involved structures included the right (30%), and main portal veins (30%). Blood cultures were done for 74 patients (80%) and were positive in 33 (45%); the most common cultured organism was E. coli (26%) followed by Strep Viridans (24%). 83 patients received antibiotics (89%), 74 received anticoagulant treatment (80%), and 67 received both (72%). Thrombectomy via surgical or endovascular methods was not performed in any patient. 38 patients (41%) developed complications including; chronic thrombosis (36%) bowel ischemia (4%) and hepatic abscess (2%). The mortality rate was 9%; most (50%) died of multiple organ failure. The table below shows the differences between our results and the literature review over the past 4 decades.
Conclusion:
Pylephlebitis is an underdiagnosed complication of intra- abdominal inflammatory conditions with seemingly improving mortality over time. Our findings do not corroborate the reported literature; rather, a new patient population has been recognized. Additionally, by identifying E. coli as the most common organism, antibiotics should be tailored towards the hospital's antibiogram for this organism. Further study with therapy directed practice guideline should be studied prospectively. Differences between our results and the literature | Criteria | Our study | Literature | | Number of cases | 93 | 100 | | Time frame | 2002-2012 | 1971-2009 | | Age range/mean | 24y-88y/ 57y | 20d-77y/ 42y | | Most common causes | Pancreatitis (32%) Diverticulitis (18%) | Diverticulitis (30%) Appendicitis (19%) | | Most common microorganism | E. coli (26%) | Bacteroides sp. (27%) | | Antibiotic use | 89% | 100% | | Anticoagulant use | 80% | 35% | | Combined antibiotic and anticoagulant | 72% | 35% | | Bowel ischemia | 4% | 10% | | Mortality | 9% | 19% |
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