(Radiographics. 1999;19:820-822.)
© RSNA, 1999
Gastrointestinal Case of the Day1
Valerie Drnovsek, MD, PhD,
Daniel Fontanez-Garcia, MD,
Masako N. Wakabayashi, MD and
Branko M. Plavsic, MD, PhD
1 From the Department of Radiology, Touro Infirmary, 1401 Foucher St, New Orleans, LA 70115 (V.D.), and the Department of Radiology, Tulane University, New Orleans, La (D.F.-G., M.N.W., B.M.P.). From the 1998 RSNA scientific assembly. Received September 14, 1998; revision requested October 21 and received November 12; accepted November 12. Address reprint requests to B.M.P.
Index Terms: Foreign bodies, 731.46 • Intestines, perforation, 731.46, 731.713 • Liver, abscess, 761.242
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HISTORY
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A 48-year-old man with no previous history of related medical problems or surgery presented to the emergency department with right upper quadrant abdominal pain. His symptoms had begun following dinner the previous evening, when he developed cramping abdominal pain and nonbilious, nonbloody emesis. Admission laboratory data included the following values: white blood cell count, 15,900 with 70% neutrophils and 6% bands; alkaline phosphatase level, 325 (normal range, 40–120); serum glumatic oxaloacetic transaminase level, 79 (normal level, <39 U/L); and serum glumatic pyruvic transaminase level, 155 (normal range, 30–65 U/L). Abdominal ultrasound (US) was performed on the evening of the day of admission, and abdominal computed tomography (CT) was performed the next morning.
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FINDINGS
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Abdominal US revealed a collection of bright echo reflectors in an irregular configuration emanating from the right lobe of the liver with acoustic shadowing and crossing midline to involve a small portion of segment III of the left lobe (Fig 1). Abdominal CT demonstrated a unilocular cavity containing a copious amount of gas and a smaller amount of fluid (Fig 2). The superior portion of the duodenum could not be differentiated from the liver, and its thickness was difficult to assess. The wall of the stomach was not thickened. There was no evidence of intra- or extrahepatic ductal dilatation or lithiasis in the gallbladder or biliary ducts. No signs of pylephlebitis were observed. An upper gastrointestinal series with water-soluble contrast medium performed 4 days after the onset of symptoms did not show extraluminal contrast material.
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Figure 1. Longitudinal sonogram of the liver demonstrates a curvilinear formation of bright echo reflectors with associated "ring-down" artifact (arrowheads), a finding suggestive of the presence of gas. Arrows indicate normal liver parenchyma.
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Figure 2a. (a) Abdominal CT scan obtained at the level of the celiac trunk demonstrates a 10 x 8-cm abscess cavity containing a large amount of gas (arrowhead) and a smaller amount of fluid (arrows). An irregularly shaped collection of gas and fluid is seen within the liver straddling the midline. Inflammatory changes are present in the adjacent peritoneal fat anterior to the liver. (b) CT scan obtained at the level of the origin of the superior mesenteric artery reveals a complex collection of gas and fluid divided into two compartments. (c) CT scan shows extension of the abscess cavity into segment IV of the liver. The cavity is seen reaching the hepatic surface adjacent to the proximal duodenum.
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Figure 2b. (a) Abdominal CT scan obtained at the level of the celiac trunk demonstrates a 10 x 8-cm abscess cavity containing a large amount of gas (arrowhead) and a smaller amount of fluid (arrows). An irregularly shaped collection of gas and fluid is seen within the liver straddling the midline. Inflammatory changes are present in the adjacent peritoneal fat anterior to the liver. (b) CT scan obtained at the level of the origin of the superior mesenteric artery reveals a complex collection of gas and fluid divided into two compartments. (c) CT scan shows extension of the abscess cavity into segment IV of the liver. The cavity is seen reaching the hepatic surface adjacent to the proximal duodenum.
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Figure 2c. (a) Abdominal CT scan obtained at the level of the celiac trunk demonstrates a 10 x 8-cm abscess cavity containing a large amount of gas (arrowhead) and a smaller amount of fluid (arrows). An irregularly shaped collection of gas and fluid is seen within the liver straddling the midline. Inflammatory changes are present in the adjacent peritoneal fat anterior to the liver. (b) CT scan obtained at the level of the origin of the superior mesenteric artery reveals a complex collection of gas and fluid divided into two compartments. (c) CT scan shows extension of the abscess cavity into segment IV of the liver. The cavity is seen reaching the hepatic surface adjacent to the proximal duodenum.
