A Salazar

AP Liappis

Belen Beltrán

D Hazzan

Guillermo Bastida

Jose Luis Grueso

Julio Grueso

JW Baddley

JY Tung

M Margalit

Mariam Aguas

N Vakil

P Sanghavi

P Singh

Pilar Nos

R Saxena

R Sherigar

RM Plemmons

S Narayanan

T Zoepf

W Miehsler

BMC Gastroenterology

English

PubMed

Crossref

BioMed CentralBMC Gastroenterology
ssOpen AcceCase report
Septic thrombophlebitis of the superior mesenteric vein and 
multiple liver abscesses in a patient with Crohn's disease at onset
Mariam Aguas*, Guillermo Bastida, Pilar Nos, Belen Beltrán, 
Jose Luis Grueso and Julio Ponce
Address: Gastroenterology Department, Hospital La Fe, Avenida Campanar, 21. 46009 Valencia, Spain
Email: Mariam Aguas* - aguas_mar@gva.es; Guillermo Bastida - gbastidap@sepd.org; Pilar Nos - pnosm@meditex.es; 
Belen Beltrán - beltran_belen@yahoo.es; Jose Luis Grueso - aguas_mar@gva.es; Julio Ponce - ponce_jul@gva.es
* Corresponding author    
Abstract
Background: Portal-mesenteric vein thrombosis, pylephlebitis and liver abscesses are rare
complications of inflammatory bowel disease (IBD). The purpose of this case report is to relate an
unusual presentation of CD in order to show how conservative treatment could be an appropriate
option as a bridge to the surgery, in patients with septic thrombophlebitis and multiple liver
abscesses with CD.
Case presentation: We report a case of a 25-year-old man with Crohn's disease (CD) who
developed a superior mesenteric venous thrombosis, multiple liver abscesses and pylephlebitis,
diagnosed through abdominal ultrasound and an abdominal computed tomography (CT) scan. The
patient was successfully treated with conservative treatment consisting of intravenous antibiotics,
subcutaneous anticoagulation and percutaneous catheter drainage of liver abscesses.
Conclusion: We reported an unnusual case of pylephlebitis in CD. Until now this association has
not been reported in adult patients at onset. We hypothesise that the infection developed as a
result of mucosal disease and predisposed by corticoid therapy. Adequated management was
discussed.
Case presentation
A 25-year-old white male smoker patient was admitted to
our hospital due to fever and right lower quadrant
abdominal pain. Six years previously he suffered from
perianal fistulas and underwent perianal surgery includ-
ing drainage and fistulectomy. Two years later CD of the
terminal ileum was diagnosed with an upper gastrointes-
tinal barium contrast study and an endoscopic examina-
tion (colonoscopy with multiple biopsies). The patient
was treated with mesalazine and was in clinical remission
most of the time, except for occasional episodes of mild
watery diarrhea without fever.
Two months prior to admission the patient had visited the
outpatient clinic with abdominal pain and diarrhoea. A
physical examination revealed a palpable mass in the
right lower quadrant and laboratory analysis showed ele-
vation of acute phase reactants. A gastrointestinal barium
contrast was performed and confirmed the presence of a
stenosis in the terminal ileum. The patient was treated
Published: 12 June 2007
BMC Gastroenterology 2007, 7:22 doi:10.1186/1471-230X-7-22
Received: 5 September 2006
Accepted: 12 June 2007
This article is available from: http://www.biomedcentral.com/1471-230X/7/22
© 2007 Aguas et al; licensee BioMed Central Ltd. 
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), 
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.Page 1 of 4
(page number not for citation purposes)
BMC Gastroenterology 2007, 7:22 http://www.biomedcentral.com/1471-230X/7/22with oral prednisone (0.5 mg/kg followed by a standard
weaning strategy), to which he responded well.
Two months later the patient was attended to in the emer-
gency department with a seven day history of abdominal
pain, fever and malaise. At the time he was still taking 5
mg of prednisone by month per day. A physical examina-
tion showed a heart rate of 120/min, blood pressure of
130/65 mmHg and temperature of 39°C. His skin, chest
and heart were normal. The abdomen was soft, non-dis-
tended, slightly tender in the right lower quadrant and
with hypoactive bowel sounds. A rectal examination gave
a normal result. Laboratory results on admission are listed
in table 1. Thrombophilia studies were normal and
included fasting plasma levels of protein C, protein S,
anti-thrombin III, lupus anticoagulant, anti-cardiolipin
and anti-phospholipid antibodies, antinuclear antibod-
ies, and genetic testing for the factor V Leiden. Chest and
abdominal X-rays were normal. An ultrasound abdominal
examination revealed multiple hypoechoic nodular
lesions in both lobes of the liver suggestive of abscesses.
Abdominopelvic contrast-enhanced computed tomogra-
phy confirmed the existence of multiple liver abscesses
and mesenteric partial thrombosis (Figure 1, 2). The latter
finding was confirmed by abdominal ultrasound with
Doppler. Computed tomography also revealed a dilated
small bowel with several thick-walled loops of terminal
