In December, 2005, a 70-year-old, previously healthy, man was admitted with a 1-week history of fever and pain in the upper abdomen without nausea or vomiting. On physical examination, he was febrile (39 5degC) and had rigors; blood pressure was 90/60 mmHg, pulse was 90 bpm, and he had epigastric and right upper quadrant tenderness. Laboratory test results showed leucocytosis of ll-2x10~9/L (neutrophils 89%), normochromic normocytic anaemia (Hb 112 g/L), high erythrocyte sedimentation rate (124 mm/h) and C-reactive protein (277 mg/L), and a total bilirubin of 27.7 umol/L with a conjugated value of 15.7 umol/L. Other laboratory tests for liver function were normal. An urgent contrast-enhanced CT of the abdomen was unremarkable. We treated the patient with broad-spectrum intravenous antibiotics (imipenem and vancomycin).On the second day of admission, MRI showed thrombosis of the left branch of the portal vein (figure A), and several diverticulae and signs of diverticulitis in the left colon (figure B);no biliary dilatation was seen. On further questioning, the patient denied any symptoms of constipation, low abdominal pain, or bloody stools. Two blood cultures grew Clostridium tertium. Doppler ultrasonography confirmed the occlusion of the left portal vein branch. No evidence of varices were found on oesophagogastroduodenoscopy. Colonoscopy confirmed the presence of multiple diverticulae as well as mucosal oedema in the sigmoid colon. His fever and abdominal pain subsided on days 5 and 6 of admission, respectively. He was started on low molecular weight heparin and then switched to oral warfarin. Further laboratory tests for a hypercoagulable state were negative. He completed a 4-week course of intravenous antibiotics (imipenem and vancomycin) and a 3-month course of oral anticoagulation. Out-patient doppler ultrasonography 1 month after the initiation of anticoagulation therapy showed complete resolution of the clot. When seen for follow-up in June, 2006, the patient was in excellent health.
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