A case of malignant gastrointestinal stromal tumor of ileum with liver abscess]

Gastrointestinal stromal tumor (GIST) is an uncommon mesenchymal tumor of the gastrointestinal tract and is generally located in the stomach and small intestine. They usually present with abdominal pain, gastrointestinal bleeding, and palpable mass. Some patients present with rare symptoms that are more common in malignant GIST. Malignant GIST combined with a liver abscess has not been reported yet in the literatures. We report a case of 67-year-old woman who suffered from liver abscess combined by malignant GIST with central necrosis and fistula in the ileum. She complained of fever, chills, and abdominal pain. Abdominal CT scan showed huge liver abscess and ileal mass with air pocket. Small bowel series showed contrast material filling into the ileal GIST mass. An operation was performed and the final diagnosis was malignant GIST of the ileum with invasion into the sigmoid colon and urinary bladder.     

Tuberculous liver abscess: a case report and review of literature

Tuberculous liver abscess is rare worldwide. We report a 45-year-old man who presented with abdominal pain, fever and weight loss. Ultrasound and computed tomography of the abdomen showed multiple cystic lesions in the liver. Ultrasound guided needle aspiration revealed yellowish brownish aspirate, which was flooded with acid-fast bacilli. The abscess was drained under ultrasound guidance. Subsequent abdominal ultrasound a few days later showed resolution of the abscess cavity. He was concomitantly started on systemic antituberculous therapy. A tuberculous liver abscess has to be thought of in the differential diagnosis of liver abscesses and to consider the role of percutaneous drainage along with systemic antituberculous chemotherapy as an alternative to surgery in the management. A greater awareness of this clinical entity is required for successful treatment.     

Endoscopic removal of chicken bone that caused gastric perforation and liver abscess.

A 40-yr-old gentleman presented with abdominal pain, nausea and vomiting since 3 weeks. CT scan of the abdomen showed a liver abscess but also a bone penetrating the left lobe of the liver. A 5-cm-long chicken bone was removed endoscopically. He was discharged on day 8 and was asymptomatic 12 months later. Endoscopic retrieval of an extraluminal foreign body causing liver abscess has not been reported previously.     

Abdominal wall abscess secondary to subcapsular tubercular liver abscess.

We report a 22-year-old woman who presented with an abdominal wall lump in the right upper quadrant 15 days after starting antitubercular treatment for right pleural effusion. CT scan revealed a right liver lobe subcapsular abscess communicating vith subcutaneous tissue. Aspiration of pus revealed acid-fast bacilli. She responded to 9 months of antitubercular treatment.     

Characteristics of Undiagnosed Liver Abscesses on Initial Presentation at an Emergency Department

Liver abscesses often present with nonspecific symptoms and laboratory examination abnormalities, resulting in missed diagnoses at emergency departments (ED). The purpose of this study was to determine if there are differences in presentation and prognosis between patients in whom liver abscess is diagnosed at an ED or once the patient has been transferred to a ward. Patients with a liver abscess who were discharged from our hospital between 2005 and 2007 were retrospectively reviewed. We compared the clinical characteristics between patients with liver abscess diagnosed at an ED or in a ward. Patients with liver abscess diagnosed at an ED had more abdominal pain (73.4% vs. 42.9%, p < 0.001), longer duration of symptoms before hospitalization (5.5 days vs. 3.8 days, p = 0.034) and fewer respiratory tract symptoms (12.5% vs. 24.5%, p = 0.05). Fewer cases with abnormal chest X-rays also existed for these patients (4.7% vs. 14.7%, p = 0.048). Cases not diagnosed at ED had delayed diagnoses for 4.41 ± 3.16 days. Rates of mortality (6.3% vs. 8.2%, p = 0.740), shock (19.5% vs. 20.4%, p = 0.896), and length of hospital stay (19.6 days vs. 22.4 days, p = 0.173) were not significantly different between the patients diagnosed at an ED and those diagnosed later in a ward. Most information collected at the ED could not be used to aid diagnosis. Only abdominal pain was highly associated with liver abscess diagnosed at the ED. Undiagnosed liver abscess presented less abdominal pain and more symptoms or examination abnormalities related to infection of the respiratory and urinary tracts. Abdominal sonography should be performed more frequently at EDs to exclude liver abscess from differential diagnosis. However, further diagnosis and treatment while the patient with liver abscess is attending a ward does not affect prognosis.     

