A case of multidrug-resistant intractable pylephlebitis and intra-abdominal abscess due to perforated appendicitis successfully treated with open abdominal management

Abstract

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.

Keywords: Acute severe appendicitis; Multidrug-resistant Bacteroides fragilis; Open abdominal management; Pylephlebitis.

Fig. 1

Contrast-enhanced CT at admission revealed a multiple bilobular ring-enhanced lesions in the liver (arrows), b a low-density area in the portal vein (arrow), c an enlarged appendix (arrow), and inflectional ascites in the right paracolic gutter (arrowheads), e and f a low-density area in the portal vein of the sagittal sections (arrowheads). CT: computed tomography

Fig. 2

CT on day 10, when CRP levels started rising again, demonstrated a an abdominal paracentesis into an intra-abdominal abscess (arrowheads). b The abscess extended to Douglas's pouch (asterisk). c and d a low-density area in the portal vein of the sagittal sections (arrowheads). CT: computed tomography; CRP: C-reactive protein

Fig. 3

Trend in the CRP and T-Bil levels, drugs administered (catecholamine, sedation, and antibiotics), and medical events during the hospitalization. A/S: ampicillin/sulbactam; B. fragilis: Bacteroides fragilis; CEZ: cefazolin; CTRX: ceftriaxone; CMZ: cefmetazole; CRP: C-reactive protein; ECMO: extracorporeal membrane oxygenation; MEPM: meropenem; NA: Noradrenaline; T-Bil: total bilirubin

Fig. 4

Intraoperative photographs. a On day 13, open abdominal cavity irrigation was performed. b During the laparotomy, the tissues were found to be highly hemorrhagic. c–e On day 34, the wound was closed using the anterior rectus abdominis sheath turnover technique with a relief incision

Fig. 5

Abdominal CT image after discharge. CT findings demonstrated a the resolution of liver abscesses, portal vein thrombus (arrow), and b the intra-abdominal abscess. CT: computed tomography