Ashley Serjilus, MD, Daniel Chang, DO, Oskar Kischner, MD, Varea Costello, MD Naval Medical Center Portsmouth, Portsmouth, VA
Introduction: Pyogenic liver abscesses (PLAs) are traditionally managed via antibiotic therapy in combination with percutaneous drainage. However, optimal management of multiloculated, larger (defined as >5 cm) or giant pyogenic liver abscesses ( >10 cm) has generally included surgical intervention given the challenges of establishing source control with percutaneous drainage alone, though this approach has undergone increased scrutiny over the past decade. In this case report, we present a case of giant, multiloculated PLA effectively treated through a non-operative approach, supporting the possibility for minimally invasive techniques as an option in select cases.
Case Description/Methods: A 39-year-old man presented to the ED with a one-week history of fevers and jaundice. He was febrile to 38.5 C with a heart rate of 116, and his exam revealed scleral icterus and diffuse abdominal tenderness on palpation. Labs were remarkable for leukocytosis to 14.7 x 10^9/L, CRP and ESR to 199.2 and 91.0, respectively, and total bilirubin of 5.4 mg/dL, AST of 357 U/L, and AKP of 203 U/L. A contrast-enhanced CT scan of the abdomen and pelvis demonstrated a multiloculated abscess measuring 12 cm x 9.4 cm x 11 cm in the right hepatic lobe. He was admitted and started on vancomycin and piperacillin-tazobactam. Interventional radiology was consulted and placed a percutaneous drain in the abscess; cultures from the aspirate grew Streptococcus viridans, which were also speciated from his admission blood cultures. Operative management with surgical debridement was deferred due to the proximity of the abscess to vasculature with concerns for significant bleeding. A non-surgical approach was ultimately pursued and successful. He completed outpatient intravenous antibiotics with four weeks of ertapenem, followed by eight weeks of amoxicillin-clavulanic acid, leading to eventual normalization of his inflammatory markers and radiographic resolution of the abscess.
Discussion: With lower rates of recurrence and treatment failures compared to percutaneous drainage, surgical management is generally recommended for multiloculated, giant PLAs, though the ideal approach remains controversial. In this case, we add to the growing body of literature suggesting that a non-operative strategy with percutaneous drainage and antibiotic therapy can be effective in treating giant, multiloculated liver abscesses.
Figure: A. Contrast Enhanced CT, Axial Slice: Large Multiloculated Rim Enhancing Collection in the Right Hepatic Lobe B. Contrast Enhanced CT, Coronal Slice: Large Multiloculated Rim Enhancing Collection in the Right Hepatic Lobe C. MRI, Fat Suppressed T1WI axial slice through the Liver: Large Multiloculated Rim Enhancing Collection. D. MRI, Fat Suppressed T1WI coronal slice through the Liver: Large Multiloculated Rim Enhancing Collection. E,F: Contrast enhanced Axial and Coronal images through the Abdomen: Near complete resolution of previously seen hypodense rim enhancing collection. Residual hypoattenuating triangular region likely represents healing/fibrous tissue.
Disclosures:
Ashley Serjilus indicated no relevant financial relationships.
Daniel Chang indicated no relevant financial relationships.
Oskar Kischner indicated no relevant financial relationships.
Varea Costello indicated no relevant financial relationships.
Ashley Serjilus, MD, Daniel Chang, DO, Oskar Kischner, MD, Varea Costello, MD. P4724 - Successful Treatment of a Multiloculated, Giant Pyogenic Liver Abscess Through Non-Operative Approach, ACG 2024 Annual Scientific Meeting Abstracts. Philadelphia, PA: American College of Gastroenterology.
