Hepatic Drainage Research Articles

Anomalous hepatic drainage and platypnea-orthodeoxia in cyanotic children.

The aetiology of cyanosis could be unclear in children, even for specialised paediatricians. Two cases were reported: first, a 6-year-old child with features of left isomerism and Fallot was fortuitously diagnosed with anomalous hepatic venous drainage before complete repair. Second, a newborn with an antenatal diagnosis of ductus venosus agenesis had an isolated intermittent right-to-left atrial shunt when upright, with favourable outcome, in contrast to the association with significant heart malformations including inferior caval vein interruption. Multimodality imaging and 3D printing helped to rule out extracardiac causes of persistent cyanosis and plan surgical repair.

Success Rate of Adrenal Venous Sampling and its Determining Factors: Experience of a Single Center in Malaysia

Primary hyperaldosteronism has been regarded as the commonest and potentially curable cause of secondary hypertension in up to 80% of cases if this condition is detected early. Laparoscopic adrenalectomy proved to be a promising curable method for primary hyperaldosteronism secondary to aldosterone producing adenoma (APA), while primary hyperaldosteronism secondary to bilateral adrenal hyperplasia (BAH) requires optimization of medical treatment. Adrenal venous sampling (AVS) has been recommended by the Endocrine Society's guideline in addressing the subtypes of primary hyperaldosteronism. Therefore, determining success rate of AVS in our centre is crucial in the management of primary hyperaldosteronism and to prevent redundant procedures. The objectives of this study were to evaluate the success rate of AVS in our centre and the associated factors that correlate with the success rate. A retrospective study in a single centre, all adult patients who were diagnosed with primary hyperaldosteronism and underwent AVS in our centre between 2014 until 2022 were included. Successful samples defined by a selectivity index (SI) of ≥ 2, that is, the ratio of adrenal vein cortisol level to the peripheral vein cortisol level, were evaluated. The baseline demographic characteristics of each patient, technical parameters of AVS, and anatomical parameters of right adrenal vein from the venographic images were evaluated and analysed to correlate with the outcome of AVS. A p-value of <0.05 was considered statistically significant. The overall success rate of AVS in our centre was 61.3%. The success rate significantly increased to 80.6% in the trained IR group, which represents a single IR who had completed specific training in adrenal venous sampling (AVS), compared to non-trained IR group which consisted of a total of 10 IRs without specific AVS training (p=0.046). The right AVS had lower success rate than the left AVS (64% vs 94.6%). The type of right adrenal vein pattern showed significant association with the outcome of AVS (p=0.014). There were 6 types of right adrenal vein patterns observed in our study; Type 1 - gland-like pattern with numerous branches, Type 2 - delta pattern, Type 3 - triangular pattern with central "blush", Type 4 - no discernible pattern and Type 5 - spidery or stellate pattern. The sixth pattern was the hepatic radicles blush with hepatic drainage, for which blood sampling were also collected due to its appearance was frequently indistinguishable from the Type 1 pattern. The results showed Type 2 pattern had the highest incidence (30.5%; 32/105 samples) and Type 5 had the highest success rate (100%; 11/11 samples), while the hepatic radicles blush pattern had the highest incidence in fail samples resulting in the highest failure rate (94.7%; 18/19 samples). The visualisation of the inferior emissary vein from the venographic images during right AVS had a significant association with the successful AVS (97.5% success rate; 39/40 samples; p=0.003). Contrariwise, blood sampling withdrawn from the right adrenal vein in the presence of hepatic drainage communication associated with the failure AVS (86.7% failure rate; 26/30 samples; p=0.001). The overall success rate of both AVS in our centre was 61.3%, and the success rate was higher in the trained IR group than the non-trained IR group. The visualisation of inferior emissary vein and the type of right adrenal vein patterns were the key determining factors with significant association to the successful right AVS. Conversely, blood sampling withdrawn from the hepatic radicles and hepatic drainage had significant association with the failure right AVS.

