Post-traumatic hepatic artery pseudoaneurysm treated with endovascular embolization and thrombin injection

Post-traumatic hepatic artery pseudoaneurysm is uncommon, appearing in approximately 1% of hepatic trauma cases. Most are extrahepatic (80%) and have a late onset. Although they are usually asymptomatic, they should always be treated becasue of the high risk of complications, especially breakage. Currently the treatment of choice is endovascular embolization with coils or the exclusion of the pseudoaneurysm using other intravascular devices. Recently there have been accounts of a treatment that combines embolization with coils and image-guided percutaneous human thrombin injection. We present a case of post-traumatic hepatic artery pseudoaneurysm that was successfully treated using this combined technique.     

结核性多发性肝脓疡2例

回顾性分析我院近年收治的2例结核性多发性肝脓肿病例，并对该病的临床表现、诊断、治疗进行讨论。2例患者经常规抗结核治疗后肝脏病变消失，半年后随访未见复发。医隹应充分认识结核性多发性肝脓肿的特点，并在临床工作中加以鉴别。     

Pyogenic liver abscess caused by Fusobacterium in a 21-year-old immunocompetent male

A 21-year-old male with no significant past medical history, presented with right upper quadrant(RUQ) abdominal pain along with fevers and chills. Lab work revealed leukocytosis, anemia, and slightly elevated alkaline phosphatase. Viral serology for hepatitis B virus, hepatitis C virus, and human immunodeficiency virus were negative and he was immunocompetent.Computed tomography imaging revealed hepatic abscesses, the largest measuring 9.5 cm. Empiric antibiotics were started and percutaneous drains were placed in the abscesses. Anaerobic cultures from the abscesses grew Fusobacterium nucleatum. This is a gram negative anaerobic bacteria; a normal flora of the oral cavity. Fusobacterium is most commonly seen in Lemiere’s disease, which is translocation of oral bacteria to the internal jugular vein causing a thrombophlebitis and subsequent spread of abscesses. Our patient did not have Lemiere’s, and is the first case described of fusobacterium pyogenic liver abscess in a young immunocompetent male with good oral hygiene. This case was complicated by sepsis, empyema, and subsequent abscesses located outside the liver. These abscesses’ have the propensity to flare abruptly and can be fatal. This case not only illustrates fusobacterium as a rare entity for pyogenic liver abscess, but also the need for urgent diagnosis and treatment. It is incumbent on physicians to diagnose and drain any suspicious hepatic lesions. While uncommon, such infections may develop without any overt source and can progress rapidly. Prompt drainage with antibiotic therapy remains the cornerstone of therapy.     

Multiple pyogenic liver abscess

Multiple pyogenic liver abscesses have been rarely described. We report a fatal case of multiple pyogenic liver abscesses affecting a 38-year-old woman requiring surgical drainage. Evolution was marked by occurrence of a septic shock with multi-organ system failure. The patient died 48 h after surgery. Causes, therapeutics and outcome of the disease are discussed.     

Predictive factors for early aspiration in liver abscess

AIM： To determine the predictive factors for early aspiration in liver abscess. METHODS： A retrospective analysis of all patients with liver abscess from 1995 to 2004 was performed. Abscess was diagnosed as amebic in 661 （68%） patients, pyogenic in 200 （21%）, indeterminate in 73 （8%） and mixed in 32 （3%）. Multiple logistic regression analysis was performed to determine predictive factors for aspiration of liver abscess. RESULTS： A total of 966 patients, 738 （76%） male, mean age 43 ± 17 years, were evaluated： 540 patients responded to medical therapy while adjunctive percutaneous aspiration was performed in 426 patients. Predictive factors for aspiration of liver abscess were： age≥ 55 years, size of abscess ≥5 cm, involvement of both lobes of the liver and duration of symptoms ≥ 7 d. Hospital stay in the aspiration group was relatively longer than in the non aspiration group. Twelve patients died in the aspiration group and this mortality was not statistically significant when compared to the non aspiration group. CONCLUSION： Patients with advanced age, abscess size 〉 5 cm, both lobes of the liver involvement and duration of symptoms 〉 7 d were likely to undergo aspiration of the liver abscess, regardless of etiology.     

