Hepatobiliary and pancreatic: Hepatic abscess associated with a hepatoenteric fistula

Abstract

What abnormalities are shown on the contrast-enhanced computed tomography scan in Fig. 1? There is a cavity in the right lobe of the liver that contains a large amount of air and demonstrates an air-fluid level. In addition, intrahepatic bile ducts are dilated and there is a possible mass involving the duodenum. The patient was a man, aged 56, who had been treated surgically for rectal cancer 5 years previously. He subsequently developed liver metastases and had undergone two wedge resections and gamma-knife therapy. On admission to hospital, his symptoms included abdominal pain, fever and jaundice. On the reformatted coronal image (Fig. 2), a fistula (arrow) was suspected between the abscess cavity and metastatic tumor involving the duodenum. The patient was treated with percutaneous drainage of the abscess and percutaneous drainage of the biliary system. With injection of contrast into the abscess cavity, some contrast passed through a fistula into the duodenal lumen. In a typical hepatic abscess, air may be present in the abscess cavity but the volume of air is relatively small and usually appears as ‘air pockets’. The presence of a large volume of air with an air-fluid level should raise the possibility of a fistula between the abscess and the alimentary tract. Indeed, there are a number of case reports where hepatic abscesses have resulted from invasion of the duodenum by a primary hepatic tumor. To our knowledge, however, this is the first report of a hepatic abscess caused by a hepatoenteric fistula associated with a metastatic tumor. Although therapeutic measures such as those described above may result in improvement in symptoms, such patients usually have a poor prognosis because of widespread malignant disease. Contributed by