[Pylephlebitis with air in the portal vein system. An unusual focus in a patient with sepsis].
METHODS
A 30-year-old male was transferred to the intensive care unit with worsening sepsis of unknown origin and a known history of Crohn's disease. The patient presented with a five-day history of nausea, fever, and serous diarrhea. Clinical examination of the abdomen was unremarkable except for mild epigastric pain on palpation.


METHODS
Computed tomography (CT) of the abdomen revealed gas within the intrahepatic branches of the portal venous system, thickening of the wall of the neoterminal ileum, and mild ascites. In addition, ultrasonography showed acute thrombosis of the portal vein and the superior mesenteric vein. No wall perfusion was seen in either the neoterminal ileum or the ascending colon on color Doppler sonography.


METHODS
Based on the combination of portal vein thrombosis along with venous gas in the portal venous system and absence of intestinal perfusion, the diagnosis of pylephlebitis with septic shock was suspected and a laparotomy was performed. Intraoperative exploration revealed phlegmonous terminal ileitis, a significant amount of cloudy fluid, and thrombosis of the mesenteric vein. A right-sided hemicolectomy with ileotransversostomy was performed. Histologic examination confirmed Crohn's disease that was associated with vasculitis and, in particular, with thrombophlebitis and subsequent transmural bowel necrosis. Antibiotic and anticoagulation therapy was resumed without further complications.


CONCLUSIONS
In the differential diagnosis of sepsis, especially in combination with abdominal pain or gas in the portal venous system, pylephlebitis should be taken into account. Because of the high mortality, immediate further diagnostic testing and appropriate therapy of this rare diagnosis are necessary.
Kluge
S
S
Zentrum für Innere Medizin, Medizinische Klinik I (Direktor: Prof. Dr. H. Greten).
Hahn
K E
KE
Lund
C H
CH
Gocht
A
A
Kreymann
G
G
D000328:Adult; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D000890:Anti-Infective Agents / Q000627:therapeutic use; D000925:Anticoagulants / Q000627:therapeutic use; D002439:Cefotaxime / Q000627:therapeutic use; D003424:Crohn Disease / Q000150:complications* / Q000473:pathology / Q000601:surgery; D003937:Diagnosis, Differential; D004618:Embolism, Air / Q000000981:diagnostic imaging*; D006493:Heparin / Q000627:therapeutic use; D006801:Humans; D008297:Male; D008642:Mesenteric Veins / Q000000981:diagnostic imaging / Q000473:pathology; D008795:Metronidazole / Q000627:therapeutic use; D010689:Phlebitis / Q000175:diagnosis* / Q000209:etiology / Q000628:therapy; D011169:Portal Vein / Q000000981:diagnostic imaging; D011859:Radiography; D012772:Shock, Septic / Q000150:complications / Q000175:diagnosis* / Q000628:therapy; D013927:Thrombosis / Q000000981:diagnostic imaging* / Q000209:etiology / Q000628:therapy; D014463:Ultrasonography
D000900:Anti-Bacterial Agents; D000890:Anti-Infective Agents; D000925:Anticoagulants; D008795:Metronidazole; D006493:Heparin; D002439:Cefotaxime