Hepatic actinomycosis: Case report and review of the literature in Japan

Hepatic actinomycosis is rare. We report an 86-year-old Japanese man with a 3-day history of high fever and anorexia who had an actinomycotic liver abscess complicated by disseminated intravascular coagulation (DIC). A definitive diagnosis was made when anActinomyces species was cultured from aspirated pus. The clinical course was satisfactory. Treatment included prompt percutaneous drainage coupled with long-term intravenous administration of high-dose minocycline and piperacillin, combined with therapy for DIC. We reviewed 11 cases in Japan ofActinomyces involving the liver, including the case reported here. In most patients, there were no predisposing factors. Common symptoms and laboratory findings included fever, abdominal pain, leukocytosis, and elevated C-reactive protein. In 6 of the 11 patients a partial hepatectomy was performed because hepatic tumor was suspected. Five patients presented with a liver abscess. Hepatic actinomycosis should be considered in the differential diagnoses of pyogenic liver abscess and space-occupying lesions of the liver.     

Resection of liver metastases from a virilizing steroid (lipoid) cell ovarian tumor

The authors report the case of a 34-year-old woman who presented liver metastases from a virilizing lipoid cell ovarian tumor. The patient complained of right upper quadrant abdominal pain, strong virilization and secondary amenorrhea. She developed hirsutism and irregular menses at the age of 23, and a salpingo-ooforectomy for a right ovarian lipoid cell tumor was performed. She was asymptomatic but 6 months before admission she presented abdominal pain. The computed tomography scan showed a large right-side hypodense liver lesion. Tumor and viral markers were normal. Serum testosterone was 7 ng/mL and the dehydroepiandrosterone was 2.5 ng/mL. A right trisegmentectomy was performed. Her recovery was uneventful, hormone levels returned to normal, and she has been asymptomatic after a follow-up of 6 months.     

Rupture of Pyogenic Liver Abscess

Objective: Our objective was to study the clinical manifestations, course, treatment, and results obtained in 23 patients with ruptured pyogcnic liver abscess and compare these findings with those of nonruptured cases. Methods: Four hundred twenty-four patients with clinical diagnoses of pyogenic liver abscess were enrolled in the study. Among these, 23 patients had ruptured pyogenic liver abscess. The clinical manifestations, incidence of septic shock, laboratory findings, concurrent diabetes mellitus, etiology of abscess, and results of the treatment were recorded. Qualitative data were analyzed by χ² test, and quantitative data were analyzed by Student's t test. Results: Except for abdominal pain and septic shock, other symptoms, such as fever, chills, and jaundice, were similar in ruptured and nonruptured groups. Laboratory findings indicated that the group with ruptured liver abscess had higher levels of bilirubin, blood glucose, and aspartate aminotransferase than the non-ruptured group. Of the patients with ruptured abscess, 14 (60.9%) had diabetes mellitus and 15 (65.2%) were cryptogenic. Klebsiella pneumoniae was the bacteria most often isolated in both blood cultures and liver aspirates. Surgical intervention—draining the abscess and cleaning the abdominal cavity—was the only means of saving the patients'lives. The overall mortality rate was higher in this group (43.5%) than in the nonruptured group (15.5%). Conclusions: Ruptured pyogenic liver abscess should be suspected if septic shock and diffuse abdominal pain are found in a patient with pyogenic liver abscess, concurrent with high levels of bilirubin. aspartate aminotransferase, and blood glucose. Surgery is the only treatment for this condition.     

