Acute Appendicitis Complicated by Pylephlebitis: A Case Report

Pylephlebitis is defined as septic thrombophlebitis of the portal vein. It is a rare but serious complication of an intraabdominal infection, more commonly diverticulitis and appendicitis. It has an unspecific clinical presentation and the diagnosis is difficult. The authors report a case of a 21-year-old man with acute appendicitis complicated by pylephlebitis. The diagnosis was made with contrast enhanced CT. 1. Introduction Pylephlebitis refers to infective suppurative thrombosis of the portal vein. It represents a rare but serious complication of an intraabdominal inflammatory process [1]. The diagnosis is difficult due to its nonspecific clinical presentation. Mortality and morbidity remain elevated, because it may be complicated by hepatic abscesses or mesenteric veins occlusion, leading to bowel ischemia and infarction [2]. However, if a prompt diagnosis is achieved, it can be treated with early and aggressive interventions. The case presented here documents the CT findings of a case of acute appendicitis complicated by superior mesenteric and portal vein thrombophlebitis. 2. Case Report A 20-year-old Caucasian male, previously healthy, presented to our hospital with a 10-day history of abdominal pain, more intense in the right lower quadrant. He complained from fever and worsening of the pain in the last 3 days. He denied bloody stools, nausea, or vomiting. The only relevant finding on the physical examination was tenderness in the right lower quadrant. Initial laboratory tests showed increased white blood cell counts (18.97 × 109/L) and increased C-reactive protein (306.2？mg/L). Liver enzyme levels were elevated (aspartate aminotransferase—58？IU/L; alanine aminotransferase—59？IU/L; gamma-glutamyltransferase—169？IU/L; alkaline phosphatase—127？IU/L). Abdominal and pelvic contrast-enhanced CT study was performed. It revealed a dilated, hyperenhancing appendix, with surrounding mesenteric densification, indicative of acute appendicitis (Figure 1). There was an acute thrombus distending the lumen of the superior mesenteric vein and its tributaries, with inflammatory changes in the surrounding fat (Figure 2). There was also portal vein thrombosis (Figure 3). Figure 1: Axial contrast-enhanced (a) and coronal reconstruction (b) CT images obtained at the level of the lower abdomen show an enlarged and thick-walled appendix (arrows), with evidence of stranding of the surrounding mesenteric fat (curved arrow in (b)). Figure 2: Axial contrast-enhanced CT images acquired at the level of the small-bowel mesentery root show nonenhancing low-attenuation