Portal Vein Thrombosis Resulted from Delay Diagnosis of Ruptured Appendicitis

Background: Portal vein thrombosis may result from different etiologies, and the clinical presentation is changeable. Septic thrombo-phlebitis of portal vein may be resulted from intra-abdominal inflammatory process such as appendicitis. Portal venous thrombosis accounts for a mortality rate of 5 - 20%. Early diagnosis, rapid usage of antibiotics and early anti-coagulation could decrease the complication.
Case presentation: We report a case of 63-year-old female who experienced fever and abdominal pain in right lower quadrant. She was referred to our emergency department with signs of septic shock and jaundice. Tenderness
was complained in the peri-umbilical area and right iliac fossa. Icteric sclera was also noted in in emergency department. Laboratory examination revealed a raised total leukocyte count (predominantly neutrophilic). Noncontrasted CT scan abdomen found swelling of appendix with peri-focal fatty stranding. Conservative treatment was arranged due to the suspicion of sepsis from cholangitis instead of appendicitis. Appendectomy was done 2
days after diagnosis and pathology proves the diagnosis of ruptured appendicitis. However, progressive elevation in bilirubin was noted for 2 days after operation. Abdomen CT with contrast was arranged and showed portal vein
thrombosis. Intravenous anti-coagulation was prescribed and patient was discharged eventually.
Conclusion: Symptoms of portal vein thrombosis may be diverse and atypical, so the diagnosis is often delayed. Highly clinical suspicion should keep in mind for patient with risk. This report described a rare complication of portal vein thrombosis in acute appendicitis. Once identified, broad-spectrum of antibiotics and anti-coagulation should be prescribed.