When the Pressure Builds: A Silent Abdominal Catastrophe
[DECEMBER 2024]

A 44-year-old male with alcohol-induced liver cirrhosis (Child-Pugh Class B), type 2 insulin-dependent type 2 diabetes mellitus, chronic pancreatitis of alcohol-tobacco etiology presented with a persistent liver abscess, diagnosed one month earlier, now suspected to have fistulized into the peritoneal cavity. The patient presented with progressive abdominal distention, fatigability, and dyspnea on minimal exertion. He also exhibited signs of hypo-anabolic syndrome, including muscle wasting and weight loss. Laboratory findings revealed leukocytosis (14000/mm3), elevated C-reactive protein (8 mg/dl) with normal procalcitonin levels, thrombocytosis (486,000/ul), and microcytic anemia (hemoglobin 10,8 g/dl, serum iron 21,6 ug/dl).

An abdominal ultrasound and contrast enhanced ultrasound revealed a cirrhotic liver with a 35 mm fluid collection in segment VI (Video 1), which communicated with a thick-walled encapsulated collection extending into the peritoneal cavity, measuring up to 45 cm cranio-caudally (Figure 1). Additionally, complete thrombosis of the portal vein was observed, extending bilaterally to the intrahepatic branches, as well as to the spleno-portal confluence and the distal portion of the superior mesenteric vein over a distance of 20 mm, with collateral circulation at the hepatic hilum. A contrast-enhanced CT scan demonstrated that this intra-abdominal collection exerted a mass effect on adjacent organs. It also revealed a well-defined collection with its own wall occupying the anterior peritoneal space, communicating with the hepatic fluid collection in segment VI (Figure 2), consistent with a hepatic abscess fistulized into the peritoneum (Figure 3).

BACKGROUND:

Hepatic abscesses, often resulting from bacterial infections or complications of prior procedures, can lead to fistulization into the peritoneal cavity, complicating their management. When an abscess ruptures, it can cause acute abdomen and peritonitis, presenting with fever, right upper quadrant pain, and signs of infection.

Imaging studies, particularly CT scans, are essential for diagnosing these abscesses and assessing complications. Management typically includes antibiotics and percutaneous drainage; however, surgical intervention may be necessary when an abscess has fistulized. Surgical approaches are guided by the size and location of the abscess as well as the patient’s condition.

CLINICAL PERSPECTIVE:

By using ultrasound guided percutaneous drainage of the fistulized abscess, we can decrease the possible risks of surgery in a patient with decompensated advanced chronic liver disease, and at the same time increase the effectiveness of antibiotic therapy and drain the infected liquid from the abdominal cavity.

THERAPY PLANNING:

Percutaneous ultrasound-guided drainage of the peritoneal abscess, using 18 Fr surgical drainage tubes (Video 2). The drainage was performed under surgical consultation, with incision made at the site of insertion and secure suturing of the catheters at the end. From an infectious point of view, lavage twice daily using antibiogram-guided antibiotics and sterile saline for 7 days, with intravenous antibiotics for at least 4 weeks was necessary for assuring complete sterilization of the abscess.

OUTCOME:

Percutaneous ultrasound guided drainage is a safe method used in hepatic abscesses, with good clinical outcome. The indication of percutaneous drainage can be extended to other indications, like in our case where surgical intervention posed a significant risk given the presence of liver cirrhosis and poor nutritional status. After drainage of the abscess, the nutrition improved with subsequent weight gain and disappearance of inflammatory syndrome. When the patient was reevaluated by ultrasound, there was minimal inflammatory modifications of the peritoneum (Figure 5) and at the contrast-enhanced evaluation of the liver, there were no hypoenhancing lesions, suggestive of liver abscess (Figure 6).

Right hepatic lobe abscess (Segment VI) fistulized into the peritoneal cavity. Chronic plastic peritonitis. Alcohol-induced liver cirrhosis, Child-Pugh B. Chronic portal vein thrombosis with cavernomatous transformation.

Hepatic abscesses, particularly when fistulized into the peritoneal cavity, present significant management challenges, especially in patients with decompensated cirrhosis. Imaging, especially CT, is essential for diagnosis and evaluation. In this case, ultrasound-guided percutaneous drainage using 18 Fr catheters was performed, followed by targeted lavage and intravenous antibiotics. This approach avoided surgical risk, improved clinical status and nutritional parameters, and led to complete imaging and clinical resolution.

[1] Alcohol-induced liver cirrhosis can lead to severe complications, such as hepatic abscess formation and fistulization into the peritoneal cavity, in most cases without an acute presentation, highlighting the need for careful monitoring and management.

[2] Abdominal ultrasound is essential for diagnosing hepatic abscesses and guiding treatment decisions, including the choice between percutaneous drainage and surgical intervention.

[3] Percutaneous ultrasound-guided drainage is a safe and effective method for treating hepatic abscesses, especially in high-risk patients, leading to improved clinical outcomes and complete recovery.

[1.] Ahmed, S., et al. (2021). Management strategies for hepatic abscesses: current approaches and future directions. Journal of Gastroenterology, 56(6), 487-497.

[2.] Metwally, A.E., et al. (2022). Predictive factors of outcomes in patients with hepatic abscesses: A retrospective study. Hepatology International, 16(2), 203-210.

[3.] Yamada, T., et al. (2020). Imaging of hepatic abscesses: Controversies and current practices. World Journal of Radiology, 12(2), 56-68.