A 17-year-old youth from a rural background presented to a secondary hospital with a 3-week history of epigastric pain, constipation and weight loss. He had a temperature of 40°C, marked right upper quadrant tenderness and a white cell count of 21.1 ´ 109/l. The chest and abdominal radiographs were normal, but an abdominal ultrasound scan showed two small areas of low echogenicity in the left lobe of the liver consistent with abscesses (Fig. 1). The main portal vein was distended, measuring 16 mm in diameter, and contained echogenic material indicative of thrombus (Fig. 2). In the right iliac fossa there were features of an inflamed appendix, as demonstrated by an 8 mm diameter tubular, non-compressible, fluid-filled viscus, with a distal blind end and an echogenic focus filling the lumen proximally (Fig. 3). A diagnosis was made of acute appendicitis, complicated by septic thrombophlebitis of the portal vein (pylephlebitis) and pyogenic liver abscesses. Appendicectomy was performed later that day, revealing an inflamed appendix, confirmed histologically. The patient was treated with perioperative intravenous triple antibiotics and commenced on anticoagulants following surgery. Discharge was on the 10th postoperative day. Regular out-patient follow-up documented progressive decrease in the size of the portal vein thrombus and the liver abscesses. The abdominal ultrasound scan 4 months post-surgery demonstrated a completely normal upper abdome