ileum and ruled out an abscess of the terminal ileum.
The patient was heparinized (sc enoxaparin 70 mg q12 h)
and treated with iv pipericillin/tazobactam 4 g q6 h and
metronidazole 500 mg q6 hr for 3 weeks. He received
total enteral nutrition and the corticosteroids were with-
drawn within the first days of treatment.
The patient underwent an ultrasound percutaneous-
guided needle aspiration and percutaneous drainage of
the largest abscess. Culture of the fluid revealed Peptostrep-
tococcus spp and Propinibacterium acnes, which were both
sensitive to the antibiotics administered. All blood cul-
tures tested negative.
Following admission, the patient's clinical evolution was
encouraging, although he was febrile until the abscesses
were drained. Follow-up angio magnetic resonance imag-
ing (MRI) on hospitalization day 20th demonstrated a
marked decrease in the size and number of liver abscesses
and no signs of thrombosis (Figure 3). After 1 month, the
patient was discharged and prescribed po amoxicillin-cla-
vulanate 2 g q12 h and metronidazole 250 mg q8 h for 4
weeks and sc enoxaparin 40 m q12 until he was operated
on 5 months later. Prior to surgical intervention, a CT scan
showed complete resolution of the liver abscesses and
recanalization of the superior mesenteric vein. The patient
underwent a surgical resection of the terminal ileum and
cecum. Pathological report confirmed the presence of
structure with no fistula. After two years follow-up the
patient remains in goog health.
Conclusion
Until now the association of pylephebitis and liver
abscesses with CD has only been reported in a paediatric
patient [1]. A reported case of a young man with pylephle-
bitis and liver abscesses associated said with CD con-
firmed was treated successfully with conservative therapy
followed by surgery.
Liver abscesses are a rare complication of IBD, and most
cases described to date have been in patients with CD [2-
4]. Although their etiology is not well known, several fac-
tors have been implicated as representing a predisposition
to developing liver abscesses. Abdominal surgery, long-
term treatment with steroids or metronidazole, inflamma-
tory and perforating diseases, fistulae and intra-abdomi-
nal abscesses and malnutrition are among those factors,
but there is a lack of evidence to support their association
with liver abscesses [2,4]. In the literature most patients
with liver abscesses have a long-standing history of IBD
although reports of CD presenting de novo with hepatic
abscess have been presented [4-6]. The only predisposing
factor in the patient whose case study we present here was
the steroid treatment he was undergoing at the time of
diagnosis.
Clinical manifestations of liver abscesses are variable, but
certain symptoms are more common, such as fever, ano-
rexia, weight loss and abdominal pain. However, their
diagnosis is often incorrect, as their clinical presentation
can resemble an exacerbation of CD.
Standard treatment of liver abscesses consists of broad
spectrum antibiotics and percutaneous drainage.
Although the hepatic abscesses were resolved with con-
servative treatment, a subsequent surgical resection of the
affected ileum is mandatory.
Thromboembolic complications of IBD are well-recog-
nized [7]. These complications can be caused by coagula-
tion abnormalities induced by inflammation or steroid
therapy [8]. Smoking has also been shown to cause mor-
phological injury in endothelial cells [9]. Other risk fac-
tors to have been associated with a thrombotic tendency
are active bowel disease, a history of clotting complica-
tions, prior abdominal surgery and sepsis, particularly in
the perioperative phase. In the present case we ruled out
an underlying hypercoagulable condition, and so it is
likely the mesenteric thrombosis was related to the CD
(bowel inflammation and steroid use).Page 2 of 4
(page number not for citation purposes)
BMC Gastroenterology 2007, 7:22 http://www.biomedcentral.com/1471-230X/7/22The combination of infection and portal-mesenteric
thrombosis can lead to the development of pylephlebitis.
Portal pylephlebitis – defined as septic thrombophebitis
of the portal vein or one of its tributaries – is an uncom-
mon complication of suppurative infections, either in the
region drained by the portal system or in strictures contig-
uous to the portal vein. Diverticulitis and appendicitis are
the most common causes of pylephlebitis, but it is also
attributed to IBD [10]. CD was first reported as a cause of
pylephlebitis in 1946. Since then, a total of six further
cases of pylephlebitis in patients with CD have been
reported, and in all but one of these cases CD was diag-
nosed prior to the development of pylephlebitis [10-12].
The clinical features of these patients have generally been
non-specific. A diagnosis of pylephlebitis should be con-
sidered in any patient with evidence of intraabdominal
infection and high grade bacteremia. Abdominal ultra-
sound with colour Doppler is crucial in establishing the
