Liver Microabscesses Due to Choledocholithiasis Masquerading as Metastatic Liver Lesions

Abstract

A 56 year-old man with a past medical history of HTN presented with 2.5 weeks of right upper quadrant abdominal pian and a 20lb weight loss. Reported fevers, chills, jaundice, and tea colored urine. Laboratory findings were significant for an elevated total bilirubin of 2.1 mg/dl and an alkaline phosphatase of 918 IU/L. A CT scan of the abdomen and pelvis with IV contrast showed multiple irregularly shaped hypoattenuating masses disseminated throughout the liver with the largest measuring 3.1 cm and a lamellated soft tissue mass within the common bile duct extending into the right and left intrahepatic bile ducts. A subsequent MRI showed several filling defects throughout the biliary tract with ductal dilation. An ERCP was performed which revealed large grape like gallstones filling the common bile duct. While performing cholangioscopy, the stones were fragmented using the holmium laser and removed with balloon sweeps. Brushings of the biliary tree did not reveal any evidence of malignancy. The patient was discharged on intravenous antibiotics. On subsequent follow up, the patient was asymptomatic and his liver was normal appearing on MRI, with no evidence of biliary obstruction, choledocholithiasis, or malignancy. There are 3 major etiologies for a liver abscess: pyogenic (80%), amebic (10%) and fungal (< 10%). A pyogenic liver abscess usually arises from the biliary tract due to the obstruction of bile flow. Typically, a patient will present with continuous or intermittent fever, right upper quadrant pain, weight loss, nausea and vomiting. Jaundice may be present in 25% of patients associated with biliary tract disease. A CT Scan with IV contrast remains the diagnostic modality of choice and can be used for guiding percutaneous aspiration and drainage, when needed. In this case, the patient presented with chronic intermittent fever, right upper quadrant pain, weight loss with no elevation in his white blood count. The CT scan finding of a lamellated mass in the common bile duct and multiple hypoattenuation liver lesions, gave the appearance of an intraductal cholangiocarcinoma, rather than choledocholithiasis which is a rare presentation of liver abscess masquerading malignancy. Because the liver abscesses were caused by the obstruction of bile flow from choledocholithiasis, the patient was treated with broad spectrum antibiotics and ERCP with cholangioscopy, lithotripsy, and stone extraction rather than percutaneous drainage of the liver abscesses.Figure 1Figure 2Figure 2