OVERVIEW
Septic portal veinitis is a purulent inflammation of the main trunk of the portal vein and its intrahepatic branches. It often coexists with multiple bacterial liver abscesses. It can occur in any donor supplied by a branch of the portal vein that has a septic lesion. The lesion may involve the main portal vein trunk or its branches, or the entire intrahepatic portal vein saphenous branch.
Etiology
The disease can be caused by septic lesions in any organ that drains a branch of the portal vein. The most common diseases are appendicitis, appendiceal abscess, abscess in the abdominal cavity, septic cholangitis, liver abscess, etc.; followed by diverticulitis of the colon and ileum, necrotizing pancreatitis, pelvic septic foci, prostate abscess, bile ducts and hemorrhoids and other post-surgical infections, gastrointestinal malignant tumors, and intra-abdominal vascular thrombosis. Infants are predominantly affected by umbilical vein infections, and appendicitis and appendiceal abscesses are most common in young adults. In the elderly, secondary infections such as biliary obstruction of different causes and malignant tumors are often the main etiology. Pathogenic bacteria are mainly gram-negative bacteria, with Escherichia coli being the most common, and anaerobic infections are also found.
Symptoms
1. Symptoms of primary disease
The disease is often secondary to a variety of conditions, such as secondary to appendiceal abscess with pressure and rebound pain in the right lower abdomen; with hepatobiliary septic disease, it may manifest as liver enlargement, pain in the liver area, and pressure and pain in the right epigastrium or Murphy’s point. There may be corresponding clinical manifestations in prostate abscess and septic infection of female genital organs.
2. Symptoms of septicemia
There are flaccid hyperthermia and chills.
3. Liver condition
The liver is enlarged with medium texture, pain and pressure in the liver area, accompanied by mild jaundice.
4. Other conditions
Abdominal muscles are tense but less pronounced due to abdominal distension caused by peritoneal irritation. ¼ have splenomegaly, and the spleen is huge when complicated by splenic phlebitis. Vomiting blood and black stools may be present due to gastrointestinal stasis. 1/5 patients have nausea, vomiting and diarrhea in the early stage of the disease. Ascites may be present in chronic liver disease.
Examination
1. Visual observation of enlarged liver
The surface is smooth and the abscess is prominent in the section; splenic vein involvement causes splenic phlebitis and splenomegaly is common; when the lesion invades the biliary tract, subphrenic, kidney, lung and brain organs, it may cause subphrenic abscess, lung and brain abscess peritonitis.
2.Histologic examination
There is purulent inflammation in the middle layer of portal vein lining and its surrounding, with thrombus and pus inside, and there may be hemorrhage if the wall of the vein is damaged.
Diagnosis
In the presence of abdominal septic infection, one should be alert to portal veinitis. The diagnosis is based on the three main symptoms of primary disease, sepsis, and hepatomegaly, combined with laboratory and imaging studies.
Differential diagnosis
In the early stage of the disease, when there is only septicemia without clinical manifestations in the liver, attention should be paid to differentiating from portal venous septicemia caused by bacterial endocarditis, osteomyelitis, mastoiditis, and so on. If typical symptoms appear, it should be differentiated from inflammatory diseases of the hepatobiliary system, such as amebic liver abscess, cholecystitis, cholecystocele, and subphrenic abscess.
Complications
Complications: (1) septicemia; (2) gastrointestinal bleeding; (3) peritonitis; (4) lung abscess.
Treatment
Once the diagnosis is confirmed, the primary lesion should be dealt with in time, and resection of the primary infected lesion or drainage of abscess is feasible, such as intrahepatic portal vein pus and hepatic abscess, percutaneous hepatic puncture and drainage is feasible. At the same time, antibiotics should be actively used, and the principle of application is early, sufficient amount, combined, in order to rapidly control the inflammation. Antibiotics need to be administered intravenously to increase the effective concentration of drugs in the blood as soon as possible. The third or second generation of cephalosporins can be used, or the use of aminoglycosides and new semi-synthetic penicillin joint application, penicillin allergy can also be used quinolones. And strengthen the systemic supportive therapy, anaerobic infections should be added with metronidazole or tinidazole.
Prognosis
If the disease can be diagnosed early, and timely and effective local lesion treatment and systemic antibiotic therapy, most of the prognosis is good. In cases with portal vein thrombotic obstruction, some cases may recanalize, or there may be dilated collateral blood flow across the portal vein obstruction to the hepatic portal, resulting in the formation of multiple reticular venous conduits in and out of the portal vein, and the development of secondary portal spongiosis. In a few cases, chronic portal phlebitis may develop as a secondary condition, which may also lead to thrombosis and calcification.