Budd-Chiari Syndrome: A Rare Complication of Hepatic Hydatid Cyst

Budd-Chiari syndrome is a rare disease characterized by a defect in hepatic venous drainage. It can be primary, occurring due to venous thrombosis, or secondary, caused by compression or invasion of the hepatic drainage veins. Symptoms can be acute, chronic, or even asymptomatic. Diagnosis is based on imaging tests that show hepatic vein obstruction, collateral circulation, and morphological changes in the liver. Treatment aims to identify and treat the underlying disease.We report a case of a patient with Budd-Chiari syndrome secondary to a liver hydatid cyst to highlight the radiological aspects of this pathology.

A case report of Y-shaped bi-directional Fontan procedure: promising long-term outcomes for single ventricle physiology patients

BackgroundAchieving optimal hepatic factor distribution and total cavopulmonary resistance is crucial for long-term outcomes in single ventricle palliation patients. Y-shaped Gore-Tex Fontan procedure redirects hepatic drainage to both the right and left pulmonary arteries. The aim of this approach is to achieve bilateral pulmonary distribution of hepatic factors and reduce the risk of arteriovenous malformations that can develop in single-ventricle patients.Case presentationWe present a unique case of a 20 years old female with symptoms of heart failure, who has a history of complex heterotaxy with polysplenia, interrupted Inferior vena-cava, and double outlet right ventricle with unbalanced atrio-ventricular septal defect, d-malposed great arteries, and pulmonary atresia. Fenestrated Y-shaped Gore-Tex Fontan procedure was successfully done which was confirmed by performing cardiac CT angiography.ConclusionsStudies have shown that achieving balanced hepatic factor distribution and low resistance in the Fontan pathway can improve long-term outcomes. This procedure has demonstrated positive results in terms of oxygen saturation and reduced asymmetric blood flow distribution. Level of Evidence Level 4, Case Report.

A comparative study of laparoscopic cholecystectomy with and without abdominal drain

Background: Laparoscopic cholecystectomy (LC) has been considered the Gold-standard for the management of benign gallbladder disease. With increasing surgeon experience and advancement of instrumentations and equipment, LC is approaching continuously toward a more safe and less invasive technique. There is a consensus that drainage should not be considered mandatory or standard after elective LC. Aims and Objectives: The aims of this study were to assess the effectiveness of the LC without abdominal drain over sub hepatic drainage and to compare the post-operative outcome between two groups. Materials and Methods: A descriptive observational comparison study has been carried out in the department of General Surgery BSMCH, from September 1, to December 1, in 130 patients undergoing elective LC. Patients have been divided into two groups: Comparison group and study group after proper matching. Data have been collected via interview, clinical examination, and scrutinizing relevant medical records. Each patient has been followed up after operation. Data have been summarized for estimating various parameters such as mean duration of surgery and hospital stay between the groups and proportion of patient complaining of pain 24 h after surgery. Results: The mean duration of surgery in drainage group is 108 min which is significantly more than the non-drainage group 88 min. In this present study, the patients with abdominal drain are showing more incidence of post-operative nausea and vomiting (PONV) 21.53% compared to no-drain group 6.15%. In this study, 35.38% of patients with subhepatic drain developed pain after surgery, whereas only 12.3% of the patients with no drain experienced the same. Overall six patients from the drain group still had significant subhepatic collection and eight patients with no drain have the same. The mean duration of stay in hospital of the drain group is 4.06 days, whereas, in no-drain group, it is 2.26. Conclusion: An uncomplicated gallstone disease can be treated by LC without need for drain with reasonable safety by an experienced surgeon. Hence, no use of drain scores over use of drain in terms of PONV, post-operative pain, and therefore, there is less use of analgesics and also short duration of hospital stay. When a dry operative field is achieved during LC the drain insertion may be avoided.

Choledochal cyst with a twist: Type 1 choledochal cyst and dilated cystic duct with aberrant accessory right hepatic drainage

Choledochal cysts are rare cystic dilations of the biliary tree that typically involve the extrahepatic bile duct and more infrequently, the intrahepatic bile ducts. Todani's classification of choledochal cysts is the most referenced system in which five types of choledochal cysts are described. Several new variants have been reported including dilations of the cystic duct and a double common bile duct. We describe a never reported variant involving dilation of the common bile duct, dilation of the cystic duct and an accessory right hepatic duct.