An unusual cause of dyspnoea complicating right upper abdominal swelling

A middle aged, non-addict male presented with right upper abdominal pain and swelling with respiratory distress. Examination revealed central cyanosis, bipedal pitting edema with prominentyepigastric and back veins. Liver was enlarged, tender, spanned 20 cm without any splenomegaly or ascites. Other systems were clinically normal. Laboratory investigations showed polymorphonuclear leucocytosis with slightly deranged liver function. Abdominal ultrasonography showed an abscess in the right lobe of the liver with compressed inferior vena cava (IVC), middle and left hepatic veins. Arterial blood gas (ABG) documented hypoxia with orthodeoxia and air-contrast echocardiography was suggestive of an intrapulmonary shunt. A diagnosis of hepato-pulmonary syndrome (HPS) was made with near normal liver function secondary to amebic liver abscess. It reversed completely following successful treatment of the liver abscess.     

Liver abscess complicating transcatheter arterial embolization: a rare but serious complication. A retrospective study after 3878 procedures

OBJECTIVES: Liver abscess is one of the complications of transcatheter arterial embolization (TAE) for hepatocellular carcinoma. We studied the clinical features and analysed the incidence, risk factors, helpful clinical clues, culture profiles and predictive factors of post-TAE liver abscess. The influence of abscess development on the evolution of the tumour process was also studied. METHODS: We retrospectively reviewed records of 3878 TAE procedures performed over a 6 year period. RESULTS: Ten cases of liver abscess developed in nine patients (eight males and one female). The incidence was 0.26% (10 episodes/3878 procedures). The main clinical presentations included fever (91.7%), chills (50%) and abdominal pain (33.3%). All but one febrile patient presented fever in a recurrent form. The positive culture rates were 41.7% for blood and 83.3% for pus. Gram negative bacteria were found in 80% of blood cultures and 68% of pus cultures. Polymicrobial infections were encountered in 60% of the blood cultures and 70% of pus cultures. Management included antibiotics, drainage and operation. Four patients died due to the direct complications of liver abscess. One patient experienced total tumour resolution after successful treatment for liver abscess. Patients with larger liver abscesses and patients with greater age carried higher mortality rates. CONCLUSIONS: Liver abscess is a rare complication after TAE for hepatocellular carcinoma. Recurrent fevers after an initial symptom free interval should arouse suspicion of an abscess. The mortality is high and a large abscess and higher age predict an unfavourable outcome. Abscess formation can lead to complete tumour resolution.     

Ulcerative colitis occurring in the course of rheumatoid arthritis: a case successfully treated with mesalamine enema

We report a case of ulcerative colitis (UC) that occurred during the course of rheumatoid arthritis (RA). A 29-year-old woman with a 25-year history of RA was hospitalized for high fever, abdominal pain and hematochezia. Colonoscopy revealed erosive and reddish mucosa from the distal transverse colon to rectum. Histology revealed cryptitis (mainly caused by neutrophils), mild crypt abscess and goblet cell depletion. She was diagnosed with left-sided UC and treated with mesalamine enema. The abdominal symptoms and colonoscopic findings were greatly ameliorated. We conclude that the mesalamine enema was effective in this case of UC occurring during the course of RA.     

A case of gas-forming liver abscess with diabetes mellitus

A 43-year-old man was admitted to our hospital with right hypochondriac and epigastric pain. An abdominal radiograph showed a large niveau in the right subphrenic space. An abdominal CT scan demonstrated a large liver abscess (diameter, 13 cm) with gas formation. Klebsiella pneumoniae cells were isolated from the abscess, and the patient was treated with antibiotics and percutaneous drainage. It is very important to treat gas-forming liver abscess immediately, because subsequent bacteremia and septic shock are frequently noted, and the associated mortality rate is high.     

An Unusual Pathogen for a Liver Abscess in a Human Immunodeficiency Virus-Infected Individual

Pyogenic liver abscesses are rarely encountered in HIV-infected patients living outside of temperate climates and are usually polymicrobial in nature, with a majority of the pathogens arising from gastrointestinal flora. We describe the second case of a liver abscess in an HIV-positive individual that was caused by methicillin-resistant Staphylococcus aureus (MRSA), most likely due to a partially treated community-acquired MRSA skin abscess. The liver abscess was successfully managed by percutaneous drainage and intravenous antibiotics. This case underlines the ubiquitous nature of community-acquired MRSA and its possible unusual presentations in immunocompromised hosts.     

