PMC5041373_01
A 47-year-old male presenting with a 3-month history of fever, rigors, and weight loss was diagnosed with pylephlebitis and hepatic abscess secondary to chronic appendicitis. Transverse ultrasound images of the right hepatic lobe demonstrate (a) an ill-defined mixed echogenic lesion (arrows) with few small cystic foci, and (b) a distended portal vein with no flow on color Doppler consistent with portal vein thrombosis (arrow). There are also associated small periportal collaterals consistent with cavernous transformation (asterisks).
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F1
An outpatient ultrasound showed an ill-defined mixed echogenic focus in the liver and portal vein thrombosis [Figure 1].
A 47-year-old male presenting with a 3-month history of fever, rigors, and weight loss was diagnosed with pylephlebitis and hepatic abscess secondary to chronic appendicitis. (a) Coronal, (b) axial, and (c) sagittal contrast-enhanced computed tomography images of the abdomen. (a and b) Show occlusion of the intra-hepatic portal vein with expansile hypodense material (asterisks) consistent with pylephlebitis, periportal collaterals (black arrow) consistent with cavernous transformation and an ill-defined pyogenic abscess (white arrow) with a "clustered" appearance, (c) demonstrates a dilated appendix (white arrow) with only minimal wall irregularity in the right lower quadrant as well as pylephlebitis (asterisks) within the liver.
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F2
A contrast-enhanced CT examination demonstrated multiple low attenuating lesions in the right lobe of a non-cirrhotic liver with suppurative thrombus of the portal vein [Figure 2].
A 47-year-old male presenting with 3 months history of fever, rigors, and weight loss was diagnosed with pylephlebitis and hepatic abscess secondary to chronic appendicitis. (a) Axial T2-weighted fat-suppressed magnetic resonance image: Expansion and occlusion of intra-hepatic portal vein by heterogeneous T2 hyperintense material - pylephlebitis (asterisk) which is contiguous with hepatic abscess (arrow), (b and c) axial diffusion-weighted magnetic resonance and apparent diffusion coefficient map: Restricted diffusion in pylephlebitis and hepatic abscess, (d) axial, and (e) coronal gadolinium-enhanced T1-weighted images: Hepatic abscess and pylephlebitis share a peripheral enhancement pattern with foci of linear internal vascularity, (f) coronal enhanced T1-weighted image shows a dilated appendix (black arrow) with mural hypervascularity.
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F3
Mild intra-hepatic biliary dilatation was also present due to mass effect from the abscess [Figure 3]. Furthermore, a distended retrocecal appendix with increased wall enhancement was noted on MRI [Figure 3].
A 47-year-old male presenting with a 3 months history of fever, rigors and weight loss was diagnosed with pylephlebitis and hepatic abscess secondary to chronic appendicitis. On the nuclear medicine white cell study with whole body coronal images performed at 24 h, a focus of photopenia (arrow) within the right lobe of the liver is noted corresponding to the hepatic abscess. No abnormal extrahepatic tracer accumulation was visualized to suggest an extrahepatic source for the sepsis.
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F4
The white cell scan did not show an extrahepatic source of infection [Figure 4].
A 47-year-old male presenting with a 3-month history of fever, rigors, and weight loss was diagnosed with pylephlebitis and hepatic abscess secondary to chronic appendicitis. Axial (a) and coronal, (b) contrast-enhanced computed tomography images performed after treatment with antibiotics and anticoagulation at 6-weeks show interval improvement with a decrease in the size of the hepatic abscess (black arrow) and pylephlebitis (white arrow).
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F5
A follow-up CT at 6 weeks demonstrated significant interval resolution of the pylephlebitis and hepatic abscess [Figure 5].