以肝脓肿为首发症状的嗜酸性粒细胞增多症1例报道

嗜酸性粒细胞增多症是以嗜酸性粒细胞增多为特点,累及一个或多个器官损伤的一组疾病.现报道1例以肝脓肿为首发症状的嗜酸性粒细胞增多症伴肝脏、胃受累,以提高对本病的认识.     

影响消化道肿瘤肝转移介入治疗疗效的因素

目的探讨影响消化道肿瘤肝转移介人治疗疗效的因素,并评价介入治疗的价值。方法９２例消化道肿瘤肝转移患者经肝动脉介人治疗３１６次,其中２９例行单纯灌注化疗,６３例行灌注化疗加栓塞治疗。化疗药物选用表阿霉素（ＥＡＤＭ）、或／和顺铂（ＰＤＤ）、丝裂霉素（ＭＭＣ）、５－一氟尿嘧啶（５—ＦＵ）＋甲酰四氢叶酸钙（ＣＦ）联台方案,栓塞剂为超液化碘油和／或明胶海绵。对可能影响介人治疗疗效的因素行ＣＯＸ模型多因素分析。结果近期疗效以ＣＴ征象作为评价依据,总有效率（ＣＲ＋ＰＲ）为４５．６５％;平均生存期１９６月;０．５．１,２,３,５年生存率分别为９５７％,７３８％,３６．３％,２０．６％,１１６％。Ｃｏｘ比例风险模型分析结果显示９例孤立性肝转移者较多发转移预后好,平均生存期为３１２个月,差异有显著性,Ｐ＜０．０５;综合治疗较单纯介人治疗疗效好,差异有非常显著性,Ｐ＜０．０１;其它因素对疗效的影响无统计学差异。全组无严重副作用或并发症。结论经肝动脉介人治疗是治疗消化道肿瘤不能手术切除肝转移瘤的较好方祛。单发肝转移、介人治疗前后的综合治疗是影响消化道肿瘤肝转移介人治疗疗效的重要因素。     

Management of early hepatic artery occlusion after liver transplantation with failed rescue

Hepatic artery thrombosis is a serious complication after liver transplantation which often results in biliary complications, early graft loss, and patient death. It is generally thought that early hepatic artery thrombosis without urgent re-vascularization or re-transplantation almost always leads to mortality, especially if the hepatic artery thrombosis occurs within a few days after transplantation. This series presents 3 cases of early hepatic artery thrombosis after living donor liver transplantation, in which surgical or endovascular attempts at arterial re-vascularization failed. Unexpectedly, these 3 patients survived with acceptable graft function after 32 mo, 11 mo, and 4 mo follow-up, respectively. The literatures on factors affecting this devastating complication were reviewed from an anatomical perspective. The collective evidence from survivors indicated that modified nonsurgical management after liver transplantation with failed revascularization may be sufficient to prevent mortality from early hepatic artery occlusion. Re-transplantation may be reserved for selected patients with unrecovered graft function.     

原位肝移植术后肝脓肿的诊断和治疗

目的 探讨原位肝移植术(OLT)后肝脓肿的病因、诊断、治疗和预防措施。方法自1993年1月至2003年6月，本中心共行OLT274例，术后并发肝脓肿6例(2．2％)。患者主要临床表现有发热、寒战、腹痛、身目黄染、肝功能损害、低蛋白血症、贫血、白细胞及中性粒细胞比例增高等。诊断主要根据临床表现及超声或CT检查。治疗方法主要包括脓肿抽吸引流、清除胆泥．抗炎和支持治疗。结果6例中2例治愈，3例放弃再次肝移植术，2例死于严重全身感染，治愈率为33．3％。结论OLT后肝脓肿病因较复杂，可能与肝动脉血栓或狭窄、甲基强的松龙冲击治疗、胆管炎症和介入治疗等有关。OLT后肝脓肿的预后较差．应加强预防措施防止其发生。     

冠状动脉支架放置术治疗肝移植术后肝动脉狭窄

目的评价肝移植术后肝动脉狭窄时冠状动脉支架应用的可行性和有效性。方法2003年11月至2005年9月,14例肝移植术后肝动脉狭窄患者接受肝动脉冠状动脉支架放置术治疗,其中早期治疗10例,延迟治疗4例。总结肝动脉冠状动脉支架放置术的技术结果、肝动脉通畅及患者临床转归等情况。结果冠状动脉支架放置术成功率达100％。中位随诊146d(9～345 d),2例患者分别于术后26 d和45 d出现再狭窄,其余患者肝动脉均保持通畅；10例早期介入治疗的患者中,2例分别于术后9 d和30 d死于败血症性多器官功能衰竭,1例患者由于反复胆道感染于术后147 d接受再次肝移植,其余患者术后肝功能指标正常且无症状生存。4例延迟治疗的患者中,1例生存至今已345 d,但肝功能反复出现异常,其余3例死于肝脓肿和胆道感染导致的多器官功能衰竭。结论肝动脉冠状动脉支架放置术可以成功治疗肝移植术后肝动脉狭窄,早期介入治疗是取得良好的临床疗效的关键。     

