A case report of a lung abscess as a rare complication of a pyogenic liver abscess

Rationale:A hepatobronchial fistula and lung abscess following a pyogenic liver abscess is a rare entity and it is not easy to diagnose this condition based on the symptoms and chest radiography.Patient concerns:An 81-year-old man presented with productive cough and dyspnea.Diagnosis:Chest radiography indicated increased opacities in the right lower lung field with an air-fluid level suggestive of pneumonia complicated by a lung abscess. Chest and abdominal computed tomography revealed an abscess in the right lower lung field that bordered an abscess at segment 7 of the liver. Tubography confirmed a fistula between the liver and lung abscesses.Interventions:Due to communication between 2 abscesses, transhepatic approach was done instead of transpleural approach to avoid complications.Outcomes:A liver abscess complicated by a lung abscess was resolved following percutaneous transhepatic drainage of the liver abscess and antibiotic administration.Lessons:Though uncommon, the lack of suspicion of sub-diaphragmatic liver abscess often lead to a delay in diagnosis and proper treatment. Our case implies the importance of computed tomography in early diagnosis of liver abscess in case of lung abscess in the right lower lung field.     

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.     

Hepatic Abscess That Formed Secondary to Fish Bone and Had a Fistula With the Ascending Colon

We present the case of a liver abscess that formed secondary to foreign bodies and formed a fistula the ascending colon and was successfully treated with percutaneous abscess drainage and colonoscopic removal of foreign bodies. A 64-year-old man presented with right upper and lower quadrant pain of 2 weeks' duration. Abdominal computed tomography was performed, demonstrating a single 3.5×1.9-cm abscess of the liver's right lobe and eccentric thickening of the colon wall at hepatic flexure. A percutaneous hepatic drainage catheter was placed under ultrasound guidance. Colonoscopic examination revealed multiple diverticula of the ascending colon and two 1.5-cm long fish bones at the ascending colon near the hepatic flexure. One end of each fish bone had impacted the edematous colonic mucosa and was surrounded by exudate polypoid inflammatory tissue. The fish bones were extracted with forceps. The patient was feeling well and was discharged after 12 days of treatment.     

Emphysematous prostatic abscess due to candidiasis: a case report

Prostatic abscess is an uncommon condition and clinical diagnosis is difficult. The classical symptoms and signs of prostatic abscess are variable and nonspecific. Here, we report a rare case of emphysematous prostatic abscess due to candidiasis in a 68-year-old man with diabetes and liver cirrhosis. The diagnosis was confirmed by pelvic computed tomography (CT) and successfully treated by antibiotics and CT-guided percutaneous abscess drainage. This case highlights the importance of early and accurate diagnosis of emphysematous prostatic abscess followed by appropriate treatment.     

Irrigation of liver abscess: proposal of a novel method and possible indications.

We present here two suggestive cases in considering the advantages and disadvantages of irrigation of pyogenic liver abscess: one patient developed an intrahepatic hematoma as an unusual sequela, while the other was successfully treated by abscess irrigation, overcoming failure of percutaneous catheter drainage and the patient's seriously ill condition. Based on these cases, we propose a novel method of liver abscess irrigation via percutaneous drainage tubes with the following three characteristics: 1) use of a drip infusion apparatus for irrigant instillation and drainage in order to avoid elevation of pressure in the abscess, a source of potential life-threatening sequelae, 2) addition of contrast medium to irrigant, and 3) employment of computed tomography in dynamic equilibrium of irrigant in order to evaluate the efficacy of current irrigation. Of interest was the parenchymal enhancement around the irrigated liver abscess revealed by computed tomography with this method, which suggested that dissemination of abscess contents may be inevitable with irrigation. Although the indications for liver abscess irrigation must be considered carefully given the critical sequelae potentially associated with it, the method we present can be used as a second-line trial exclusively for liver abscesses refractory to first-line treatment with percutaneous catheter drainage or needle aspiration, since it can be used not only as a therapeutic procedure with mechanical washing or dilution of abscess contents but also as a diagnostic aid enabling more effective subsequent treatment by defining the areas in which drainage and irrigation is not effective.     

