Pyogenic Liver Abscesses: Incriminating Perforated Appendicitis

Abstract

We report a case of a 26 year old male with no prior medical history who presented with nausea, vomiting, abdominal pain, diarrhea and fevers for 3 weeks. Diarrhea was watery, non-bloody, occurring 2-3 times daily, associated with intermittent bilious vomiting. The patient admitted to anorexia with 15 pound unintentional weight loss over this time period. Abdominal pain was sharp, right upper quadrant, non-radiating, and progressively worsening. He denied any recent travel or sick contacts. On exam, the patient was febrile and tachycardic, with right upper quadrant tenderness. There was no rebound or tenderness at McBurney's point, and psoas and obturator signs were negative. Laboratory investigation revealed a WBC 16,500cells/mcL, AST 111U/L, ALT 74U/L, ALP 146U/L, total bilirubin 3.5mg/dL and direct bilirubin 2.4mg/dL. Abdominal CT scan showed multiple coalescing hypoattenuated peripherally enhancing masses throughout the right hepatic lobe, superior mesenteric vein thrombus, and a conglomeration of multiple nodular masses in the right lower quadrant. The patient was started on intravenous antibiotics and heparin; however, he remained febrile and symptomatic. He subsequently underwent percutaneous drainage of the hepatic abscesses. Despite these interventions, the patient deteriorated clinically. An abdominal MRI showed 10 T2 bright lesions in the right hepatic lobe and an involuting pericecal lesion. The patient underwent exploratory laparotomy, where a perforated appendix was discovered and resected. Following surgery, the patient's symptoms improved with no further signs of sepsis. He was treated with an extended course of antibiotics on discharge. Pyogenic liver abscesses (PLA) are rare and potentially life threatening infections. While most commonly caused by bacteria originating in biliary and portal tracts, perforated appendicitis has rarely been implicated. This case illustrates not only a rare etiology of PLA, but an unusual course of these two clinical entities. Literature indicates that patients classically present with appendicitis, undergo appendectomy, but continue to deteriorate until PLA are identified and treated. The example in this vignette suggests that physicians should be aware of perforated appendicitis as a cause for PLA in a patient not improving with antibiotics and drainage. Further, in cases where imaging studies are non-diagnostic, exploratory laparotomy should be considered for diagnostic and therapeutic implications.Figure 1