A case of Salmonella liver abscess]

Liver abscess can be caused by bacterial, parasitic, or fungal infection. Amebic abscesses are more common, but pyogenic abscesses account for three quarters of hepatic abscess in developed countries. Most common pathogens of the pyogenic liver abscess are Escherichia coli, Klebsiella pneumoniae, Bacteroides, Enterococci, Streptococci, and Staphylococci. However, liver abscess caused by Salmonella species has rarely been reported. We experienced a case of Salmonella liver abscess which improved after antibiotic therapy and percutaneous drainage. The patient was 52 years-old man who had an episode of intermittent fever, chills and epigastric pain for 2 weeks. He was diagnosed as liver cirrhosis eight years ago and diabetes three years ago. Salmonella group D, non-typhi was cultured from blood and pus from the liver respectively at the same time. With percutaneous drainage and susceptible antibiotic therapy, liver abscess decreased in size with improvements in fever and abdominal pain.     

Hepatic actinomicosis: a case report in a diabetic patient

We report the case of an Hispanic female diabetic patient admitted to our hospital complaining of progressive abdominal pain, weight loss, nausea and vomiting. Work-up included an abdominal computed tomography (CT) scan which reported a large liver mass consistent with atypical abscess. Serum alpha-fetoprotein value was normal, so a fine needle aspiration biopsy of the liver was performed and the report was consistent with an actinomycosisinduced abscess. Patient was treated with intravenous and oral amoxicillin with satisfactory clinical response.     

Acute liver failure complicating jejunojejunal intussusception presentation in a gastric bypass patient

Over 200 000 weight loss procedures are performed annually in the United States. Physicians must there-fore be cognizant of the unique array of complications associated with these procedures. We describe a case of jejunojejunal intussusception in a gastric bypass patient who presented with acute liver failure (ALF) due to acetaminophen (APAP) toxicity. Our patient is a 29 year-old female who had undergone Roux-en-Y gastric bypass surgery seven years prior. She was evaluated in the emergency department for confusion. Her family reported a 3-wk history of progressive abdominal pain and vomiting, for which she had ingested 40 acetamin-ophen/oxycodone tablets over the past 2 d. Physical examination showed icteric sclerae, a distended abdomen, and grade Ⅰencephalopathy. She fulfilled the criteria for ALF and was listed for liver transplantation. Abdominal computed tomography scan revealed a je-junojejunal intussusception. She under went emergent exploratory laparotomy and resection of the infarcted intussusceptum and the previous jejunojejunostomy. She had rapid clinical improvement, with decreasing liver enzymes and improved hepatic synthetic function. She had complete resolution of coagulopathy and encephalopathy, and was removed from the liver transplant list. She was discharged home 20 d after hospitalization with normal liver tests. This case demonstrates that acute abdominal catastrophes can potentiate liver injury in the setting of acetaminophen toxicity. Encephalopathy may obscure history and physical exam findings. This case also exemplifies the pitfalls in the management of the bariatric surgery patient and the importance of multispecialty collaboration in patients presenting with organ failure.     

Fatal amoebic liver abscess: An autopsy study

An autopsy study of 20 cases is presented. The mean age was 32 years (range: 14-45). Four cases (20%) presented with jaundice. Another four (20%) had continuous fever with abdominal pain. Six had loose motions with blood and mucus in the stools. The mean duration of illness was 7.2 days. All cases were thin and emaciated. Liver was grossly enlarged (mean weight: 2680 g). The abscess was single in all cases except one. The right lobe was involved in 15 cases, the left in four and both in one. The average size of abscess was 13 cm. The abscess had ruptured in the abdomen in 3 patients, for which laparotomy was performed. Pulmonary involvement was seen in 3 cases. Colon showed ulceration in half the patients. In 2 cases perforation was also present. No cerebral involvement was present. A number of interesting features emerged from this study. Although amoebic liver abscess is a common disease, its diagnosis can be missed due to unusual presentation. In the present study, diagnosis of viral hepatitis, carcinoma lung, bacillary dysentery and enteric fever with perforation were made, which probably contributed materially to fatal outcome.     