Liver abscess caused by an unnoticed swallowed toothpick perforating the colonic wall

We present an unusual case of a liver abscess caused by a swallowed toothpick in a 43-year-old man. The abscess was first punctured under percutaneous ultrasound control and intraveneous administration of antibiotics whereas the diagnosis of the foreign body stuck in the sigmoid bowel wall was only made by a follow-up computed tomography since the patient had no complains indicating a colonic pathology. Even more, the patient did not remember ever having ingested a foreign body. The wooden toothpick was then successfully removed by endoscopy. The case report stresses the need for a search of the cause of unexplained liver abscesses and highlights the importance of computed tomography as the first imaging technique as the foreign body was missed on the ultrasound examination. Finally, the non-surgical treatment as first line management of liver abscesses will be discussed.     

Metallic cough and pyogenic liver abscess

The curious symptom of a metallic cough in association with a pyogenic hepatic abscess should heighten awareness of a fistula. We describe a 78-year-old female with severe diverticular disease, on long-term steroid treatment for polymyalgia rheumatica. She developed a pyogenic liver abscess, treated initially by antimicrobial therapy, and subsequently drained by ultrasound and computed tomography-guided percutaneous transhepatic pigtail catheterization. This was complicated by a fistulous communication between the abscess cavity and the bronchus, confirmed by radiology. After repeated attempts at drainage and antimicrobial therapy the abscess cavity, including the hepatobronchial fistula, resolved.     

A case of amoebic liver abscess complicated by a gastric fistula cured with oral medication only

A 26-year-old man was admitted to our hospital because of a high-grade fever and abdominal pain. A blood test showed marked inflammation. Enhanced computed tomography (CT) showed an 8.0×6.0cm cystic lesion in the left hepatic lobe. Esophagogastroduodenoscopy showed a huge egg-yolk-like mass in the gastric submucosa in the lesser curvature of the gastric body from the gastric angle. There were 3 ulcers on the mass, out of which milky pus flowed. Trophozoites of Entamoeba histolytica were detected from cultures of the liver abscess and a biopsy of the gastric ulcers. The amoebic dysentery antibody titer was increased 1600 times. An amoebic liver abscess complicated by a gastric fistula was diagnosed. As therapy, oral metronidazole was administered for 2 weeks without percutaneous drainage. The systemic inflammatory findings improved immediately and the abscess decreased markedly in size.     

Percutaneous drainage of intra-abdominal abscesses guided by real-time ultrasonography

From October 1982 to October 1984, a percutaneous drainage under realtime ultrasound guidance was performed in 53 patients with abdominal abscesses. The location of the abscesses was subphrenic (23), retroperitoneal (16), and intrahepatic (14). A safe access route was found by using ultrasound and fluoroscopy in 53 out of 55 patients (96 p. 100). Percutaneous drainage failed in 8 patients and 3 of these patients died. The causes of death were: cerebral abscess (1), renal failure after surgery for correction of a duodenal fistula (1), and pancreatic abscess (1). The other five patients were cured by surgical drainage. Two complications were observed: one case each of pneumothorax and purulent peritonitis. Forty-five patients were healed by percutaneous drainage without operation. The duration of the catheter drainage was 14 days +/- 13 (m +/- 1 SD). Our results suggest that percutaneous drainage under realtime ultrasound guidance is an efficient and safe way to treat abdominal abscesses.     

Hepatobronchial fistula with percutaneous pyogenic abscess drainage of the liver

Percutaneous abscess drainage has been successfully used in the treatment of hepatic abscesses. We present a case of a posttraumatic pyogenic liver abscess treated by CT-guided percutaneous catheter drainage with an unusual complication of a hepatobronchial fistula. Patient management and the subtle roentgenographic features of this case are presented. Early signs of hepatobronchial fistula including paroxysms of coughing and a peculiar metallic taste during the performance of an abscessogram are reported.     

Liver abscess complicating intratumoral ethanol injection therapy for HCC

We report a patient who developed multiple liver abscesses and sepsis caused by lactobacilli after the percutaneous intratumoral injection of ethanol for hepatocellular carcinoma. We diagnosed the liver abscess at an early stage because of a the finding of gas on ultrasound and computed tomography. Blood cultures grew Gram-positive rods, which were of the Lactobacillus species. The patient responded to the administration of antibiotics, and his hepatic tumors have not recurred in the 7 months since treatment. This is the first report of liver abscess following percutaneous ethanol injection therapy.     

