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[Emergency Care Journal 2013; 9:e12] [page 33]

Pylephlebitis secondary 
to strangulated umbilical hernia
with small bowel ischemia
Ennio Bruschi,1 Giovanna Graziani,1
Maurizio Vergendo,1 Antonello Conte,2
Massimo Valentino1
1Radiology Department, Sant’Antonio
Abate Hospital; 2Surgery Department,
Sant’Antonio Abate Hospital, Tolmezzo,
Italy

Abstract

Pylephlebitis is a septic thrombophlebitis of
the portal venous system that infrequently
complicates small bowel infarction. We present
a case of pylephlebitis with portomesenteric
vein gas bubbles secondary to small bowel
ischemia caused by a strangulated umbilical
hernia, diagnosed on computed tomography
(CT) and confirmed in the operating theater.
This case is an example of the usefulness of
CT in early recognition of suggestive radiolog-
ic findings of pylephlebitis associated with
intestinal ischemia for prompt treatment of
the patient.

Introduction

We report a case of portomesenteric venous
gas combined with band-like pneumatosis, a
diagnosis based on computed tomography
(CT) evidence of both findings. We performed
an emergency laparotomy for suspected acute
bowel ischemia, which was confirmed by the
operative findings.

Case Report

A 58-year-old man came to Sant’Antonio
Abate Hospital with severe abdominal pain,
tachycardia, hypotension and hypoxia. His med-
ical history included hypertension, congestive
heart failure, atrial fibrillation, replacement of
the ascending aorta, HCV-related liver disease
and obesity. Laboratory studies revealed leuko-
cytosis (white cell count of 12.13×103/µL vs nor-
mal range 4.20-11.0×103/µL), with normal
hemoglobin level and platelet count. Liver
enzyme levels were normal. Total bilirubin level
was normal and direct bilirubin level was elevat-
ed (0.56 mg/dL vs normal range 0-0.40 mg/dL).
International normalized ratio was 10.52 (nor-
mal range 2-4.5) and C-reactive protein (CRP)
was 69 mg/L (normal range 0-5 mg/L).

Ultrasound examination, which was per-
formed in the emergency department, revealed
absence of fluid in the abdominal cavity,
although the examination was limited because
of the patient’s body type and the presence of
abundant meteorism.

Computed tomography examination, per-
formed before and after intravenous adminis-
tration of contrast media (120 mL of Ioexolo 350
mgI/mL, Omnipaque 350; Schering, Berlin-
Wedding, Germany) showed evidence of several
gas bubbles within superior mesenteric vein
and its branches diffusely extended to the intra-
hepatic portal branches (Figures 1 and 2). Signs
of pneumatosis parietalis were also demonstrat-
ed (Figures 2 and 3). In the umbilical region, a
strangulated small bowel hernia was demon-
strated, with dilatation of multiple proximal
small bowel loops (Figure 4), which showed
thickened and contrast-enhancing walls.
Diagnosis of small bowel ischemia secondary to
strangulated hernia with pylephlebitis was
made on the basis of CT findings. The patient
underwent surgical treatment with resection of
a small bowel loop and latero-lateral ileal anas-
tomosys was made. The patient gradually recov-
ered with reduction of white blood cell (WBC)
levels and CRP.

Discussion

Pylephlebitys is a septic thrombophlebitis of
the portal venous system, usually secondary to
an infection in the region drained by the portal
system or in the structures contiguous to the
portal vein. Pylephlebitis begins with throm-
bophlebitis of the small veins that drain the
infected area.1 There are a few articles that
describe the imaging presentation of pyle-
phlebitys, an infrequent but known complica-
tion of small bowel infarction.2-7 Portomesen -
teric vein gas is most commonly caused by
mesenteric ischemia but may have a variety of
other causes. Main causes of this complication
include: complicated diverticulitis, appendici-
tis, urinary infections, pelvic infections, biliary
diseases, inflammatory bowel diseases, necro-
tizing pancreatitis, infections with unknown
source (Table 1).

Primary factors that favor the development
of this pathologic entity are intestinal wall
alterations, bowel distention, and sepsis.
Although the pathogenesis of portomesenteric
venous gas and pneumatosis intestinalis in
acute bowel ischemia has not been estab-
lished, it may be related to the ulcers and rup-
tures in the continuity of the bowel wall in
necrotic mucosa where normal resistance to
intraluminal gas pressure is lost.7 Extension of
the thrombophlebitis into larger veins leads to
septic thrombophlebitis of the mesenteric
vein, which can extend further to involve the

portal vein. Symptoms and diagnostic imaging
findings of small bowel ischemia have been
described. Pylephlebitis is a severe clinical
entity, having a mortality of 11-32%. Clinical
manifestations are usually confusing, varying
from asymptomatic through minimal symp-
toms related to the primary infection site, to
acute abdomen. In the subacute form of
venous mesenteric thrombosis, patients may
have abdominal pain for days or weeks, with-
out bowel infarction. In 88% of patients there
is bacteriemia, with E. coli and B. fragilis as
the main pathogens. Liver involvement can
cause hepatomegaly, elevation of liver enzyme
levels, abscesses and jaundice. Seldom, there
is a hypercoagulable state associated.8 Imaging
findings of pylephlebitis are related to venous
involvement with presence of intravascular
thrombi or air, the primary source of infection
and intrahepatic anomalies, such as unopaci-
fied branches of the portal vein, transient
parenchymal attenuation differences and
intrahepatic abscesses.8 At CT, portal vein gas
appears as tubular areas of decreased attenua-
tion in the liver, predominantly in the left lobe.
These low-attenuation areas are caused by the
accumulation of gas in the intrahepatic portal
veins, where it is carried by centrifugal blood
to the hepatic periphery. Portal vein gas can be
visualized at conventional radiography, but
substantial amounts must be present for detec-
tion.7 The radiographic criterion for portal vein
gas is a branching area of low attenuation
extending to 2 cm of the liver capsule.3

Intrahepatic portal vein gas must be differenti-
ated from air in the biliary tree (pneumobilia).
In latter condition, the air is located centrally

Emergency Care Journal; volume 9:e12

Correspondence: Ennio Bruschi, Radiology
Department, Sant’Antonio Abate Hospital, via
Morgagni Giobatta 18, 33028 Tolmezzo, Italy.
Tel. +39.347.9904714 - Fax: +39.0433.48833.
E-mail: bruschie73@gmail.com 

Key words: pylephlebitis, strangulated umbilical
hernia, small bowel ischemia.

