Acute cholecystitis complicated by pylephlebitis
Patient treated for 3 weeks for acute cholecystitis with persistent abdominal pain and fever, WBC = 17 400 cells/mm3. No history of obstructive jaundice, hypercoagulative status, trauma, or abdominal surgery.
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The gallbladder demonstrates a thick and enhancing wall, containing numerous small gallstones. The intrahepatic biliary ducts are not dilated. The diameter of the common bile duct measures 7 mm with no distal stone. The common hepatic duct shows minimal stricture.
The left portal vein and its branches are thrombosed. It appears dilated with high signal intensity on T1WI fat sat and T2WI, with no enhancement following IV contrast on arterioportal phase. The right portal vein is patent.
An increased attenuation of the left hepatic parenchyma is noted on arterioportal phase usually due to increased arterial flow to compensate the decreased portal flow.
Pylephlebitis is a septic thrombosis of the portal vein or its branches secondary to an abdominal or pelvic infection (regions that drain to the portal venous system). It is considered a serious complication with significant morbidity and mortality.
The management of pylephlebitis consists of aggressive antibiotic therapy and surgical intervention if there is an indication. The use of anticoagulation therapy remains controversial.