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A case of multidrug-resistant intractable pylephlebitis and intra-abdominal abscess due to perforated appendicitis
Yu Norimatsu1, Nobuyuki Takemura2, Kaoru Yoshikawa1
1Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, National Center for Global Health and Medicine, 1-21-1 Toyama, Shinjuku-ku, Tokyo, 162-8655, Japan.
Background:
Pylephlebitis, a rare and lethal form of portal venous septic thrombophlebitis, often arises from infections in regions drained by the portal vein. Herein, we report a case of peritonitis with portal vein thrombosis due to acute severe appendicitis, managed with intensive intraperitoneal drainage via open abdominal management (OAM).
Case Presentation:
A 19-year-old male with severe appendicitis, liver abscesses, and portal vein thrombosis developed septic shock and multi-organ failure. After emergency interventions, the patient was admitted to the intensive care unit. Antibiotic treatment based on cultures revealing multidrug-resistant Escherichia coli and Bacteroides fragilis and anticoagulation therapy (using heparin and edoxaban) was initiated. Despite continuous antibiotic therapy, the laboratory results consistently showed elevated levels of inflammatory markers. On the 13th day, open abdominal irrigation was performed for infection control. Extensive intestinal edema precluded wound closure, necessitating open-abdominal management in the intensive care unit. Anticoagulation therapy was continued, and intra-abdominal washouts were performed every 5 days. On the 34th day, wound closure was achieved using the anterior rectus abdominis sheath turnover method. The patient recovered successfully and was discharged on the 81st day.
Conclusions:
Alongside appropriate antibiotic selection, early surgical drainage and OAM are invaluable. This case underscores the potential of anticoagulation therapy in facilitating safe surgical procedures.
Insights
This case report highlights the successful management of pylephlebitis, a severe portal vein septic thrombophlebitis, using open abdominal management and anticoagulation therapy. Early surgical drainage is crucial for treating complex appendicitis with portal vein thrombosis.
Area of Science:
- Abdominal Surgery
- Vascular Surgery
- Infectious Diseases
Background:
- Pylephlebitis, a rare and lethal form of portal venous septic thrombophlebitis, originates from infections drained by the portal vein.
- This case involves peritonitis with portal vein thrombosis secondary to acute severe appendicitis.
Purpose of the Study:
- To report a case of severe appendicitis with pylephlebitis managed with intensive intraperitoneal drainage via open abdominal management (OAM).
- To emphasize the role of anticoagulation therapy in managing portal vein thrombosis in this context.
Main Methods:
- A 19-year-old male with appendicitis, liver abscesses, and portal vein thrombosis presented with septic shock and multi-organ failure.
- Treatment included antibiotics for multidrug-resistant organisms, anticoagulation (heparin and edoxaban), and open abdominal management with serial irrigation.
- Wound closure was achieved on day 34 using the anterior rectus abdominis sheath turnover method.
Main Results:
- The patient received targeted antibiotic therapy and anticoagulation.
- Open abdominal management and repeated intra-abdominal washouts were performed for infection control.
- Successful recovery and discharge were achieved on day 81.
Conclusions:
- Early surgical drainage and open abdominal management (OAM) are critical for treating pylephlebitis secondary to appendicitis.
- Anticoagulation therapy can facilitate safe surgical procedures in patients with portal vein thrombosis.
- This case demonstrates the efficacy of a multidisciplinary approach in managing a life-threatening condition.
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