MR Masood, M Ali, R Burgaul, A Smith
Departments of Surgery and Radiology, Stirling Royal Infirmary, Stirling FK8 2AG
SMJ 2008 53(1): 60
Abstract
Pyogenic hepatic abscess is an uncommon
disease, and hepatic abscess secondary to gallbladder
perforation is even rarer. We present a case of hepatic abscess secondary to
gallbladder perforation, who presented with nonspecific clinical features. The
diagnosis was made by radiological imaging and it was treated by percutaneous
drainage followed by drainage of hepatic abscess and cholecystectomy. There are
very few reported cases of hepatic abscess secondary to gallbladder perforation,
we report one such case and also review the literature for similar cases.
Key Words: Hepatic abscess, gall bladder
perforation, radiological drainage
Introduction
Hepatic
abscess is an uncommon disease and liver abscess secondary to acute gallbladder
disease or perforation is even rarer. Acute cholecystitis may result in
perforation of gallbladder in 3 to 12% of cases. Niemeier classified gallbladder
perforation into acute with free perforation into the peritoneal cavity,
subacute with formation of pericholecystic abscess and chronic with
cholecystoenteric fistula.1, 2, 3 There are very few cases of hepatic
abscess secondary to gallbladder perforation in the English literature. We
report one such case with a review of English literature for similar cases.
Case
Report
A
69 year old male was admitted to the medical unit with a low grade fever, night
sweats, dizziness, anorexia and weight loss. Two weeks previously, he was
admitted with similar complaints and was subsequently discharged on oral
antibiotics. His past medical history included hypertension, chronic obstructive
airway disease, depression and atrial fibrillation. His medication included
digoxin and warfarin. At admission he
was afebrile, and general physical and abdominal examination did not reveal any
gross abnormality.
Blood
results showed elevated inflammatory markers and ultrasound scan demonstrated a
thick wall gallbladder with adjacent collection containing stones. The CT scan
confirmed features of acute cholecystitis and also presumed perforation and
secondary liver abscess within segment 5. Ultrasound guided percutaneous
aspiration yielded 50 ml of pus. After aspiration he became acidotic and
developed septic features along with upper abdomen tenderness.
At
this stage he was transferred to surgical unit. He responded well to intravenous
fluids and antibiotics. Follow up
CT on third day demonstrated obliteration of the abscess cavity but the patients
pyrexia and pain did not settle.
Laparotomy
was performed, revealing an abscess cavity extending onto the liver surface
which contained multiple pigment stones. The abscess cavity was washed out,
stones were removed and cholecystectomy was performed. He was discharged home on
fifth postoperative day.
Six
days after discharge from hospital, he presented with upper abdominal pain,
vomiting and elevated alkaline phosphatase. The CT scan showed minimal
collection in subcapsular area which was aspirated under radiological guidance
and an ERCP showed free flow of bile. His symptoms settled and he was discharged
home and when reviewed six weeks after discharge from hospital, he was doing
well.
LITERATURE REVIEW
Fletcher,
et al4 reported a series of gallbladder perforations and included
five patients with gallbladder being perforated into liver with resultant
abscess. These patients were classified to have Niemeier type II gallbladder
perforation.
A
case of empyema of the gallbladder complicated by liver abscesses in a 62 years
male patient was reported by Danher, et al.5 Clinical feature was
suggestive of liver malignancy, diagnosis of abscess was made by ultrasound and
CT scan, this was treated initially by a percutaneous drainage and
cholecystotomy, followed be elective cholecystectomy.
Bakalakos
et al2 reported a 76 years old male patient with clinical and
radiological features highly suggestive of hepatic metastasis, no primary lesion
was however identified. Liver abscess was diagnosed by laparoscopic ultrasound.
Subsequent laparotomy revealed a necrotic gallbladder with perforation into a
large abscess cavity within the liver. The abscess was evacuated, irrigated and
cholecystectomy was performed. A 60 years old male patient was reported by Chen
et al,6 to have presented with features of acute cholecystitis.
Ultrasound scan suggested gallbladder rupture into the liver with associated
liver abscess. He was successfully treated with abscess drainage and
cholecystectomy.
Peer
et al7 reported four patients (2 male and 2 female) ranging in age
from 61-81 years, who presented with features of cholecystitis. Liver abscess
was diagnosed by ultrasound or CT scan, all patients had percutanous drainage of
abscess, two patients had subsequent cholecystectomies revealing partially
intrahepatic gallbladder. Teefy3 reported two male patients of 55 and
69 years of age, who also presented with features of cholecystitis. The
diagnosis was made by ultrasound and CT scan. They were treated by aspiration,
drainage and cholecystectomy. Gallbladders were noted to be partially or
completely intrahepatic.
Fischer8
reported 17 patients of hepatic abscess, out of which two were associated with
acute cholecystitis. These hepatic abscesses were found at surgery to be the
result of direct extension from an acutely inflamed gall bladder. Zerman9
reported 5 cases of hepatic abscess secondary to acute cholecystitis (4 male and
1 female), aged from 46 to 78 years. They presented with fever, abdominal pain
and one with jaundice. Liver abscess were diagnosed by USS and CT scan. In acute
phase all patients were treated with percutaneous drainage and subsequently four
had elective cholecystectomy.