Endoscopic ultrasound‐guided drainage of pelvic abscess without fluoroscopy guidance

Background and Aims: Few case series are reported on endoscopic ultrasound (EUS)‐guided drainage of pelvic abscesses under fluoroscopy guidance. We hypothesized that EUS‐guided drainage of pelvic abscesses without fluoroscopy is an effective alternative to surgery in patients whose abscesses are not amenable to percutaneous drainage techniques. The aim of this study is to evaluate the clinical efficacy of EUS‐guided trans‐rectal/transcolonic drainage of pelvic abscess without fluoroscopy. Methods: Fourteen consecutive patients with pelvic abscesses not amenable to percutaneous drainage underwent EUS‐guided drainage over a period of 22 months. Main outcome measures were the resolution of the pelvic abscess on repeat imaging and improved clinical symptoms. Results: Fourteen consecutive patients were enrolled. EUS‐guided aspiration was performed in three patients. In two patients, dilatation and aspiration was performed, while trans‐rectal stent was placed in nine patients. All patients became afebrile within 72 h. Stent was removed in all patients, after confirming the resolution of the abscess on repeat computed tomography after 7 days. One patient in whom only aspiration was done had recurrence of fever and abscess on the seventh day and was treated by surgical drainage. A follow‐up EUS done in 13 of the patients after 3 months revealed no recurrence, and all patients were asymptomatic at 6 months. The procedure was uneventful in all patients. Conclusion: Endoscopic ultrasound‐guided drainage without fluoroscopy is a safe and effective modality of treatment for pelvic abscesses not amenable to radiologically guided drainage, thus reducing the need for surgical intervention.     

THERAPEUTIC FISTULOSCOPY FOR THE MANAGEMENT OF PROLONGED POSTOPERATIVE INTRA‐ABDOMINAL ABSCESS CAUSED BY SMALL INTESTINAL PINHOLE PERFORATION

Fistuloscopy is an effective treatment for intractable fistula, a sometimes difficult to manage postoperative intra‐abdominal complication. A case of a 69‐year‐old male with an abdominal abscess after he underwent right hemi‐colectomy for cecum cancer with invasions into the ileum and sigmoid colon is reported. A re‐operation for lavage and drainage was performed 2 weeks after surgery. However, no obvious origin for the pus was located. Although physiological saline lavage was repeatedly performed, the effusion of pus persisted in the drain at the midline incision about 7 months after surgery. Then, fistuloscopy with an upper gastrointestinal endoscope was performed through the hole of the tube. A pinhole that produced a bubble just below the midline incision was observed. Then, an endoscopic retrograde cholangiopancreatography (ERCP) tube was inserted to obtain images of the small intestine by fluorography and findings suggested a diagnosis of perforation of the small intestine, which appeared to explain why resolution of the abscess was prolonged. After direct drainage to the small intestine with a 40‐cm‐long 7 Fr percutaneous transhepatic cholangio drainage (PTCD) balloon catheter, pus from the tube notably decreased. After confirming that the abscess cavity had disappeared by abdominal computed tomography scan, the PTCD catheter was extracted about 8 months after primary surgery. Since then, no recurrence of cancer or abscess has been observed. In cases of intractable postoperative intra‐abdominal abscess, fistuloscopy using smaller diameter gastrointestinal endoscopy appears to be a valuable diagnostic tool.     

Intraductal papillary cholangiocarcinoma with aneurismal dilation: a case of the mimicking abscess

A case of cystic intraductal papillary cholangiocarcinoma is presented. A 58-year-old male patient presented with fever, chills, epigastric and right upper quadrant pain for 15 days. Clinically and radiologically, he was diagnosed as having liver abscess. After ultrasonography and abdominal computed tomography were taken, percutaneous drainage was performed and pus was drained. Computed tomography revealed a huge, multiloculated, septated cystic lesion in the right lobe of the liver. On the pathologic exam, the cystic lesion was an aneurismally dilated tumor, which spread diffusely and contiguously along the intrahepatic bile duct and microscopically the lesion was composed of a single layer of tall columnar tumor cells with short intraluminal papillary projections. We present the unusual case of intraductal papillary cholangiocarcinoma with aneurismal dilation and with superimposed infection.     

