S5065 A Rare Case of Pylephlebitis Arising From Sigmoid Diverticulitis

Introduction: Pylephlebitis is defined as septic thrombophlebitis of the portal vein or its branches, most commonly in the presence of an intra-abdominal infection. Case Description/Methods: A 49-year-old woman with past medical history of gastroesophageal reflux and hypertension presented with epigastric pain, nausea, and vomiting. She was recently evaluated by her primary physician and treated for presumed viral gastroenteritis. Upon admission, she was febrile, had leukocytosis with neutrophilic predominance and an unremarkable physical exam. Computed tomography (CT) of her abdomen and pelvis revealed sigmoid diverticulitis with intramural abscesses, septic thrombophlebitis with occlusive left portal vein thrombosis and a left hepatic lobe abscess. Later on, she developed peritoneal signs. Repeat CT scan revealed interval worsening of the hepatic abscess, which was then drained. Culture revealed Streptococcus constellatus and Escherichia coli. Initial blood cultures grew Streptococcus constellatus. Patient was treated with ampicillin-sulbactam and discharged on amoxicillin-clavulanate. Thrombophlebitis was thought to be provoked, heparin drip was initiated, and transitioned to Eliquis with plans for 3 months of therapy. Furthermore, 8 weeks after this acute presentation, patient to undergo colonoscopy. Discussion: Septic thrombophlebitis of the portal venous system is commonly associated with intra-abdominal infections such as diverticulitis and pancreatitis. Typical presenting symptoms are fever and abdominal pain. Broad-spectrum antibiotic coverage for anaerobes and enteric flora is critical for reducing the morbidity and mortality. The use of anticoagulation in pylephlebitis remains controversial due to limited data and increased risk of bleeding. According to the American Association for the Study of Liver Diseases, in patients without cirrhosis, limited retrospective data shows concurrent use of anticoagulants leads to higher thrombus resolution and lower long-term complications of portal hypertension. It was also noted that these cases were successfully managed without a significant increase in bleeding risk. On the contrary, some similar cases with thrombus limited to the portal vein were appropriately managed without anticoagulation. It was seen that these individuals did not have an underlying hypercoagulable state or mesenteric vein involvement. Overall, the decision to use anticoagulation should be individualized to patient risk factors and comorbidities.