Dr. Johnny Cai presented a case of a woman with a history of a pancreatic tail cyst who had two weeks of progressive RUQ pain, fever, and night sweats. She was hemodynamically stable, but her labs revealed a hepatocellular liver injury and a severe leukocytosis. RUQ ultrasound revealed pneumobilia without common bile duct dilatation, cholelithiasis or pericholecystic fluid.
Pneumobilia, you say?
The differential for pneumobilia is short -- post-procedural vs BADNESS (like gas-producing bacterial infection).
The team then proceeded with a CT (shown here):
“gas and fluid filled structure 5x4 cm in segment 4 of the liver consistent with abscess without clear source.”
When thinking about a liver abscess, it can be helpful to try to classify it further into pyogenic (most common) vs less common causes such as amebic or unusual infections (TB, Echinococcus, candidal). Your history should alert you if you should be thinking about atypical liver abscesses. Echinococcus has a very distinct look on imaging and should not be aspirated for culture as this can be lethal.
You should also ensure you get blood cultures as liver abscesses can form from hematogenous spread.
A liver abscess?
The patient was started on pipercillin/tazobactam and IR aspirated the liver abscess and placed a drain. The aspirate culture never grew anything (suspected sterilized with antibiotics).
Her leukocytosis was not improving and thus she was -reimaged without change in abscess and had another drain placed. THIS IS A GOOD TEACHING POINT: if the clinical picture isn’t improving, make sure you truly have source control (drain not in right place, another process going on, wrong antibiotics, etc.) After her clinical picture started to improve, she was transitioned to metronidazole and moxifloxacin to complete a 6 week course.
UptoDate “Pyogenic Liver Abscess”
Lübbert C, Wiegand J, Karlas T. Therapy of Liver Abscesses. Viszeralmedizin. 2014;30(5):334–341
Rathimian, J et al. Clinical Infectious Diseases. 2004 Dec 1;39(11):1654-9
Tan YM, Chung AY, Chow PK, et al. Ann Surg. 2005;241(3):485–490
Wong, Wai Man et al. Journal of Gastroenterology and Hepatology. (2002) 17, 1001–1007