Prostatic abscess as a delayed complication following cryosurgery for primary prostate cancer

Prostatic abscess is a rare and potentially life-threatening disease when left untreated. We report the first case of a man who developed a prostatic abscess as a long-term complication of cryoablation for primary prostate cancer. Timely diagnosis with non-contrast computed tomography (CT) scan, retrograde CT cystogram to ensure no bladder involvement, percutaneous drainage under CT-guidance, and antibiotic treatment sensitive to the causative organism were crucial for prompt recovery.     

Tuberculous liver abscess in an immigrant patient with pulmonary tuberculosis

Liver abscess due to Mycobacterium tuberculosis associated with pulmonary tuberculosis is a rare diagnosis, particularly in patients without AIDS. We report the case of a male immigrant with no HIV infection who developed a tuberculous liver abscess and pulmonary tuberculosis simultaneously. Ziehl-Neelsen stain, PCR and L?wenstein-Jensen culture of material sampled from the abscess established the microbiological diagnosis. The patient's course was good, with disappearance of symptoms and the abscess after tuberculostatic treatment and drainage of the abscess with monitoring by computed tomography.     

A case of hepatocolic fistula after percutaneous drainage for a gas-containing pyogenic liver abscess

We describe a rare of gas-containing pyogenic liver abscess which penetrated the adjacent colon, forming a hepatocolic fistula, after percutaneous transhepatic abscess drainage (PTAD) had been performed. To the best of our knowledge, this is the first report of hepatocolic fistula associated with a gasforming liver abscess in a diabetic patient, with radiological and surgical confirmation of the fistula.     

A case of pancreatic intraductal papillary-mucinous carcinoma with penetration to the stomach and splenic abscess]

We report the case of an 80-year-old man given a diagnosis of pancreatic intraductal papillary-mucinous carcinoma (IPMC) and early gastric cancer. He refused surgery, therefore endoscopic mucosal resection (EMR) for gastric cancer and careful observation were performed. Penetration of the IPMC to the stomach was observed 3 months later. Ten months after the initial diagnosis, he was found to have a splenic abscess and was subsequently treated by antibiotics and percutaneous drainage, and a fistula between the IPMC and the splenic abscess was observed. We suppose IPMC penetration to the spleen and bacterial transmission from the stomach through the fistula caused the splenic abscess. While IPMC is recognized as a low-grade malignancy, some cases of invasive carcinoma with fistulation to adjacent organs have been reported. To the best of our knowledge, this is the first case of IPMC associated with splenic abscess due to pancreatosplenic fistula.     

老年人糖尿病合并细菌性肝脓肿的超声介入治疗

目的 评价超声引导下穿刺抽脓及置管引流治疗老年人糖尿病合并细菌性肝脓肿的临床应用价值。方法 对46例老年糖尿病合并细菌性肝脓肿的患者进行经超声引导下脓汁抽吸、置管引流治疗。结果 46例患者穿刺抽脓及置管引流全部成功，治愈率93．5％（43／46），所有患者均未出现穿刺并发症。随后30、60、180d经门诊随访未见复发。结论 超声引导下介入治疗老年人糖尿病合并细菌性肝脓肿安全、有效，可以明显缩短疗程，可作为首选的治疗方法。     

Complete recovery after spontaneous drainage of pancreatic abscess into the stomach.

Pancreatic abscess is a dreaded complication of acute pancreatitis, with a high death rate even with aggressive surgical treatment. We report two cases in which recovery followed spontaneous drainage into the stomach. A 75-year-old woman with biliary pancreatitis and a 63-year-old man with ethanol-induced pancreatitis both developed pancreatic abscess, diagnosed by computed tomography scans and ultrasound. The spontaneous gastric fistula was heralded by a large emesis of purulent and necrotic material in one case and copious nasogastric tube secretions of a similar material in the other. Defervescence was immediate, and both patients went on to complete recovery without any further interventions. Contrast studies showed the fistulae. It is concluded that in the event that a pancreatic pseudocyst spontaneously drains into the stomach a 'wait and see' policy should be adopted, and a favorable outcome can be expected.