EUS-Guided Hepaticogastrostomy with Lumen-Apposing Metal Stent (LAMS) for Management of Pyogenic Liver Abscess: Presidential Poster Award

Abstract

A 45 year old man with history of remote open cholecystectomy in the Dominican Republic presents with two weeks of abdominal pain and fevers. The patient reported onset of epigastric and RUQ pain two weeks prior. The pain was progressive and nonradiating. He reported nausea without vomiting. On exam, he was noted to be febrile and tachycardia. He was alert and in no actue distress. No scleral icterus or jaundice was noted. His abdomen was soft and tenderness to palpation in the epigastrum was noted. On CT scan, a 7.5 x 8.7 cm heterogenous, multiseptated mass was noted in the left hepatic lobe. Blood cultures and fungal cultures were sterile. Based on the location of the lesion, EUS-guided hepaticogastrostomy was attempted for abscess drainage. On EGD, extrinsic compression was noted along the lesser curvature of the proximal body of the stomach. On EUS, a large, heterogenous hypoechoic mass was noted in the left hepatic lobe. An electrocautery-enhanced 15 mm Axios stent was deployed into the abscess cavity. Purulent drainage was noted in the stomach after deployment of the proximal phlange of the stent. The stent was dilated with a CRE balloon to 15 mm to maximize drainage. The patient defervesced 24 hours after stent placement and his abdominal pain fully resolved three days after stent placement. He was continued on antibiotics. A repeat CT scan performed one week after stent placement revealed complete resolution of the abscess cavity. A repeat EGD performed ten days after stent placement noted a completely decompressed abscess cavity and the stent was subsequently removed with a rat-tooth forceps. At one month followup, the patient reported feeling well without symptom recurrence. Watch the video: https://goo.gl/GKg3iE1684_A Figure 1. CT images of hepatic abscess1684_B Figure 2. MRI images of hepatic abscess