Percutaneous recanalization in hepatic vein-type Budd-Chiari syndrome: hepatic or accessory hepatic vein

Purpose This study was designed to assess the clinical efficiency and long-term outcomes of hepatic vein (HV) and accessory hepatic vein (AHV) recanalization in patients with HV-type Budd-Chiari syndrome (BCS). Material and methods A total of 27 patients with HV-type BCS underwent AHV recanalization and 94 patients had HV recanalization at our center from January 2012 to December 2019. The treatment effectiveness and long-term outcomes were compared. Results Technical success was accomplished in all patients, without any procedure-related complications. The clinical success rates were 96.3% (26/27) and 95.7% (90/94) (p = 1.000). In the AHV and HV groups, re-obstruction was observed in 5 and 36 patients, respectively (p = 0.056). The median primary durations of AHV and HV patency were 64 and 49 months, respectively (p = 0.036), while the median secondary durations of AHV and HV patency were 70 and 64 months, respectively (p = 0.134). The median overall survival after AHV and HV recanalization was 73 and 78 months, respectively (p = 0.263). Conclusions Our findings suggest that AHV could be employed as a replacement for HV, as a hepatic drainage vein, in HV-type BCS patients.

Superior mesenteric venous thrombosis presenting with hematemesis: a case report

The superior mesenteric vein (SMV) is one of the two tributaries to the portal vein, which is the main pre- hepatic drainage channel of the splanchnic circulation. Venous thrombosis in the SMV is one of the rare causes of splanchnic ischemic syndrome. Clinical presentation is often vague abdominal symptoms. It seldom presents with hematemesis, which may further confound diagnosis, thereby increasing the risk of poor outcomes. This case highlights an otherwise healthy 31-year-old woman, who presenting at a tertiary hospital in Nairobi with a 2-day history of epigastric pain and copious hematemesis. She had been treated for Helicobacter pylori gastritis 2 months prior. Common differentials were considered. However, with normal esophagogastroduodenoscopy findings and dark- colored fluid sequestered in the upper gastrointestinal tract, mesenteric venous congestion with associated small bowel ischemia was suspected. Three-phase abdominal computed tomography angiogram confirmed proximal superior mesenteric venous thrombosis extending into the portal vein confluence. Associated small bowel necrosis was suspected, and surgery involving resection and primary ileo-jejunal anastomosis was performed. Post-operative 2-week parenteral nutrition and anticoagulation were administered. The patient was discharged after 3 weeks of hospitalization and remains in excellent condition.

Recent advances regarding endoscopic biliary drainage for unresectable malignant hilar biliary obstruction.

Biliary drainage for unresectable malignant hilar biliary obstruction (UMHBO) is still associated with a number of controversies to be resolved. The superiority of bilateral drainage in comparison to unilateral drainage has not been proven obviously yet. However, bilateral drainage is necessary to treat obstructive jaundice in some UMHBO patients, and this may be connected with preservation of the functional liver volume. The partial stent‐in‐stent (SIS) method and side‐by‐side (SBS) method developed as bilateral drainage methods. There is no significant difference in the technical or clinical success rates of the SIS and SBS methods. In addition, these methods are comparable in terms of adverse events, patency period, and survival period. On the other hand, reintervention for recurrent biliary obstruction (RBO) after the SBS method seems to be easier in comparison to cases with RBO after the SIS method; however, there is no remarkable difference in the clinical results of these procedures. Endoscopic ultrasound (EUS)‐guided biliary drainage also has become an option for patients with UMHBO. Left hepatic drainage using EUS‐guided hepaticogastrostomy (EUS‐HGS) has become common; however, few studies have reported the results of bridging drainage for the right lobe using the EUS‐HGS route or EUS‐guided hepaticojejunostomy. A few studies addressed the results of newly designed stents, such as the 6‐mm braided metal stent and inside stent. The development of various drainage methods and new devices is necessary for the further advancement of endoscopic biliary drainage for patients with UMHBO, further studies to evaluate those methods and devices are warranted.

