S3657 Delayed Presentation of Pyogenic Liver Abscess Following an Appendectomy

Abstract

Introduction: Historically, appendicitis was a common cause of pyogenic liver abscess (PLA), however, antibiotics and early surgical intervention have improved outcomes. This case depicts a delayed presentation of liver abscess secondary to perforated appendicitis. Case Description/Methods: A 34-year old male presented with a 2-week history of right upper quadrant pain, 4 days of fever with chills, nausea, and vomiting. Six months ago he had a perforated appendix with a subsequent appendectomy. He denied any alcohol use, illicit drug use, and recent travel. Vitals revealed a temperature of 101.1°F, HR of 112, and SBP fluctuating from 70-90 mmHg. Labs were significant for WBC 18.2, AST 50, ALT 66, ALP 255, TBILI 1.0, INR 1.64, PT 18.5, PTT 30.7, and lactate 3.4. A CT of the abdomen without contrast demonstrated a 6.0 x 9.0 cm bilobed lesion in the right lobe of the liver suspicious for hepatic abscess. The abscess was percutaneously drained and cultures grew moderate E. coli and many Bacteroides fragilis with stool ova/parasite positive for Blastocystis hominis. Based on antimicrobial sensitivity the patient was discharged on ciprofloxacin and metronidazole. On outpatient follow-up, repeat imaging showed that the abscess had decreased in size to 3.0 x 3.0 cm and was responding to antibiotic treatment and drainage. Discussion: Appendicitis was previously one of the most common etiologies for liver abscesses, however with better diagnostic and treatment modalities for appendicitis, it is seldom considered. PLA is defined as one or more discrete lesions in the liver associated with a positive bacterial culture and accounts for 48% of all visceral abscesses in the US. PLA is usually due to polymicrobial infections, most commonly E. coli and Klebsiella but may also include Streptococcus, Staphylococcus, and anaerobes. Risk factors include male gender, advanced age, diabetes, chronic PPI use, malignancy, cirrhosis, and liver transplant history. Liver abscesses are most commonly found in the right lobe of the liver due to receiving venous drainage from the cecum and ascending colon. Screening colonoscopy should be considered when there are cultures with anaerobic growth as anaerobic abscesses are associated with silent colon cancer. In-hospital mortality for PLA is estimated to range between 2.5-19%. Management of PLA is largely dependent on the size of the abscess. Antibiotic use is the treatment of choice for small abscesses of < 3-5 cm, while anything larger also requires percutaneous or surgical drainage.Figure 1.: CT abdomen pelvis without IV contrast demonstrated a 6.0 x 9.0 cm bilobed lesion in the right lobe of the liver suspicious for hepatic abscess.