A 40-year-old man, 6 days after conservative management of a perforated appendix, develops high spiking fever, right upper quadrant pain, and jaundice. Ultrasound shows multiple small liver abscesses and patent ducts without stones. Blood cultures grow Escherichia coli. What is the underlying mechanism?

• A Haematogenous seeding of the liver during an episode of bacteraemic endocarditis
• B Ascending cholangitis from intermittent common bile duct obstruction
• C Suppurative pylephlebitis with septic embolisation through the portal venous system ✓
• D Direct transdiaphragmatic spread of infection through the bare area of the liver

Explanation

Portal pyaemia (suppurative pylephlebitis) is a recognised complication of appendiceal suppuration: infected thrombus in the mesoappendiceal and portal veins releases septic emboli that seed the liver, producing multiple abscesses, jaundice, and enteric organisms on culture. Ascending cholangitis requires biliary obstruction, which the ultrasound excludes. Endocarditic seeding gives large solitary lesions with different valves findings, and transdiaphragmatic spread follows subphrenic collections rather than producing multifocal abscesses with portal venous septicaemia.

Reference: Bailey and Love's Short Practice of Surgery, 27th ed.

High-yield for: NEET PGINI-CETNExTFMGEUSMLEPLABMRCP

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