Contributions: the authors contributed equally.

Conflict of interests: the authors declare no
potential conflict of interests.

Received for publication: 21 March 2013.
Revision received: 29 May 2013.
Accepted for publication: 30 May 2013.

This work is licensed under a Creative Commons
Attribution 3.0 License (by-nc 3.0).

©Copyright E. Bruschi et al., 2013
Licensee PAGEPress, Italy
Emergency Care Journal 2013; 9:e12
doi:10.4081/ecj.2013.e12

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[page 34] [Emergency Care Journal 2013; 9:e12]

(i.e. it does not extend to 2 cm of the liver cap-
sule) and a confluence of air is seen in the
common hepatic duct. Pneumobilia also has a
left lobe predilection at CT due to its more ven-
tral location. Gas in the small mesenteric veins
appears as tubular or branched areas of
decreased attenuation in the mesenteric border
of the bowel. At CT, pneumatosis may manifest
with small isolated gas bubbles within an
ischemic bowel wall or as broad rims of air dis-
secting the entire bowel wall into two layers.3

The reported specificities of pneumatosis and
portal venous gas for acute bowel ischemia usu-
ally approach 100%.3 In agreement with the lit-
erature,7 not only is the presence of full-thick-
ness bowel wall necrosis, but also the extent of
transmural bowel infarction that determines
the clinical outcome of affected patients.
Computed tomography findings of pneumatosis
intestinalis and portomesenteric venous gas
due to bowel ischemia do not generally allow
prediction of transmural bowel infarction,
because they may be observed in patients with
only partial ischemic bowel wall damage. The
clinical outcome of patients with bowel
ischemia with these CT findings seems to
depend mainly on the severity and extent of
their underlying disease. Pylephlebitis remains
an entity with high morbidity and mortality, sel-
dom having subtle signs and symptoms. Still,
early recognition of suggestive radiologic find-
ings with the combination of findings of small
bowel infarction and multiple venous thrombo-
sis and/or gas bubbles in the region drained by
the portal system, thanks to modern imaging
modalities, may improve the prognosis of
patients.

Conclusions

Computed tomography findings of pneumato-
sis intestinalis and portomesenteric venous gas
due to bowel ischemia do not generally allow
prediction of transmural bowel infarction,
because they may be observed in patients with
only partial ischemic bowel wall damage. The
clinical outcome of patients with bowel ischemia
with these CT findings seems to depend mainly
on the severity and extent of their underlying
disease.6 The presence of portomesenteric
venous gas has been previously indicative of an
unfavorable clinical outcome, with a poor prog-
nosis in patients having bowel ischemia. We
agree with the theory that it is not only the pneu-
matosis, the severity of bowel ischemia and the
presence of a full-thickness bowel wall necrosis,
but also the extent of transmural bowel infarc-
tion that mainly determine the clinical outcome
of affected patients.6 However, urgent laparoto-
my is mandatory in patients at risk of ischemic
bowel, with CT findings of portomesenteric
venous gas and bandlike pneumatosis.

Case Report

Table 1. Reported causes of portomesenteric venous gas.

Necrotic bowel 
SMA syndrome
Cholangitis 
Organ transplant (liver, kidney, bone marrow)
Inflammatory bowel disease 
Bowel obstruction 
Acute suppurative cholecystitis
Graft-vs-host reaction
Peptic ulcer 
Blunt abdominal trauma 
Colonic diverticulitis 
Pulmonary disease (chronic obstructive pulmonary disease, bronchopneumonia, asthma)
Acute necrotizing pancreatitis 
Child abuse 
Colitis steroid and cytostatic therapy
Intraperitoneal tumor
Barotraumas 
Abdominal tuberculosis 
Seizures
Severe enteritis 
ERCP 
Intra-abdominal abscess
Colonoscopy
Retroperitoneal abscess
Barium enema
Gangrene
Portal phlebitis
SMA, superior mesenteric artery syndrome; ERCP, endoscopic retrograde cholangio-pancreatography.

Figure 1. Computed tomography scan.
Preliminary scout view demonstrates intra-
hepatic gas (a). Contrast material-
enhanced computed tomography scans
obtained at the top of the liver show tubu-
lar areas of decreased attenuation in the
periphery of the liver (b, c; white arrows).
These findings are consistent with the pres-
ence of gas in the intrahepatic portal veins.

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[Emergency Care Journal 2013; 9:e12] [page 35]

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Case Report

Figure 2. Contrast-enhanced computed tomog-
raphy scan showing tubular or branched areas
of decreased attenuation as expression of
mesenteric vein gas (yellow arrows).

Figure 3. Bubble-like pneumatosis in small
bowel. Enhanced computed tomography scan
showing intramural bowel gas (white arrow).

Figure 4. a) Humbilical hernia loop of the
small intestine; b) sagittal view. White
arrow in a) and b) indicates dilatation of
the upstream part of small bowel.

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