Pyogenic Liver Abscess Spontaneously Drained Into the Stomach
1
Image of the Month Pyogenic Liver Abscess Spontaneously Drained Into the Stomach EUGENIO CATURELLI,* PAOLA ROSELLI,* and GIORGIA GHITTONI ‡ *Unità Operativa di Gastroenterologia, Ospedale Belcolle, Strada Sammartinese, Viterbo, Italy; ‡ VI Dipartimento di Medicina Interna ed Ecografia Interventistica, Policlinico “S. Matteo” IRCCS, Pavia, Italy A 46-year-old Caucasian man presented with septic fever (intermittent, with spikes up to 40.5°C) and intense ab- dominal pain in the upper quadrants. He had drunk 2 infusions of unspecified herbs of uncertain origin 1 week previously in Jamaica. His fever had started about 2 days after the consump- tion of such beverages, and increasing abdominal pain had developed shortly afterward. At clinical examination an intense tenderness could be elic- ited in the right upper abdominal quadrant. Blood investiga- tions were within the normal limits apart from an erythrocyte sedimentation rate of 60 mm (normal, 12), white blood cell count (leukocytes, 18,500 mm 3 ; neutrophils, 84.3%), and a se- rum alkaline phosphatase level of 211 U/L (normal range, 38 –126 U/L). A slight increase of both transaminases was present too. Blood samples for cultures were taken and empiric intravenous antibiotic therapy with ceftriaxone (2 g every 12 h) was started. An ultrasound upper-abdominal scan showed a 7-cm diameter focal lesion in the left liver lobe, emerging on the lower liver surface and adhering to the stomach. A contrast- enhanced ultrasound scan was performed immediately on the lesion, showing thin portions of strongly enhancing liver pa- renchyma, either peripheral or in some internal septa, bounding large fluid areas. These findings strongly suggested an abscess (Figure A). An abdominal contrast-enhanced computed tomog- raphy scan confirmed the diagnosis of a liver abscess adhering to the gastric wall (Figure B, arrow). The day after admission, the patient underwent a gastroscopy that showed a submucosal mass protruding into the stomach. Purulent material oozing from a fistulous orifice (Figure C) was aspirated by a cannula. Cultures of such material proved positive for Klebsiella pneu- moniae, sensitive to ceftriaxone. The same microorganism was found in a blood culture, and the antibiotic therapy was con- tinued without modifications. The fistulization of the liver abscess into the stomach, allowing its spontaneous drainage, induced the early improvement of the patient’s conditions, without the need for any interventional procedure. Ultrasound showed the progressive decreasing of the dimensions of the left liver lesion, and gastroscopy revealed the disappearance of the gastric submucosal lesion and fistula. The complete resolution of the abscess was documented by both ultrasound and com- puted tomography scan after 31 days. Conflicts of interest The authors disclose no conflicts. © 2009 by the AGA Institute 1542-3565/09/$36.00 doi:10.1016/j.cgh.2009.05.010 CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2009;7:e65
Transcript of Pyogenic Liver Abscess Spontaneously Drained Into the Stomach
I
P
E
*P
AdoJtd
itscr3piw7lelrl(rttmfCmf
mage of the Month
yogenic Liver Abscess Spontaneously Drained Into the Stomach
UGENIO CATURELLI,* PAOLA ROSELLI,* and GIORGIA GHITTONI‡
Unità Operativa di Gastroenterologia, Ospedale Belcolle, Strada Sammartinese, Viterbo, Italy; ‡VI Dipartimento di Medicina Interna ed Ecografia Interventistica,
oliclinico “S. Matteo” IRCCS, Pavia, Italytaiwslgop
C
46-year-old Caucasian man presented with septic fever(intermittent, with spikes up to 40.5°C) and intense ab-
ominal pain in the upper quadrants. He had drunk 2 infusionsf unspecified herbs of uncertain origin 1 week previously inamaica. His fever had started about 2 days after the consump-ion of such beverages, and increasing abdominal pain hadeveloped shortly afterward.At clinical examination an intense tenderness could be elic-
ted in the right upper abdominal quadrant. Blood investiga-ions were within the normal limits apart from an erythrocyteedimentation rate of 60 mm (normal, �12), white blood cellount (leukocytes, 18,500 mm3; neutrophils, 84.3%), and a se-um alkaline phosphatase level of 211 U/L (normal range,8 –126 U/L). A slight increase of both transaminases wasresent too. Blood samples for cultures were taken and empiric
ntravenous antibiotic therapy with ceftriaxone (2 g every 12 h)as started. An ultrasound upper-abdominal scan showed a-cm diameter focal lesion in the left liver lobe, emerging on the
ower liver surface and adhering to the stomach. A contrast-nhanced ultrasound scan was performed immediately on theesion, showing thin portions of strongly enhancing liver pa-enchyma, either peripheral or in some internal septa, boundingarge fluid areas. These findings strongly suggested an abscessFigure A). An abdominal contrast-enhanced computed tomog-aphy scan confirmed the diagnosis of a liver abscess adheringo the gastric wall (Figure B, arrow). The day after admission,he patient underwent a gastroscopy that showed a submucosal
ass protruding into the stomach. Purulent material oozingrom a fistulous orifice (Figure C) was aspirated by a cannula.ultures of such material proved positive for Klebsiella pneu-oniae, sensitive to ceftriaxone. The same microorganism was
ound in a blood culture, and the antibiotic therapy was con-
inued without modifications. The fistulization of the liverbscess into the stomach, allowing its spontaneous drainage,nduced the early improvement of the patient’s conditions,ithout the need for any interventional procedure. Ultrasound
howed the progressive decreasing of the dimensions of the leftiver lesion, and gastroscopy revealed the disappearance of theastric submucosal lesion and fistula. The complete resolutionf the abscess was documented by both ultrasound and com-uted tomography scan after 31 days.
onflicts of interestThe authors disclose no conflicts.
© 2009 by the AGA Institute1542-3565/09/$36.00
doi:10.1016/j.cgh.2009.05.010
CLINICAL GASTROENTEROLOGY AND HEPATOLOGY 2009;7:e65
