eP701 - Superior Mesenteric Vein Thrombosis, Liver Abscesses, and Splenic Infarcts Secondary to Acute Appendicitis: A Case Report

Purpose/Background: Approximately 45 cases of portal venous system thrombosis secondary to appendicitis have been reported in the literature from 1971 to 2023, but none have described the association of acute appendicitis with isolated Superior Mesenteric Vein (SMV) thrombosis in combination of both liver abscesses and splenic infarcts.Methods/Interventions: Data for this case report was obtained from patient’s electronic medical record.
This a healthy 26-year-old Hispanic male who presented to the emergency department with a 3-day history of right lower quadrant (RLQ) abdominal pain associated with fevers, nausea, vomiting, non-bloody diarrhea, and dark urine. On presentation, patient was normotensive, tachycardic (HR 117 bpm), and afebrile. On exam, he was jaundiced, and the abdomen was diffusely tender to palpation, worse in the RLQ, without peritonitis. Lab studies were significant for Hgb 13.0 g/dL, WBC 21.0 THOU/mcL, platelets 47 THOU/mcL, creatinine 1.36 mg/dl, total bilirubin 10.4 mg/dL, direct bilirubin 7.0 mg/dL, alkaline phosphatase 301 IU/L, ALT 51 IU/L, AST 51 IU/L, lactate 1.6 mmol/L, INR 1.2. Computerized Tomography (CT) of the abdomen/pelvis with contrast demonstrated an appendix measuring up to 12 mm with an enhancing wall and adjacent inflammation, consistent with acute appendicitis, associated with non-occlusive thrombosis of SMV, wedge-shaped areas of splenic infarcts, and hypodense areas of the liver concerning for abscesses (Figure 1). This was followed by Magnetic Resonance Imaging (MRI) of the abdomen, that confirmed two 5 mm liver abscesses. Non-operative management was elected, and patient was started on piperacillin/tazobactam and heparin drip. Additional work-up included: normal echocardiogram, negative hepatitis panel and HIV. Autoimmune investigation demonstrated positive ANA 1:80, negative anti-smooth Ab, anti-mitochondria Ab, and ceruloplasmin. Blood culture was positive for Enterobacter spp., Streptococcus spp., and Escherichia coli. After initial clinical and laboratorial improvement, patient deteriorated on hospital day 8. A repeat CT abdomen/pelvis showed increased inflammation and distention of the appendix now measuring up to 20 mm, associated with new inflammation of the cecum and terminal ileum (TI), new pelvic free fluid, progression of splenic infarcts, and persistent heterogenic liver appearance (Figure 2). On that day, patient underwent laparoscopic appendectomy. Intraoperatively, he was found to have a necrotic perforated appendix associated with an old RLQ hematoma with a significant inflammatory rind extending to the TI. A Jackson-Pratt drain was left near the staple line.Results/Outcomes: The patient recovered appropriately. On postoperative day 4 (hospital day 12) the drain was removed, and patient was discharged on a 3-month course of rivaroxaban and a 2-week course of oral ciprofloxacin/metronidazole. Pathology report demonstrated a 5.0 x 1.3 cm ruptured appendix, consistent with acute necrotizing appendicitis. On 2-week postoperative routine follow-up, patient was doing well.Conclusion/

Discussion: In this unique case of acute appendicitis complicated by isolated SMV thrombosis, hepatic abscesses, and areas of splenic infarct, the patient was successfully managed with laparoscopic appendectomy, antibiotics, and anticoagulation. Patients presenting with appendicitis associated with jaundice should raise suspicion for portal venous system septic thrombophlebitis."Figure 1

CT abdomen/pelvis on presentation.
Figure 2

Repeat CT abdomen/Pelvis"