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DIAGNOSIS: Pyogenic liver abscess caused by perforation by a swallowed wooden toothpick.
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DISCUSSION
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Early diagnosis of pyogenic liver abscess remains a challenge because findings are typically nonspecific so that a high degree of suspicion is required to make the diagnosis (1). A recent study addresses a shift in the clinical spectrum of this entity, which was once considered a fatal disease in a high percentage of cases (2). Regardless of its cause, pyogenic liver abscess is more commonly single than multiple. Biliary tract disease remains the most common known cause of pyogenic liver abscess, but in a majority of affected patients no underlying cause can be identified. When present, jaundice and a markedly elevated alkaline phosphatase level may be clues to the possibility of biliary tract disease. Hyperbilirubinemia and an elevated alkaline phosphatase level are present in the majority of patients but have low specificity. Large abscesses, regardless of cause, may lead to abnormal liver function test results (2).
Escherichia coli is the most prevalent microorganism isolated from pyogenic liver abscess, followed by Klebsiella, Streptococcus, and Bacteroides species (3). Only a handful of cases of pyogenic liver abscess caused by bowel perforation after ingestion of a foreign body have been reported in the recent literature (4,5). Affected patients are typically unaware of having swallowed the foreign body. Along with the variability of the clinical presentation, the often radiolucent nature of ingested objects further impedes preoperative diagnosis. Chest radiography may show a right pleural effusion, an elevated right hemidiaphragm, and subsegmental atelectatic changes, whereas findings at abdominal radiography may be nonspecific in 87% of cases (6). US and CT are critical not only in establishing the diagnosis of pyogenic liver abscess but also in determining the cause of the abscess. Due to nonspecific manifestation, the average delay in diagnosis in the early 1980s was reported to be as long as 4 weeks (7,8).
Although in our patient the upper gastrointestinal series was negative for perforation, the amount of gas in the abscess cavity and the continuity of the abscess with the hepatic surface in the vicinity of the first portion of the duodenum were suggestive of bowel perforation as a likely cause of the abscess. This tentative diagnosis was confirmed at surgery. Because bowel perforation was suspected, percutaneous drainage was not considered as a treatment option. No foreign body was identified at preoperative imaging, but a toothpick was discovered during surgery. The patient was not aware of ever having swallowed the toothpick, which must have occurred some time before the clinical symptoms first appeared given the size of the abscess at the time of diagnosis. Three microorganisms were isolated from the abscess cavity and included Streptococcus viridans, anaerobic Bacteroides melaninogenicus, and Propionibacterium (anaerobic Diphtheroids). Of the three microorganisms, only Streptococcus viridans was grown from blood cultures. The fact that multiple organisms were isolated from the abscess strongly suggested direct spread from perforated bowel into the liver. Hematogenously seeded abscesses would more likely be multiple and caused by a single microorganism. Seeding from the portal vein would likely result from breakdown of the bowel mucosa, as in enterocolitis. Our patient was free of such symptoms. If there is a strong indication of bowel perforation by a foreign body or if a foreign body is detected preoperatively, surgery is the treatment of choice. Therapy for solitary pyogenic liver abscess from other causes consists of percutaneous US- or CT-guided drainage combined with intravenous administration of antibiotics, which has proved successful in 90% of patients (9). The prognosis is particularly favorable in a subgroup of patients with little or no elevation in bilirubin or alkaline phosphatase levels and solitary right-sided pyogenic liver abscess with no readily identifiable cause (2). Fatal outcome is now limited primarily to those patients with severe underlying disease processes.
After undergoing surgery, our patient received antibiotics intravenously and was discharged 18 days after admission with a normal white blood cell count and without fever or residual abscess.
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References
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DeCock KM, Reynolds TB. Amebic and pyogenic liver abscess. In: Schiff L, Schiff ER, eds. Diseases of the liver. 7th ed. Philadelphia, PA: Lippincott, 1993; 46:1320-1333.
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Branum GD, Tyson GS, Branum MA, Meyers WC. Hepatic abscess: changes in etiology, diagnosis and management. Ann Surg 1990; 212:655-662.[Medline]
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Rajak CL, Gupta S, Jain S, Chawla Y, Gulati M, Suri S. Percutaneous treatment of liver abscess: needle aspiration versus catheter drainage. Am J Roentgenol 1998; 170:1035-1039.[Abstract/Free Full Text]
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HISTORY
FINDINGS
