SciELO - Scientific Electronic Library Online

vol.107 issue6Well differentiated neuroendocrine tumor of the appendix and low-grade appendiceal mucinous neoplasm presenting as a collision tumor author indexsubject indexarticles search
Home Pagealphabetic serial listing  


Services on Demand




Related links

  • On index processCited by Google
  • Have no similar articlesSimilars in SciELO
  • On index processSimilars in Google


Revista Española de Enfermedades Digestivas

Print version ISSN 1130-0108

Rev. esp. enferm. dig. vol.107 n.6 Madrid Jun. 2015




Pylephlebitis and liver abscesses secondary to acute advanced appendicitis

Pileflebitis y abscesos hepáticos secundarios a apendicitis aguda evolucionada


Key words: Appendicitis. Liver abscess. Pylephlebitis (thrombosis).

Palabras clave: Apendicitis. Absceso hepático. Pileflebitis (trombosis).


Dear Editor,

Currently, pylephlebitis (septic thrombophlebitis of the porto-mesenteric veins) and liver abscesses are exceptional complications of acute advanced appendicitis.


Case report

A 53-year-old male patient consulted our service for distension, abdominal pain and general malaise for one month. The patient was in regular general condition with fever, hypotension, pain in right hemiabdomen, and hepatomegaly. Laboratory testing revealed a leukocyte count of 33,000x106/L, dissociated cholestasis and lactic acid concentration of 43.7 mg/dL. Abdominal computed tomography (CT) showed mesenteric-portal thrombosis, multiple liver abscesses and an inflammatory process in the right iliac fossa (RIF) suggestive of acute appendicitis (Fig. 1). Antibiotic treatment with Meropenem® was started, and later switched to Ceftriaxona®-Metronidazol®, based on blood culture results (multisensitive Escherichia coli and Bacteroides fragilis). Initially, a non-surgical approach was adopted and anticoagulation with low-molecular-weight heparin treatment was administered.



During the first days, the patients developed ascitis with transnudate characteristics, negative culture and occurrence of collateral venous circulation in abdominal wall. Ascites was suspected in a context of portal thrombosis (presinusoidal) as the patient showed no signs of underlying chronic liver disease. Depletion therapy and serum albumin treatment were initiated with a good response.

Control CT revealed global radiographic improvement but no significant changes in the thrombosis.

Five weeks after admission, the patient was discharged on oral anticoagulant and amoxicillin-clavulanic acid for one month. Control CT performed at six months showed persistence of thrombosis and anticoagulation treatment was continued. The patient now receives regular follow-up at our outpatient clinic.



Although acute appendicitis is a frequent emergency (7%) (1), such advanced cases are currently exceptionally rare (2,3). Clinical diagnosis of pylephlebitis may be missed in the presence of other abdominal infections. Abdominal CT is the most reliable diagnostic tool (2,3).

Management of this condition is based on 3 principles:

1. Control of the abdominal septic focus. Although appendectomy is considered the treatment of choice for acute appendicitis (4,5), conservative management is contemplated in cases of advanced appendicitis (plastron and/or intraabdominal abscess). Some authors (6) report better results with a conservative approach. Yet the superiority of the exclusively medical conservative treatment of advanced appendicitis has not been demonstrated to date.

2. Resolution of liver abscesses with empirical intravenous antibiotics for 2 weeks (considering that E. coli and B. fragilis are frequently isolated in such cases) associated with oral antibiotics for a further 4-6 weeks (7), adjusted to antibiogram results, assessing the need for percutaneous drainage.

3. Treatment of pylephlebitis (acute portal vein thrombosis) with early anticoagulation. A recently published study (8) observed a more favourable evolution in patients who received early anticoagulation compared to those who on antibiotics only. Antibiotics associated with anticoagulant seem to accelerate the process of recanalisation (9). The rate of complete recanalisation of portal thrombosis (PT) treated with anticoagulation is 22-45% while that of partial recanalisation is 15-35% (10).

Finally, we wish to stress that the management of these patients is complex and requires multidisciplinary management.


Anna Serracant-Barrera1, Heura Llaquet-Bayo1, Jordi Sánchez-Delgado2,3,
Andreu Romaguera-Monzonis1, Blay Dalmau-Obrador2, Natàlia Bejarano-González1,
Ana María Navas-Pérez4,5, Eva Llopart-Valdor4,
Francisco Javier García-Borobia1 and Salvador Navarro-Soto1

1Department of General and Gastroenterological Surgery.
2Digestive Diseases Unit. Unit of Hepatology. Hospital de Sabadell.
Corporació Sanitària Parc Taulí. Institut Universitari Parc Taulí - Universitat Autònoma de Barcelona.
3Centro de Investigación Biomédica en Red de enfermedades hepáticas y digestivas (CIBERehd).
4Critical Care Area. Hospital de Sabadell. Corporació Sanitària Parc Taulí.
Institut Universitari Parc Taulí - Universitat Autònoma de Barcelona.
5Centro de Investigación Biomédica en Red de enfermedades respiratorias (CIBERes). Spain



1. Tellado JM, Sitges-Serra A, Barcenilla F, et al. Pautas de tratamiento antibiótico empírico de las infecciones intraabdominales. Emergencias 2005;17:221-7.         [ Links ]

2. Álvarez M, Rodrigo S, González JJ, et al. Pileflebitis tras apendicitis aguda. Rev Esp Enferm Dig 2007;99:49-60.         [ Links ]

3. Granero P, Raposo L, Moreno M, et al. Pileflebitis como complicación de apendicitis aguda. Rev Esp Enferm Dig 2010;102:144-8.         [ Links ]

4. Ruffolo C, Fiorot A, Pagura G, et al. Acute appendicitis: What is the gold standard of treatment? World J Gastroenterol 2013;19:8799-807.         [ Links ]

5. Ansaloni L, Catena F, Coccolini F, et al. Surgery versus conservative antibiotic treatment in acute appendicitis: A systematic review and meta-analysis of randomized controlled trials. Digestive Surgery 2011;28:210-21.         [ Links ]

6. Simillis C, Symeonides P, Shorthouse AJ, et al. A meta-analysis comparing conservative treatment versus acute appendectomy for complicated appendicitis (abscess or phlegmon). Surgery 2009;147:818-29.         [ Links ]

7. Reid-Lombardo KM, Khan S, Sclabas G. Hepatic cysts and liver abscess. Surg Clin North Am 2010;90:679-97.         [ Links ]

8. Kanellopoulou T, Alexopoulou A, Theodossiades G, et al. Pylephlebitis: An overview of non-cirrhotic cases and factors related to outcome. Scand J Infect Dis 2010;42:804-11.         [ Links ]

9. Hall TC, Garcea G, Metcalfe M, et al. Impact of anticoagulation on outcomes in acute non-cirrhotic and non-malignant portal vein thrombosis: A retrospective observational study. Impact of anticoagulation in acute non-cirrhotic and non-malignant portal vein thrombosis: A retrospective observational study. Hepato-Gastroenterology 2013;60:317-23.         [ Links ]

10. Tripodi A, Anstee QM, Sogaard KK. Hypercoagulability in cirrhosis: Causes and consequences. J Thromb Haemost 201;9:1715-23.         [ Links ]

Creative Commons License All the contents of this journal, except where otherwise noted, is licensed under a Creative Commons Attribution License