Pyogenic Liver Abscess Spontaneously Drained Into the Stomach

Article Outline

• Copyright

A 46-year-old Caucasian man presented with septic fever (intermittent, with spikes up to 40.5°C) and intense abdominal 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 consumption of such beverages, and increasing abdominal pain had developed shortly afterward.

At clinical examination an intense tenderness could be elicited in the right upper abdominal quadrant. Blood investigations were within the normal limits apart from an erythrocyte sedimentation rate of 60 mm (normal, ≤12), white blood cell count (leukocytes, 18,500 mm³; neutrophils, 84.3%), and a serum 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 parenchyma, either peripheral or in some internal septa, bounding large fluid areas. These findings strongly suggested an abscess (Figure A). An abdominal contrast-enhanced computed tomography 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 pneumoniae, sensitive to ceftriaxone. The same microorganism was found in a blood culture, and the antibiotic therapy was continued 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 computed tomography scan after 31 days.

• 
  • View Large Image
  • Download to PowerPoint