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- Tue Jul 13, 2010 10:45 pm
My lower right abdominal pain came on suddenly in March, 2010. Saw my doc after 1 week. Suspecting a smoldering appendix, he sent me for a CT scan/with contrast. Appendix, ovaries look normal, but a secondary finding of portal vein thrombosis. Don't worry, I'm told - looks like an 'old' clot, plenty of ancillary flow, and extensive blood work showed no clotting/genetic issues. Have since had abdominal and pelvic ultrasounds, colonoscopy and endoscopy....all normal. Today, pain remains, though not as severe. Moves from deep lower right, to a 'trapped gas' feeling, to upper rt. abdomen (below the ribs), and at times wraps around side to back. No fever, change in bowels, or other symptoms. IBS and diverticulitis ruled out. What could it be? Is it possible that the appendix is inflamed without showing up on the scans? Can the PVT cause this chronic pain? Doctor is stumped! Your thoughts are appreciated.
| Dr.M.Aroon kamath
- Fri Jul 16, 2010 11:24 am
Portal hypertension per-se does not cause any major abdominal symptoms.The porto-systemic anastamoses that result as a result of portal hypertension can cause severe effects such as bleeding.
Studies have shown that portal hypertension causes changes in the mucosa of the stomach, small intestine and colon(gastropathy, enteopathy and colopathy respectively).Of these, gastropathy has been thought to cause either a decrease or an increase of gastric emptying.
Infections in parts of the gastrointestinal tract drained by the portal system can result in portal pyemia and infective suppurative thrombosis of the portal vein
thrombosis(pylephlebitis). Portal vein thrombosis can be caused by many other pathologies besides pylephlebitis (perhaps excluded in your case).
Some studies indicate that there in portal vein stenosis of
< 50%, patients are often asymptomatic. If the stenosis is >80% of its diameter, symptoms of portal hypertension usually result.
Diagnosis: can be made in most instances by
Angiographically assisted CT(CT arterial portography).
Pylephlebitis appears as gas + thrombosis in portal vein
Non-visualization of the portal vein is strongly suggestive of complete occlusion.
In so far as appendicitis is concerned, skepticism still persists among many clinicians concerning the legitimacy of the entity called "chronic appendicitis". Some prefer to call it as "recurrent appendicitis".
Some of those who agree that there is such a specific entity, have proposed that Chronic appendicitis should be defined by the following:
- the patient has a history of RLQ pain of at least 3 weeks' duration without an alternative diagnosis,
- after appendectomy, the patient gets complete relief of symptoms, and
- histopathologically, the appendix shows evidence of chronic inflammation.
Chronicity is seen on histopathology as presence of lymphohistiocytic or eosinophilic infiltrates coupled with fibrosis (suggesting recurrent infection). In acute appendicitis on the other hand, one would find acute transmural (involing all layers of the wall) inflammation.
One may derive from the foregoing discussion that in your case, you perhaps did suffer an episode of acute appendicitis which led to pylephlebitis and portal vein thrombosis, which is perhaps <50% occlusion.
One of the possibilities for your continuing symptoms could well be "chronic appendicitis", which by definition, can be conclusively proven by histopathology of an appendicectomy specimen.
Your surgeon will be the best placed to diagnose and take a decision in your case.