Liver microcirculation after hepatic artery embolization with degradable starch microspheres in vivo

AIM: To observe the dynamic changes of liver microcirculation in vivo after arterial embolization with degradable starch microspheres (DSM). METHODS: DSM were injected into the proper hepatic artery through a silastic tube inserted retrogradely in gastroduodenal artery (GDA) of SD rats. Fluorescent microscopy was used to evaluate the dynamic changes of blood flow through the terminal portal venules (TPVs), sinusoids and terminal hepatic venules (THVs). The movements of DSM debris were also recorded. Six hours after injection of DSM, percentages of THVs with completely stagnant blood flow were recorded. RESULTS: Two phases of blood flow change were recorded. In phase one: after intra-arterial injection of DSM, slow or stagnant blood flow was immediately recorded in TPVs, sinusoids and THVs. This change was reversible, and blood flow resumed completely. In phase two: after phase one, blood flow in TPVs changed again and three patterns of blood flow were recorded. Six hours after DSM injection, 36.9%±9.2% of THVs were found with completely stagnant blood flow. CONCLUSION: DSM can stop the microcirculatory blood flow in some areas of liver parenchyma. Liver parenchyma supplied by arteries with larger A-P shunt is considered at a higher risk of total microcirculatory blood stagnation after injection of DSM through hepatic artery.     

Clinical characteristics and progression of liver abscess caused by toxocara

AIM: To evaluate the clinical characteristics and progression of liver abscess caused by toxocara.METHODS: We retrospectively reviewed the medical records of patients with serum Ig G antibody to Toxocara canis and liver abscess diagnosed using abdominal computed tomography between February 2010 and February 2015. Among 84 patients exhibiting serum Ig G antibody to Toxocara canis, 34 patients were diagnosed with liver asbscess and treated with albendazole. A follow-up period of 1 year was conducted. RESULTS: Mean patient age was 53(34-79) years, with 26(76.5%) patients being male. Twenty-one(61.7%) patients were moderate or heavy drinkers, 23(67.6%) patients had a history of eating raw meat or liver and 6(17.6%) patients owned pet dogs or cats. Main patient symptoms consisted of right upper quadrant pain, fever, and fatigue; 18(52.9%) patients, however, presented with no symptoms. Lung involvement was detected in 444(11.7%) patients. The eosinophil count increased in 29(85.3%) patients at initial diagnosis, and decreased in most patients after albendazole treatment. The initial serum Ig E level increased in 25(73.5%) patients, but exhibited various response levels after albendazole treatment. Liver abscess formation improved in all patients.CONCLUSION: The liver abscess was improved with albendazole treatment.     

Methicillin-resistant Staphylococcus aureus hepatic abscess in a patient with sickle-cell disease

We report a case of a 16-year-old female patient with sickle-cell disease with a liver abscess secondary to methicillin-resistant Staphylococcus aureus (MRSA). She had initially presented with jaundice and abdominal pain and subsequently underwent endoscopic retrograde cholangio-pancreaticography followed by laparoscopic cholecystectomy for removal of gallstones. However, post-cholecystectomy she presented with generalized abdominal pain and computed tomography scan of the abdomen revealed a liver abscess. A pigtail catheter was inserted into the abscess and culture of the aspirate yielded MRSA (susceptibility pattern of the organism was compatible with community-acquired MRSA). She was treated with intravenous clindamycin for 6 weeks with complete resolution of the abscess.     

A middle-aged lady with a pyogenic liver abscess caused by Clostridium perfringens

The pyogenic liver abscess caused by Clostridium perfringens (C. perfringens ) is a rare, but rapidly fatal infection. It is usually associated with malignancy and immunosuppression. We report the case of 50-year-old lady with the secondary liver metastases from rectal cancer presented with fever and epigastric pain. The identification of Grampositive bacilli septicaemia, the presence of gas-forming liver abscess and massive intravascular hemolysis should lead to the suspicion of C. perfringens infection. Here we review twenty cases published since 1990 and their clinical features are discussed. The importance of "an aggressive treatment policy" with multidisciplinary team approach is emphasized.     

