Pyogenic Liver Abscess Due to Diverticulitis

Abstract

Purpose: AIM: Diverticulitis involving the colon can occasionally present with complications, including perforation, obstruction and abscess. This report describes a case of sigmoid diverticulitis which presented with a protracted illness related to a large hepatic abscess. CASE REPORT: A 43 yo male with a history of systemic hypertension and sleep apnea presented in 7/10 with complaints of fever, upper abdominal pain and 12 lb weight loss over the preceding 6 mos. Physical examination revealed signs of dehydration, lowgrade fever and right upper quadrant tenderness. CT scan showed a 12.3 cm x 9.9 cm heterogeneous right liver lobe mass and a 3.5 cm peri-sigmoid soft tissue mass which contained an air locule. Lab tests indicated: serum bilirubin 1.6 mg/dl (N=0.2-1.1), serum transaminase levels 3 X ULN, serum alkaline phosphatase 3X ULN and peripheral leukocyte count 16,100 (N=4,200-10,800). A serum CEA level was 0.2 (N= < 2.5 mg/ml for non-smoker). The patient was admitted to the hospital for hydration and expedited evaluation. Colonoscopy revealed moderate sigmoid diverticulosis and a short segment of mid-sigmoid luminal erythema and edema. A diagnosis of presumptive sigmoid diverticulitis with pericolonic and pyogenic liver abscess was made and broad-spectrum antibiotics (levofloxacin and metronidazole) were instituted. The patient underwent aspiration of the liver lesion under CT-guidance, which yielded ˜750 ml of purulent material. A percutaneous drain was left in the liver and antibiotics were continued. The fluid did not grow any pathogens, although the pyogenic abscess was presumed to be bacterial in etiology. It was believed that bacterial pathogens were not isolated from the abscess as the patient had been receiving antibiotics for ˜ 36 hrs prior to the CT-guided liver drainage procedure. He was discharged home on ertapenem intravenously. The patient was followed on an outpatient basis by serial CT scanning and clinical evaluation, and periodic repositioning of the drain within the liver abscess cavity occurred. The abscess progressively diminished in size and the final CT scan, performed 16 weeks after his initial presentation, revealed collapse and resolution of the liver abscess cavity. The patient then underwent uneventful elective laparoscopic sigmoid resection. The patient ultimately made a full and unremarkable recovery. CONCLUSION: This case describes a patient presenting with sigmoid diverticulitis with localized peri-sigmoid abscess, and large pyogenic liver abscess. Combined prolonged antibiotic therapy and percutaneous liver abscess drainage led to clinical and radiographic resolution of the abscess.