Clinical features in six patients with liver abscess caused by Streptococcus milleri]

Among 39 patients with pyogenic liver abscess who were admitted to our institute, six (15%) were infected by Streptococcus milleri (S. milleri). We investigated clinical features of these six patients. There were five males and one female, aged 43-81 years old (mean: 61). Five of the six patients had underlying illness. All patients had fever, and three of them complained of abdominal pain. Three patients had mixed infections; particularly intraoral anaerobes, Fusobacterium, were found in two of the three patients. There were no differences in clinical features between patients with S. milleri liver abscess and those with other bacterial liver abscess. In conclusion, on selecting antibiotics for the treatment of liver abscess, it is necessary to consider the S. milleri and intraoral anaerobes.     

A case of amebic liver abscess complicated by hemobilia due to rupture of hepatic artery aneurysm

We report the case of a 51-year-old man with hepatic amebic abscess complicated by hepatic artery aneurysm. The patient first presented with peritonitis caused by perforating appendicitis. Surgical treatment resolved peritonitis but Entamoeba histolytica was detected in the colonic mucosa. Subsequently, liver abscess developed and the size of the abscess increased gradually after surgery in spite of continued treatment with metronidazole. Brown pus was drained from the abscess but 13 days after the drainage process the patient complained of right upper abdominal pain and the drained fluid became blood-colored and stool became tarry in color. Enhanced computed tomography showed a hepatic artery aneurysm that had ruptured into the liver abscess and duodenoscopy revealed bleeding from the ampulla of Vater. Transcatheter arterial embolization with several steel coils was successfully performed which resulted in cessation of bleeding from the ampulla of Vater. The patient was discharged without any complications five weeks after rupture of the aneurysm. Our case demonstrates rupture of the hepatic artery aneurysm as a rare complication of amebic liver abscess and the effectiveness of interventional embolotherapy in this condition.     

Methicillin-resistant Staphylococcus aureus prosthetic aortic valve endocarditis with paravalvular abscess treated with daptomycin

Prosthetic valves have been used extensively for severe cardiac valvular dysfunction for the past 3 decades. Prosthetic cardiac valves may be infected with organisms causing bacteremia, particularly gram-positive cocci. Staphylococcus epidermidis (coagulase negative staphylococci) and Staphylococcus aureus , both methicillin-susceptible S. aureus and methicillin-resistant S. aureus (MRSA) strains, are the most frequent pathogens causing prosthetic valve endocarditis (PVE). Vancomycin has been the cornerstone of therapy for serious MRSA infections including bacteremia and endocarditis. Clinicians have noted that MRSA bacteremias treated with vancomycin often fail to clear even with prolonged therapy. Persistent or prolonged MRSA bacteremia unresponsive to vancomycin therapy has led to the treatment of these infections by other agents, that is, quinupristin, dalfopristin, linezolid, or daptomycin. These antibiotics have been found particularly useful in treating MRSA bacteremias unresponsive to vancomycin therapy. We report a case of a patient who presented with MRSA PVE complicated by perivalvular aortic abscess with persistent MRSA bacteremia unresponsive to vancomycin therapy. The patient's MRSA bacteremia was cleared with daptomycin therapy (6 mg/kg/d). Because the patient refused surgery, daptomycin therapy was continued in hopes of curing the endocarditis and sterilizing the perivalvular aortic abscess. Transesophageal echocardiogram revealed a decrease in abscess in the aortic perivalvular abscess after 1 week of daptomycin therapy. The patient made an uneventful recovery. The cure of PVE and perivalvular abscesses usually requires removal of the prosthetic device and abscess drainage. In this case, in which surgery was not an option, medical therapy of PVE and a decrease in size of the aortic perivalvular abscess were accomplished with daptomycin therapy. Daptomycin is an alternative to vancomycin therapy in patients with prolonged or persistent MRSA bacteremia secondary to endocarditis or abscess.