肝动脉介入联合全身静脉化疗预防大肠癌术后肝转移的临床研究

目的探讨肝动脉介入联合全身静脉化疗预防大肠癌术后肝转移的疗效及毒副反应。方法治疗组48例大肠癌术后病人,术后3周行肝动脉介入联合全身静脉化疗6个周期,药物奥沙利铂130 mg/m2,亚叶酸钙300 mg/m2,氟脲苷(FUDR)500/m2,羟基喜树碱15～20 mg/m2,对照组38例病人则仅予以同样药物全身静脉化疗6个疗程。所有病例术前、术后、化疗前后均行影像学检查以评价疗效,随访48个月,评价肝转移及毒副反应。结果肝转移率:治疗组4.17%(2/48)、对照组28.95%(11/38),近期疗效显著,两组均未发生化疗引起的造血系统、肝肾功能的损害,无化疗相关死亡,两组之间呈显著性差异(P<0.01)。结论肝动脉介入联合全身静脉化疗近期可有效预防大肠癌术后肝转移的发生,毒副反应小,安全有效。     

Actinomycotic liver abscess: A rare complication of colonic diverticular disease

We present the first case of hepatic actinomycosis requiring both medical and surgical intervention due to liver dissemination from a primary colonic abscess. A 52-year-old white male had a computerised (CT) abdominal scan following an episode of collapse and was found to have peri-colonic and hepatic abscesses. Prior to this episode, he suffered with a two month history of fever, unexplained weight loss, and anaemia suggesting possible malignancy. He was treated with both radiological and surgical drainage of the abscesses, alongside the antibiotic cover and underwent an anterior colonic resection with primary anastomosis. There have been no previous reports of an actinomycotic liver abscess complicating colonic diverticular abscess. A multi-team approach is recommended when disseminated actinomycotic infection is encountered.     

替硝唑治疗阿米巴肝脓肿的疗效观察

目的观察替硝唑对阿米巴肝脓肿的临床疗效。方法以每日顿服替硝唑２．０ｇ，５日疗法治疗３３例阿米巴肝脓肿患者，并与甲硝唑１４日疗法治疗３１例阿米巴肝脓肿患者进行比较。结果替硝唑组患者体温恢复正常时间（３．７±０．５天），平均住院天数（２４．３±１．５天）及总有效率（７８．８％）与甲硝唑组比较，差异无显著性（Ｐ＞０．０５）。但替硝唑组患者脓腔缩小所需时间较短，肝区疼痛消失较早，不良反应亦比甲硝唑组较少（Ｐ＜０．０５）。结论替硝唑是一种治疗阿米巴肝脓肿的新的良好药物     

A prediction model for liver abscess developing after transarterial chemoembolization in patients with hepatocellular carcinoma

BackgroundLiver abscess is a rare but potentially fatal complication of transarterial chemoembolization. Other than for biliary abnormalities, risk factors for liver abscess formation after transarterial chemoembolization have rarely been discussed.AimsTo identify other risk factors of liver abscess after transarterial chemoembolization in patients with hepatocellular carcinoma.MethodsData for 5299 patients with hepatocellular carcinoma who underwent transarterial chemoembolization from July 1999 to December 2009 were retrospectively reviewed. 72 patients who experienced liver abscess after transarterial chemoembolization were enrolled as a case group, which was compared with a randomly selected control group (n = 1009) of patients who did not develop liver abscess after transarterial chemoembolization.ResultsPneumobilia, type 2 biliary abnormality, type 1 biliary abnormality, diabetes mellitus, tumour number (≥3), tumour size (≥3 cm), and tumour necrosis on the pre-transarterial chemoembolization computed tomography, and gelfoam embolization and vessel injury during transarterial chemoembolization were all significant predisposing factors for liver abscess after transarterial chemoembolization. A prediction model for postembolization liver abscess was developed from these risk factors.ConclusionThe group of patients with risk scores greater than 71 showed a significantly increased risk of liver abscess after transarterial chemoembolization. These high-risk patients should be monitored carefully after transarterial chemoembolization.