Biliary Complications and Its Management After Laparoscopic Cholecystectomy: A Review

Laparoscopic cholecystectomy has emerged as a gold standard therapeutic option for the management of symptomatic cholelithiasis. However, adaptation of LC is associated with increased risk of complications, particularly bile duct injury ranging from 0.3 to 0.6%. Occurrence of BDI results in difficult reconstruction, prolonged hospitalization, and high risk of long-term complications. Management of Bile duct injury depends on the nature of injury, time of detection, and the expertise available and would range from simple sub hepatic drainage to Roux-en-Y hepaticojejunostomy particularly performed at specialised centers. By constant and continuous analysis of the problem and information to the surgical community it should be possible to decrease the prevalence of iatrogenic BDI and even to avoid it.This article based on the literature review aims to review the biliary complications following laparoscopic cholecystectomy and the management approach.

Radiological Intervention and Imaging Procedures in Management of Patients with Malignant Obstructive Jaundice

AbstractBackground: Malignant biliary obstruction has a bad prognosis and adverse effect on the quality of life, with most of those patients are inoperable at time of diagnosis. Patients who underwent whipple operation may develop anastomotic site (choledocho-jujenostomy) stenosis with subsequent ele-vated bilirubin level and related complications.Aim of Study: This prospective study will be conducted to evaluate the efficacy of different modalities of interventional radiological and imaging procedures as Percutaneous Trans hepatic Cholangiography (PTC), Percutaneous Trans hepatic Drainage (PTD) and biliary stenting in management of patients with malignant obstructive jaundice.Patients and Methods: This study was conducted on 30 patients (19 males and 11 females) with mean age of 56 years, 28 of 30 patients (93.3%) are non operable and the other 2 of 30 patients (6.7%) operated patients for choledocho-jujenostomy stenosis were subjected to intervention techniques. 10 of 30 patients (33.3%) underwent percutaneous external biliary drainage, 15 of 30 patients (50%) underwent percuta-neous stent insertion (8 of 30 patients (26.7%) with metallic stents & 7 of 30 patients (23.3%) with plastic stents), 3 of 30 patients (10%) underwent internal external drainage and 2 of 30 patients (6.66%) underwent biliary drainage through combined (randez-voux) technique.Results: High success rate (86.6%) with reduction of total bilirubin level was observed in metallic stenting group of patients.Conclusion: Biliary intervention procedures help to reduce high bilirubin level, bypass obstruction level and help in dilatation of post-operative stenosis site.

Comparison of mean pain scores for the patients with sub hepatic drainage to those without it after elective uncomplicated laparoscopic cholecystectomy.

Objective:The sub hepatic drain is often placed after laparoscopic cholecystectomy is considered to affect post operative infection, pain and sub hepatic collections. The objective of this study was to compare the degree of postoperative pain in patients with routine drainage with those without it after elective, uncomplicated laparoscopic cholecystectomy.Methods:This randomized control trial (RCT) was done over six months from 9th June 2015 to 8th December 2015 at Military Hospital Rawalpindi. Sample calculated with WHO calculator and consecutive non probability random sampling used to divide 170 patients undergoing laparoscopic cholecystectomy in two groups. One group had routine sub hepatic drain and other didn’t. Degree of postoperative pain was assessed according to VISUAL ANALOGUE SCALE by duty doctor at 24 hours. Data was collected and analyzed applying chi square test and p value was <.05 considered statistically significant.Results:Our results demonstrated that intensity of post operative pain in routine drainage group is higher as compared to non drainage group after elective, uncomplicated laparoscopic cholecystectomy.Conclusion:Routine placement of sub hepatic drain in elective uncomplicated laparoscopic cholecystectomy should be avoided to reduce post-operative pain.

