Pylephlebitis and liver abscess mimicking hepatocellular carcinoma

To characterize the clinical and radiographic findings in patients with pylephlebitis and liver abscess with an emphasis on the findings that help to differentiate this disorder from portal vein occlusion associated with hepatocellular carcinoma.

We analyzed the clinical findings and radiographic images of four patients with pylephlebitis and liver abscess(es) who had been misdiagnosed as having hepatocellular carcinoma with portal vein thrombosis. Their medical records were reviewed in terms of clinical presentation, physical findings, laboratory data, treatment, and follow up.

All patients undergoing color duplex ultrasonography had an echogenic thrombus within an expanded portal vein with negative color-flow findings within the thrombus. Contrast enhanced CT in all the patients demonstrated portal vein thrombosis associated with "liver masses". An intra-abdominal site of infection responsible for the subsequent ascending infection of the portal vein and liver was not identified in any patient on initial CT scan. At presentation, all patients were febrile and three of them had an elevated white blood cell count as well. All patients showed abnormalities of liver function.

Liver abscess(es) associated with pylephlebitis may mimic hepatocellular carcinoma with portal vein thrombosis. Clinical features that help to distinguish the two entities include presence or absence of fever, elevated white blood cell count, elevated alpha-fetoprotein, cirrhosis, and risk factors for hepatocellular carcinoma.