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home - Liver - Vascular Problems - Pylephlebitis Written by Dr Sebastian Zeki
Knowledge


Understands the risk of variceal bleeding as a complication of with
portal hypertension


Knows risk of variceal haemorrhage in cirrhotics who have not bled

Knows risk of bleeding related to variceal size endoscopic findings
and severity of liver dysfunction


Knows range of therapeutic options (both endoscopic and
pharmacological).

Skills
Recognises and can treat portal hypertension.
Behaviours
Manages patients with oesophageal varices with skill and
compassion

Able to convey the serious risks to patients and their relatives.

Also...

Knowledge


Recognises and shows understanding of vascular liver disease
including Budd-Chiari syndrome veno-occlusive disease and
portomesenteric venous thrombosis; understands the underlying
anatomy and physiology of these often complex conditions

Aware of need for investigation for associated myeloproliferative and
procoagulant conditions

Understands the role of anticoagulation and indications for further
intervention including TIPS surgery or transplantation

Skills
Can make careful clinical of these conditions and has
heightened awareness of liver vascular disease in differential
diagnosis

Able to make a potentially difficult diagnosis of less common variants
of vascular conditions

Behaviours
Shows ability to keep patient and relatives informed and to refer
appropriately for specialist management

Pylephlebitis

Percutaneous techniquesCatheter insertion into the portal vein with aspiration of throm-bus and/or pus has been reported.Intraportal infusion of antibiotics has also been described.Further clinical experience is required before this technique can be routinely recommended.SurgeryOnly for the cause Diagnosis Written by Dr Sebastian Zeki TreatmentAntibiotics- depending on source/ sensitivities.Anticoagulation is indicated only if there is mesenteric vein involvement or progression, or persistent fever, or hypercoagula-ble stateThe length of anticoagulation is unknown- time to recanalization unknown.There is no conclusive evidence of efficacy of thrombolytic therapy. =Portal vein thrombosis and feverImaging studiesCT to look for protal vein gas/ thrombosisUltrasoundShows PV echogenic material and can show progression/ recanalizationColor flow Doppler ultrasonography may improve diagnostic Pylephlebitis (=infective suppurative thrombosis of the portal vein) ComplicationsLiver abscess and bowel ischaemia may complicate pylephlebitis.Portal hypertension is a long term complication of pylephlebitis; sequelae of portal hypertension can include a dilated splenic vein and numerous venous collaterals in the hepatoduodenal ligament. Laboratory findings:Bacteraemia in 88 % (Bacteroides fragilis and Escherichia coli).A raised or normal WCC.3x alk phos.Usually normal/ mild increased bilirubin depending on aetiology. Clinical ManifestationsPatients usually generalised abdo pain and fever and associated features of underlying pathology.It is usually acute but can present chroni-cally. PathogenesisPylephlebitis begins with thrombophlebitis of small veins draining an area of infection (any intraabdonminal/ pelvic infection).Extension of the thrombophlebitis into larger veins leads to septic thrombophlebi-tis of the portal vein, which can extend further to involve the mesenteric veins (SMV in 1/3rd).Mesenteric vein involvement can lead to bowel ischemia, infarction and death.Most common causes are appendicitis or diverticulitis. Infection eg appendicitis or diverticulitis OutcomeOverall 20 % mortality rate

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