Emergency endoscopic treatment of acute obstructive suppurative cholangitis

Objective To determine the best endoscopic treatment for acute obstructive suppurative cholangitis(AOSC). Methods Data of 93 patients who were diagnosed as having AOSC in endoscopic center in the last three years were retrospectively analyzed. All patients were divided into three groups according to the different treatment methods: ENBD group, ENBD+ ERBD group and double ERBD group. Postoperative temperature, bilirubin levels and mortality were compared. Results For patients with high level obstruction, incidence of fever in ENBD+ ERBD group and double ERBD group were significantly higher than that of ENBD group(1/18 VS 4/10, P<0.05; 0 VS 4/10, P<0.05). There were no significant differences in incidence of fever(1/18 VS 0) or bilirubin level decrease (17/18 VS 14/15) between ENBD+ ERBD group and double ERBD group. For high level obstruction, if the patient had biliary imaging with contrast medium during operation, they would have higher incidence of high fever[(4/10 VS 3.45%(1/28)] and mortality(3/11 VS 0), lower declining rate of bilirubin level [10/14 VS 96.55%(28/29)] than those without. Conclusion Both left and right hepatic ducts drainage should be recommended for high level biliary obstruction. During the operation, contrast medium should be limited to minimum dose, and should be avoided in high level obstruction cases. Air biliary imaging could be used when necessary. Key words: Emergency; Cholangitis; Endoscopic therapy

Application of three dimensional visualization techniques in the research of hepatic venous anatomy

Hepatic veins as the only hepatic drainage veins are the important functional part of liver anatomy in the field of surgery. With the development of imaging technology, especially the application of three-dimensional visualization technology, it can provide precise and comprehensive information in the study of hepatic veins. And thus this paper comprehensively reviewed the recent researches on the three dimensional visua-lization technology for observign the hepatic veins. Key words: Hepatic veins; 3-D visualization techno-logy; Anatomy

A comparative study to evaluate the outcome of routine use of drain verses no drain after laparoscopic cholecystectomy: a tertiary care teaching centre experience

Background: Laparoscopic cholecystectomy (LC) is the currently the gold standard method of cholecystectomy for symptomatic cholelithiasis. The role of routine drainage after LC to decrease postoperative morbidity is still an issue of considerable debate. This study aims to assess the benefits and harms of routine abdominal drainage and to compare the outcome of sub hepatic drainage with no drainage after uncomplicated LC. Methods: This retrospective study was conducted in two phases, as open, randomized controlled trial (RCT), conducted in general surgery department of Civil Hospital - Sola, Ahmedabad, from April 2013 to March2014 for phase I and From April 2014 to December 2014 for phase II. In this study, in phase I, total 160 patients with chronic calculus cholecystitis underwent LC. Patients were divided into two groups, sub hepatic drainage (group A: 78 patients) or no drainage (group B: 78 patients). The rest 4 patients were excluded either due to conversion or elective sub hepatic drainage. In phase II, 110 consecutive patients were enrolled, who underwent LC with No sub hepatic drainage. Results: Duration of operation, character and amount of drain fluid (if placed), postoperative ultrasound for sub hepatic collection, postoperative pain, postoperative nausea/vomiting, duration of hospital stay, and preoperative or postoperative complications were noted and analysed. Duration of operation and hospital stay was slightly longer in group A patients (P values 0.002 and 0.029, respectively); postoperative pain perception, nausea/vomiting, and postoperative complications were nearly same in both groups (P value 0.064, 0.078, 0.003, respectively). Sub hepatic fluid collection was more in group A (P=0.002). Phase II results were nearly similar to group B patients in phase I. Conclusions: Routine sub hepatic drainage after LC is not necessary in uncomplicated cases.

Intrahepatic Vascular Anatomy in Rats and Mice--Variations and Surgical Implications.

