Abstract
BackgroundJuxta-papillary duodenal diverticulum (JPDD) has been associated with obstructive jaundice and ascending cholangitis. Potential mechanisms include periampullary colonization of pathogenic bacteria and mechanical obstruction. However, the relation of JPDD with pyogenic liver abscess (PLA) has not been reported. Moreover, approximately one third of patients with PLA have no identifiable risk factors and are labelled as “cryptogenic”. We hypothesized that JPDD is an unidentified risk factor for cryptogenic PLA and the aim of this study was to examine this association.MethodsWe conducted a retrospective chart review to identify cases of PLA (n = 66) and compare those to matched controls (n = 66). 66 patients met the study inclusion criteria of a diagnosis of PLA using computerized tomography (CT) imaging and either positive culture or confirmed resolution after antibiotic therapy. Patients with diagnoses of amebic liver abscess, traumatic liver abscess, post cholecystectomy liver abscess, concurrent acute cholecystitis, and hepatobiliary malignancy were excluded. Controls were identified from a radiology database and matched one-to-one with the cases by age and sex. Demographic and clinical data was extracted from electronic medical records. CT scan images of all cases and controls were reviewed by a single expert radiologist to identify the presence of JPDD. Statistical tests including Chi-square and t-test with multiple logistic regression were used to examine the group differences in JPDD and other factors.ResultsAmong 132 study samples, 13.6% (9/66) of the cases were found to have JPDD, compared to 3.0% (2/66) among controls (p = 0.03). This corresponded to an odds ratio (OR) of 5.05 [OR 5.05; CI 1.05–24.4] on multiple logistic regression analysis. In addition, 1/3rd of PLA cases with JPDD had no other traditional risk factors (cryptogenic PLA). However, a statistically significant association of JPDD with cryptogenic PLA could not be established possibly because of a small number of cases. We found significantly high rate of diabetes mellitus (DM) (42.4%; n = 28/66) among cases compared to controls (21.2%; n = 14/66; p = 0.01).ConclusionWe found a significant association between JPDD and PLA. We need studies with larger sample sizes to confirm this relationship and to explore if JPDD could be related to cryptogenic liver abscesses.
Highlights
Juxta-papillary duodenal diverticulum (JPDD) has been associated with obstructive jaundice and ascending cholangitis
It seems plausible that JPDD may cause pyogenic liver abscesses by promoting infection ascent to the liver, it has not been studied to date
The logistic regression results showed that patients with pyogenic liver abscess (PLA) were 5.05 [odds ratio (OR) 5.05; CI 1.05–24.4] times more likely to have a comorbid diagnosis of JPDD than those without PLA (Fig. 1)
Summary
Juxta-papillary duodenal diverticulum (JPDD) has been associated with obstructive jaundice and ascending cholangitis. The relation of JPDD with pyogenic liver abscess (PLA) has not been reported. Approximately one third of patients with PLA have no identifiable risk factors and are labelled as “cryptogenic”. We hypothesized that JPDD is an unidentified risk factor for cryptogenic PLA and the aim of this study was to examine this association. Approximately 20–30% cases have no identifiable traditional risk factors and have been labeled as “cryptogenic” [2, 3]. The literature describes them as juxta-papillary or peri-ampullary duodenal diverticula. Juxta-papillary duodenal diverticula have been associated with choledocholithiasis, cholelithiasis as well as cholangitis [4]. We performed a retrospective case control study to evaluate whether JPDD is associated with cryptogenic PLA
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