Discussion
Pyogenic
abscess of the liver is still a serious illness and can be a diagnostic
challenge. Classic clinical features included fever, abdominal pain, jaundice
and tender hepatomegaly. Nevertheless we noted a variable clinical presentation,
from patients being pyrexial and systemically unwell to nonspecific illness, and
those mimicking hepatic malignancy. Inflammatory markers are not always elevated
and liver frunction tests can vary from normal to mildly deranged. Ultrasound
and CT imaging were diagnostic in the majority of cases and enabled simultaneous
treatment by aspiration and drainage.
Radiological
appearances of ‘cholecystohepatic fistula’ and ultrasonic ‘hole sign’
has been described in previous studies.2, 6 Studies also suggested
injection of contrast material into hepatic abscess cavity to define any
communication with biliary tree.8
Laparoscopy can also be useful if radiological findings are inconclusive.2,
10
The
clinical presentation of gallbladder perforation is often indistinguishable from
uncomplicated cholecystitis. Ultrasound and CT are used to diagnose suspected
gallbladder perforation. Recently MRI scan also has been suggested as more
accurate than these two conventional imaging techniques.11
Percutaneous drainage has become an increasingly preferred method for
treating hepatic abscesses with a success rate of 70% to 90% according to number
and location of abscesses. Surgical drainage is reserved for those abscesses
which can not be treated percutaneously for whatever reason, including
anatomical site, complications of percutaneous drainage or if hepatic carcinoma
is suspected.2, 6, 9
The
mode of spread from the gall bladder to liver is speculative. Possible routes
include direct invasion into liver parenchyma, subcapsular route or
haemotogenously via the portal veins. Perforation of the intrahepatic
gallbladder invariably results in a hepatic abscess, three patients in this
review had partial or completely intrahepatic gallbladder3,9, a
higher index of suspicion is appropriate in such patients. There have also been
several similar reports outside the English literature,12-15 which
suggests that this condition is not that uncommon. Both radiologist and surgeons
should be well aware of possibility of presence of hepatic abscess in patients
presenting with acute gallbladder disease. The chance of such an abscess is
higher if imaging shows demonstrates the presence of an intrahepatic
gallbladder.
References
1. Niemeier OW. Acute free perforation of the gallbladder. Ann Surg 1934; 99: 922.
2. Bakalakos EA, Melvin WS, Kirkpatrick R. Liver abscess secondary to intrahepatic perforation of the gallbladder presenting as a liver mass. Am J Gastroenterol 1996; 91: 1644-6
3. Teefey SA, Wechter DG. Sonographic evaluation of pericholecystic abscess with intrahepatic extension.. J Ultrasound Med 1987; 6: 659-662
4. Fletcer AG, Ravdin IS. Perforation of the gallbladder. Am J Surg 1951; 81:178-185
5. Danher J, Campbell H, Mendelson RM. Case report:atypical presentation of empyema of the gallbladder. Clin Radiol 1987; 38: 655-6
6. Chen JJ, Lin HH, Chiu CT, et al. Gallbladder perforation with intrahepatic abscess formation. J Clin Ultrasound 1990; 18: 43-5.
7. Peer A, Witz E, Manor H, et al. Intrahepatic abscess due to gallbladder perforation. Abdom Imaging 1995; 20: 452-5.
8. Fischer MG, Beaton HL. Unsuspected hepatic abscess associated with biliary tract disease. Am J Surg 1983; 146: 658-62.
9. Zerman G, Bonfiglio M, Borzellino G, et al. Liver abscess due to acute cholecystitis. Report of five cases. Chir Ital 2003; 55: 195-8.
10. Yanaga K, Kitano S, Hashizume M, et al. Laparoscopic drainage of pyogenic liver abscess. Br J Surg 1994; 81: 1022.
11. Sood B, Jain Manoj, Khandelwal N, et al. MRI of perforated gall bladder. Australian Radiology 2002; 46: 438-40.
12. Guy-Grand B, Slama G, Moreanux J, et al. Liver abscess caused by gallbladder rupture during pyocholecystitis. Sem Hopp 1971;47: 2737-40.
13. Pratschke E, Berger H Perforation of the gall bladder into the liver in gallstone occlusion of the cystic duct. Chirurg 1989; 60: 433-4.
14. Teebken OE, Bartles M, Fangmann J, et al. Chronic cholecystitis simulating gallbladder tumour with liver abscess. Case report. Swiss Surg 2001; 7: 28-31.
15.
Radzikhovskii AP, Babenko VI. The surgical procedure and treatment of
paravesical abscesses in acute cholecystitis in middle-aged and elderly
patients. Klin Khir 1992; 9-10: 33-7.
Fig 1: Trans-abdominal ultrasound showing abnormal and thickened gallbladder
Fig 2: Contrast enhanced CT demonstrating segment 5 abscess cavity containing stones