Pileflebitis. Septic thrombophlebitis of the portal vein or some of its tributary branches, which is an infrequent complication of intra-abdominal inflammatory processes that can also be accompanied by liver abscesses. The thrombosis of the portal vein can occur outside the liver (extra-hepatic) or within the liver (intrahepatic).
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- 1 Etiology
- 2 Epidemiology
- 3 Pathogenesis and pathology
- 4 signs and symptoms
- 5 Diagnosis
- 6 Forecast
- 7 Treatment
- 8 Prevention
- 9 Sources
The intestinal flora (species of Bacteroides and other anaerobes, Escherichia coli and the enterococcal group, Streptococcus species ), usually predominate in pyelphlebitis; Staphylococcus aureus can also be detected .
The actual incidence of anaerobic bacteria has not been established, since adequate techniques for anaerobic culture were not used in most of the series studied, however, anaerobes are undoubtedly important and, apparently, participate in at least 50% of those affected with pyogenic liver abscess . However, applying adequate methods for specimen transport and correct anaerobic methodology, in two thirds of cases that provide anaerobic bacteria, anaerobes are the exclusive isolates. The most predominant anaerobes in liver abscesses are anaerobic and microaerophilic streptococci, Fusobacterium nucleatum, Bacterioides fragilis and B. melaninogenicus.
Pilephlebitis and liver abscesses are rare infections with an incidence ranging from 0.05 to 0.5% of all hospital admissions or autopsy , and it is predominantly observed in males. There is no apparent racial susceptibility. Multiple abscesses probably outnumber solitary abscesses, and the right lobe is affected much more frequently than the left.
Pathogenesis and pathology
Pilephlebitis is either secondary to suppurative disease in the tissues drained by tributaries of the portal vein or to suppuration in adjacent structures. The most common underlying causes are acute appendicitis and bile duct infections . Other causes include chronic ulcerative colistis, diverticulitis, and carcinoma of the intestine. In pylephlebitis, the portal vein and its intrahepatic radicles show an acute inflammatory reaction and frequently contain pus or thrombi.
Microscopically, an infiltration of round cells in the venous wall with leukocytes and cellular debris inside the vein is observed . Adjacent liver cells exhibit varying degrees of inflammation or degeneration. The pathology of this entity is the same as that of any abscess .
Signs and symptoms
The manifestations of pileflebitis include chills, fever , right upper quadrant or epigastric abdominal pain , nausea , vomiting , enlargement, and hypersensitivity of the liver to touch and sometimes splenomegaly . Jaundice is not constant and is usually mild when it occurs. The condition may be complicated by signs of liver abscess or acute portal vein thrombosis ( abdominal pain , ileus , vomiting , diarrhea ; perhaps later, ascites , splenomegaly, and even gastrointestinal infarction).
Fever, which is the most common manifestation in liver abscess, may be accompanied by chills and profuse sweating . The second most common manifestation is pain in the upper right quadrant of the abdomen. The pain is intense and tends to be located on the liver itself or on the epigastrium. It can radiate to the right shoulder when exacerbated by breathing . Percussion of the liver is painful. Also, a local mass below the costal margin can be palpated, or hypersensitivity and inflammation of the intercostal spaces.
Sometimes there is firm local edema of the right lateral chest wall or the adjacent abdominal wall. Anorexia , nausea, and vomiting are not usually frequent . The hepatomegaly typically it develops in Ascending and is detected in two – thirds of the cases. Weight loss and prostration are common. The jaundice is unusual and probably indicates a poor prognosis. Quite often the course is more indolent, or an indolent course can be interrupted by acute symptoms.
In pileflebitis a noticeable leukocytosis is normally observed , with a greater number of immature neutrophils. In the case of prolonged illness, anemia may ensue. Liver function tests usually give normal results, although in abscess cases, the level of alkaline phosphatase almost always appears elevated. Cultures of blood give positive results in one third to one half of cases, while probably even higher proportions would be obtained with suitable anaerobic blood cultures.
Complications arising from pileflebitis include liver abscess, peritonitis, and sepsis . Portal vein thrombosis, which occurs either quickly or slowly, and the development of portal hypertension are not frequent.
When liver abscess can be diagnosed, before the patient becomes seriously ill, mortality is relatively low. Unfortunately, many liver abscesses are first discovered at autopsy. Complications of this type of abscess include bacteremia , empyema, pneumonia , lung abscess , hepatobronchial fistula, intrapericardial rupture, peritonitis , subphrenic abscess , and metastatic abscesses in other organs .
Surgical drainage, with or without excision, is usually essential for eliminating the cause of pileflebitis. In liver abscess, the most important aspect of therapy is surgical drainage.
Liver abscesses are sometimes missed by abdominal laparotomy because of their superior to lateral location. Although it is often possible to drain a liver abscess through a transabdominal abscess route, posterior access through the 12th rib bed is generally preferable. If the liver abscess is accompanied by cholangitis, drainage through the extrahepatic bile ducts may be effective , however, effective drainage may not be possible in the case of multiple abscesses. In this circumstance, the administration of microbicides through the umbilical vein has produced improvements.
In order of importance, microbicides are secondary to surgery; however, it must be administered at a complete and systematic dose over a long period of time. Chloramphenicol is generally effective against the aerobic and anaerobic microorganisms most commonly detected in pileflebitis. The tetracycline is less active but may be useful because of the relatively high concentrations achieved in liver tissue.
Adequate medical and surgical therapeutics for infections, and other conditions that predispose to pileflebitis, will reduce the incidence of these conditions.