Pileflebit – the purulent inflammatory process which is followed by thrombosis of a vorotny vein and its branches. The clinical picture is not specific: temperature with a fever, belly-aches, anorexia, are possible ascites and jaundice. The gold standard of diagnostics is KT of abdominal organs; for confirmation of the diagnosis carry out the general and biochemical blood test, ultrasonography and a dopplerometriya of vessels of a liver, MRT, a survey X-ray analysis of abdominal organs. Treatment is usually conservative, the main role belongs to antibacterial and antikoagulyantny therapy, also carry out infusional and symptomatic therapy. Surgical treatment is shown only for elimination of the center of an infection (appendicitis).
Pileflebit is rather rare disease which in most cases develops against the background of an acute appendicitis, often leads to formation of abscesses in a liver and to death. Prior to the beginning of an era of a computer tomography in gastroenterology this diagnosis was established only posthumously, however today KT is the gold standard as allows to visualize trombotichesky masses in a vorotny vein prizhiznenno. Due to rather rare identification of a pileflebit of official statistics does not exist, however distinctions on age and a floor among the registered patients are not revealed. The fact that thrombosis of a vorotny vein practically never develops at patients with viral hepatitises though positive serological markers cannot exclude the diagnosis of a pileflebit is interesting.
Reasons of a pileflebit
Formation of a pileflebit requires a combination of two factors: bacteremia and thrombosis of a vorotny vein. To bacteremia can give any purulent inflammatory processes in an abdominal cavity and a small basin; to thrombosis – cirrhosis, the increased coagulability of blood, a tumor, invasive interventions on vessels and some other states.
Development of a pileflebit is promoted most often appendicitis, holangit, divertikulit. More rare as a background for its emergence the penetration of stomach ulcer and DPK, dysentery, abscesses in pararectal cellulose, an inflammation of gemorroidalny knots, phlebitis act at gynecologic pathology, nadpechenochny abscesses, abscesses in a spleen and mezenterialny lymph nodes, pancreatitis and cholecystitis, nonspecific ulcer colitis. Separately is considered pileflebit newborns, developing at infection of the umbilical rest (omfalita).
In the presence of the infection center in an abdominal cavity or a small basin of a bacterium gradually get into a blood-groove, in vessels microblood clots are formed. With blood current microorganisms are carried on the venous course of an abdominal cavity, gradually pathological process reaches the vorotny vein and its branches located in the thickness of hepatic fabric.
The inflammation in a vorotny vein is led to a thickening and an ulceration of its walls, a purulent imbibition by an endoteliya. During certain time the pristenochny or completely filling a vessel gleam trombotichesky masses is formed. Gradually blood clots decay microorganisms and also become impregnated with pus. If the inflamed vorotny vein is opened during operation, a wall its dim and muddy, and from a gleam pus is emitted.
Progressing of a pileflebit most often leads to spread of an infection on other bodies, to formation of abscesses in a liver, lungs, a brain, to development of sepsis. Formation of abscesses of intestines is possible. Most often in crops of flora from abscesses reveal colibacillus and proteas, bakteroida, streptococci, klebsiyella. Fungal flora is much less often sowed.
Symptoms of a pileflebit
Complexity of identification of a pileflebit is that its symptomatology is not specific, reflects clinic of inflammatory process in an abdominal cavity. The clinical picture of a pileflebit can sometimes mask symptoms of the main disease (for example, appendicitis). Refer weakness, intoxication, high fever with a fever to the leading signs of a pileflebit, belly-ache. Pain is most often localized in the right podreberye, the lower half of a thorax on the right, can irradiate in a back, a shovel.
When forming primary center of an infection in intestines of the patient lack of appetite, nausea, vomiting, diarrhea can disturb. Pileflebit sometimes leads to development of the portal hypertensia which is shown bleedings from a stomach and intestines, vomiting scarlet blood meleny, ascites. Formation of abscesses in a liver leads to development of jaundice.
Diagnostics of a pileflebit
All patients with pileflebity need consultation of the gastroenterologist and surgeon. Laboratory analyses reveal signs of generalized inflammatory process ( with shift to the left), and hepatic tests – increase in level of bilirubin, strengthening of activity of ShchF and GGTP. Practically at 90% of patients with pileflebity haemo culture (bacteriological crops of blood) positive.
Any of laboratory and clinical signs of a pileflebit does not allow to establish the correct diagnosis with complete certainty. Sufficient sensitivity for verification of a pileflebit only such methods of a research as ultrasonography, a dopplerometriya of vessels of a liver, MPT, KT of abdominal organs and hepatic veins have. Advantage of a computer tomography is the possibility of identification of primary center of an infection. The survey X-ray analysis is carried out only for the differential diagnosis according to indications.
To differentiate pileflebit follows with thrombosis of a vorotny vein without inflammation, liver abscess, Badda-Kiari's syndrome (a lightning current), cholecystitis, holangity, thrombosis of bryzheechny arteries and zabryushinny veins, sepsis, shistosomozy, typhus.
Treatment of a pileflebit
The main direction of treatment at a pileflebita is antibacterial therapy. The antibiotics of a broad spectrum of activity capable to influence the most probable source of an infection are appointed. Medicines of a piperatsillin, tsefalosporina of the third generation are most often applied. Some authors suggest to inject antibacterial drugs through the catheter established in an umbilical vein or a chrevny trunk, however the evidence of bigger efficiency of this technique is not obtained.
The combination of antibacterial therapy to anticoagulants is much more effective, than monotherapy by antibiotics. Usually begin treatment with low-molecular medicines of heparin, in the subsequent transition to oral forms of medicines is possible. According to indications carry out symptomatic and dezintoksikatsionny therapy, parenteral food.
Surgical intervention is necessary for elimination of primary center of an infection (an appendektomiya, a holetsistektomiya). Earlier for patients with appendicitis the technique of surgery during which bandaging of a.ileocolica at emergence of the first symptoms of a pileflebit was made was offered, however this operation did not receive practical application.
Forecast and prevention of a pileflebit
The forecast at a pileflebita alerted though with introduction to practice of a computer tomography and MRT the lethality managed to be lowered from 90% to 40%. Prevention of a pileflebit consists in timely treatment of inflammatory diseases of an abdominal cavity and small pelvis, accurate performance of operations and invasive researches on vessels. It is known what after an appendektomiya pileflebit accepts a lightning current, often leads to a lethal outcome. For this reason on operation for removal gangrenozno of the changed worm-shaped shoot it is necessary to examine attentively vessels of its bryzheyka in due time to reveal thrombosis of bryzheechny veins and spread of an infection on a vorotny vein.