Hospital: Complejo Hospitalario de Navarra.
Nº: C2019-601
Aut@r o Autores: G. Unzue, M.P. Lorente, P. Lopez, N. Alberdi, L. De Llano, B. Alvarez.
Presentación
54 years old man came to the emergency department with 37º fever the last 6 days and shivering. Previous treatment included metmorfin, ibuprofen and paracetamol. Physical exploration revealed minimal abdominal pain in the left lower quadrant. No peritoneal irritation signs were observed. Chemistry showed leukocytosis and neutrophilia. To begin with, ultrasound exam was performed in our radiology department. Left lower quadrant exploration highlighted big bowel wall thickening, surrounding fat hyperecogenicity, free fluid and several diverticula. IVC CT scan was performed to confirm the findigs. Inflammatory changes and several diverticula were showed in the left lower quadrant. No surrounding collections or free air were appreciated. Thus, several, free air bubbles were observed along the inferior mesenteric vein pathway. Finally, inflammatory changes consisting in free fluid and fat stranding, were shown around the vein. Acute diverticulitis complicated with septic tromboflebitis of the inferior mesenteric vein was the final diagnosis.
Discusión
Pylephlebitis is defined as serious septic thrombophlebitis of the portal vein or one of its tributaries. It usually develops secondary to infection in the drainage of the portal venous system The exact incidente of IMV thrombophlebitis is unknown. Since the routine administration of antibiotics and early surgical intervention, the incidence of ascending infections portal thrombophlebitis has dropped to 0.05 %. Clinical features are non-specific. High fever, chills, malaise and abdominal pain are initial clinical manifestations. Laboratory findings are usually non-specific and they include leukocytosis and neutrophilia. Imaging techniques help the early diagnosis of acute phase pylephlebitis. IVC CT scan can simultaneously detect the primary source of infection, extent of pylephlebitis and intrahepatic abnormalities such as liver abscess. The principal treatment is to remove the source of infection and eradicate the toxic microorganisms using appropriate antibiotics. Anticoagulant therapy is essential.The optimum duration of anticoagulation is unclear in the literature.
Conclusión
Inferior mesenteric venous thrombophlebitis is a rare and potentially fatal complication of acute intraabdominal infection. A high index of suspicion is required to allow prompt recognition and treatment. IVC CT Scan is essential to detect the primary source of infection and the extent of pylephlebitis.
Bibliografía
- Duran R, Denys AL, Letovanec I, Meuli RA, Schmidt S. Multidetector CT Features of Mesenteric Vein Thrombosis. Radiographics 2012, 32(5):1503-22 - Karam MM, Abdalla MF, Bedair S. Isolated superior mesenteric venous thrombophlebitis with acute appendicit