S2251 Liver Abscess Associated With Diverted Ileal Pouch

Abstract

INTRODUCTION: Pyogenic liver abscess (PLA) is a rare disease with an incidence of 3.6 cases per 100,000 in the United States. There is no existing literature about PLA developing in a patient with UC who had undergone long-term bowel diversion. We present the first case of a patient with chronic pouchitis and recurrent stricture formation, presenting with a PLA. CASE DESCRIPTION/METHODS: 46-year-old female with UC status post-total proctocolectomy with ileal pouch-anal anastomosis (IPAA) at age 22 and loop ileostomy at age 43 presented to an outside hospital with a three-week history of intermittent right upper quadrant abdominal pain and increased non-bloody ileostomy output. Her UC had been complicated by a history of anal fistula, chronic pouchitis and recurrent strictures treated with needle knife stricturotomy (NKSt) every six months. The last NKSt session was four months prior to admission. On presentation, the patient was hypotensive and tachycardia. Labs revealed WBC count of 13,600/mm 3 , hemoglobin 8.8 g/dL, AST/ALT 157/170 IU/L, ALP 95 IU, and total bilirubin 0.9 mg/dL. The patient was started on IV fluids and empiric meropenem. Abdominal ultrasound revealed a liver mass, and abdominal CT showed a 10 cm heterogeneous liver mass concerning for malignancy.The next day she was transferred to our institution for further evaluation. A repeat abdominal CT scan showed a 12.7 cm hepatic abscess with a mass effect on the main portal vein. Liver abscess was drained and fluid cultures were positive for streptococcus anginosus. Patient was discharged on IV meropenem for an additional 3 weeks before being switched to oral amoxicillin-clavulanate for an additional 2 weeks. Three months later the patient underwent surgical excision of the diverted pouch and creation of end ileostomy, to prevent future risk of PLA. DISCUSSION: This report highlights the first case of pyogenic liver abscess in a patient with a long-standing history of diversion pouchitis and recurrent pouch strictures. Previously, twelve cases of PLA associated with UC have been reported. The associated pathogens were usually normal gut flora, such as the Streptococcus anginosus family. In animal models the mucosa in a diverted colon becomes a breeding ground for bacteria, increasing the probability of bacterial penetration through the mucosal barrier. Pouch excision and permanent diversion is necessary if there is pouch failure due to pelvic sepsis, chronic pouchitis or recurrent stricture/fistula formation in the pouch.Figure 1