diagnosis of this condition. However, CT scan is more
sensitive than ultrasound for detecting a thrombus within
the splenic and mesenteric veins, and therefore should be
the preferred imaging technique for detecting both
thrombi and pericolonic abscesses [10]. It should be
pointed out that the detection of thrombus in the portal
vein or one of its tributaries does not necessarily indicate
septic thrombophebitis. Treatment in these circumstances
is based on a strategy of antibiotics and eradication of the
septic focus. A broad spectrum antibiotic coverage is cru-
cial, but the appropriate timing of their administration is
less clear. Given the frequency of hepatic abscesses as a
complication of pylephlebitis, and since they may not be
visualized in a CT scan (with or without drainage), a min-
imum of 6 weeks antibiotic therapy seems prudent
[13,14]. The role of anticoagulation or thrombolytic ther-
Abdominopelvic contrast-enhanced computed tomographyFigure 2
Abdominopelvic contrast-enhanced computed tomography. 
Multiple liver abscesses and mesenteric partial thrombosis.
Table 1: Laboratory findings on patient admission.
Leukocyte count × 103/μL 15.7 [4.8–10.8]
Neutrophil count × 103/μL 13.7 [1.4–5.6]
Hemoglobin in g/dL 10.9 [14–18]
Platelet count × 103/μL 457 [125–400]
Erythrocyte sedimentation rate mm/h 100 [<15]
C-reactive protein in mg/dL 479 [0–8]
Fibrinogen in mg/dl 661 [170–400]
Albumin in g/L 2.2 [3.5–5]
Alkaline phosphatase in IU/L 329 [40–130]
Gamma-glutamyl transferase in IU/L 524 [11–50]
Total bilirrubin in mg/dL 2.2 [0.1–1.1]
Direct bilirrubin in mg/dL 1.1 [0.0–0.3]
Lactate deshydrogenase in mlU/ml 710 [0–480]
Prothrombin time in seconds 15.8" [11.5–13.7]
Coagulation parameters
Protein S, protein C, anti-thrombin III Anticardiolipin antibodies Normal Negatives
Abdominopelvic contrast-enhanced computed tomographyFigure 1
Abdominopelvic contrast-enhanced computed tomography. 
Multiple liver abscesses and mesenteric partial thrombosis.Page 3 of 4
(page number not for citation purposes)
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apy in the treatment of pylephlebitis in the setting of IBD
has not been standardized, but systemic anticoagulation
for a minimum of 6 months has been recommended.
Delay in initiating the appropriate treatment can result in
unfavourable outcomes such as liver abscess formation
(as occurred in our case), complications due to portal
hypertension or venous infarction of the bowel [15].
Competing interests
The author(s) declare that they have no competing inter-
ests.
Authors' contributions
MA and GR have participated in the acquisition of data,
have written the manuscript and have given final approval
of the version to be published. Other authors have been
involved in revising the manuscript critically for impor-
tant intellectual content and have given final approval of
the version to be published.
All authors have read and approved the final manuscript.
Acknowledgements
Written consent of the case report: "Septic thrombophlebitis of the supe-
rior mesenteric vein and multiple liver abscesses in a patient with Crohn's 
disease at onset" was obtained from the patient.
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Pre-publication history
The pre-publication history for this paper can be accessed
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pub
Magnetic resonance imagingFigure 3
Magnetic resonance imaging. Decrease in the size and 
number of liver abscesses and no signs of thrombosis.Page 4 of 4
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Septic thrombophlebitis of the superior mesenteric vein and multiple liver abscesses in a patient with Crohn's disease at onset

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Crohn's Disease presenting as septic Thrombophlebitis of the portal vein (pylephlebitis): Case report and review of the literature.

Liacouras CA: Portal-Mesenteric Pylephlebitis with Hepatic Abscesses in a patient with Crohn's disease treated successfully with Anticoagulation and Antibiotics.

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Liver abscess in inflammatory bowel disease: Report of two cases and review of the literature.

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Portal vein thrombosis and multiple liver abscesses in Crohn's disease – an example for successful conservative treatment. Z Gastroenterol

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Pylephlebitis: A case report and review of outcome in the antibiotic era.

RN: Septic thrombophlebitis of the portal vein (Pylephlebitis): Diagnosis and Management in the modern era. Clin Infec Dis

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Valic E, et al.: Is inflammatory bowel disease an independent and disease specific risk factor for thromboembolism? Gut

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Septic thrombophlebitis of the superior mesenteric vein and multiple liver abscesses in a patient with Crohn's disease at onset

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