Septic Thrombophlebitis in the Portal Veins: A Case of Pylephlebitis Linked to Colo-Venous Fistula and Diverticulitis

BACKGROUND Pylephlebitis is a septic thrombosis in the portal or mesenteric venous system that occurs as a complication of an intra-abdominal inflammatory process. We present the case of a 43-year-old man with a septic thrombosis of the portal drainage area and a colo-venous fistula complicating a sigmoid diverticulitis. CASE REPORT The patient presented after collapsing at home with unspecific symptoms such as diffuse abdominal pain. On physical examination, he was tachycardic (140 beats/minute), with chills and fever to a temperature of 38.3°C. The remaining examination findings were unremarkable. Initial laboratory investigations were significant for an infection. Computed tomography (CT) with contrast of the abdomen and pelvis showed a sigmoid diverticulitis with covered perforation, forming a colo-venous fistula to the superior mesenteric vein, with gas trapped in the hepatic portal branches and a pylephlebitis of the superior mesenteric vein. An en bloc resection of the sigmoid and segmental resection of adherent ileum were performed, preserving intestinal continuity. Pylephlebitis was treated conservatively with antibiotics and anticoagulation. The patient recovered completely. CONCLUSIONS Pylephlebitis is the term used for septic thrombophlebitis of the portal veins. It is a rare but potentially fatal complication of an intra-abdominal infection, which can lead to septic shock, intestinal ischemia, or liver abscesses. The unspecific symptoms make early diagnosis difficult. Surgical removal of the inflammatory process, antibiotic therapy, and anticoagulation form the cornerstones of therapy. Although the unrestricted use of anticoagulation in pylephlebitis continues to be the subject of controversy due to conflicting results in the literature.