IntroductionThe intra-hepatic vascular anatomy in rodents, its variations and corresponding supplying and draining territories in respect to the lobar structure of the liver have not been described. We performed a detailed anatomical imaging study in rats and mice to allow for further refinement of experimental surgical approaches.MethodsLEWIS-Rats and C57Bl/6N-Mice were subjected to ex-vivo imaging using μCT. The image data were used for semi-automated segmentation to extract the hepatic vascular tree as prerequisite for 3D visualization. The underlying vascular anatomy was reconstructed, analysed and used for determining hepatic vascular territories.ResultsThe four major liver lobes have their own lobar portal supply and hepatic drainage territories. In contrast, the paracaval liver is supplied by various small branches from right and caudate portal veins and drains directly into the vena cava. Variations in hepatic vascular anatomy were observed in terms of branching pattern and distance of branches to each other. The portal vein anatomy is more variable than the hepatic vein anatomy. Surgically relevant variations were primarily observed in portal venous supply.ConclusionsFor the first time the key variations of intrahepatic vascular anatomy in mice and rats and their surgical implications were described. We showed that lobar borders of the liver do not always match vascular territorial borders. These findings are of importance for the design of new surgical procedures and for understanding eventual complications following hepatic surgery.

Use of Accessory Hepatic Vein Intervention in the Treatment of Budd-Chiari Syndrome.

To evaluate the clinical value of accessory hepatic vein (AHV) intervention in the treatment of Budd-Chiari syndrome (BCS). From August 2008 to July 2014, consecutive patients with BCS caused by obstruction of three hepatic veins (HVs) with or without obstruction of inferior vena cava (IVC) were treated by recanalization or transjugular intrahepatic portosystemic shunt in our center. Patients who had the compensatory AHV and successfully underwent recanalization of AHV outflow were enrolled in this retrospective study. The clinical response to AHV drainage was analyzed. Compensatory AHV was found in 69 of 97 (71.1%) patients, and 66 patients successfully underwent recanalization of AHV outflow (IVC recanalization, n = 49; AHV recanalization, n = 15; both, n = 2). In total, 78 AHVs were used instead of HV as the hepatic drainage vein after treatment. Fifty-five patients had one AHV, 10 patients had two AHVs, and 1 patient had three AHVs. The average diameter of all AHV stems was 8.0 ± 2.6 mm (range 5-21 mm). Clinical response to AHV drainage was positive in all patients. Patients' symptoms and liver function improved progressively after treatment. During the follow-up of 3-74 months (average 39.4 ± 11.0 months), 11 patients experienced reobstruction at 6 to 36 months (average 16.8 ± 9.8 months) after treatment. Compensatory AHV can be effectively used instead of HV for drainage of hepatic blood in patients with BCS. AHV intervention can help to simplify the BCS treatment procedure.

Advances in endoscopic retrograde cholangiopancreatography for the treatment of cholangiocarcinoma.

Cholangiocarcinoma (CCA) is a malignancy of the bile ducts that carries high morbidity and mortality. Patients with CCA typically present with obstructive jaundice, and associated complications of CCA include cholangitis and biliary sepsis. Endoscopic retrograde cholangiopancreatography (ERCP) is a valuable treatment modality for patients with CCA, as it enables internal drainage of blocked bile ducts and hepatic segments by using plastic or metal stents. While there remains debate as to if bilateral (or multi-segmental) hepatic drainage is required and/or superior to unilateral drainage, the underlying tenant of draining any persistently opacified bile ducts is paramount to good ERCP practice and good clinical outcomes. Endoscopic therapy for malignant biliary strictures from CCA has advanced to include ablative therapies via ERCP-directed photodynamic therapy (PDT) or radiofrequency ablation (RFA). While ERCP techniques cannot cure CCA, advancements in the field of ERCP have enabled us to improve upon the quality of life of patients with inoperable and incurable disease. ERCP-directed PDT has been used in lieu of brachytherapy to provide neoadjuvant local tumor control in patients with CCA who are awaiting liver transplantation. Lastly, mounting evidence suggests that palliative ERCP-directed PDT, and probably ERCP-directed RFA as well, offer a survival advantage to patients with this difficult-to-treat malignancy.

Disseminated Rhizopus microsporus infection following allogeneic hematopoietic stem cell transplantation in a child with severe aplastic anemia

Disseminated Rhizopus microsporus infections are uncommon in children and are resistant to echinocandin and azole antifungal agents. We describe a child with severe aplastic anemia who developed disseminated R. microsporus infection following allogeneic hematopoietic stem cell transplantation. R. microsporus was identified microscopically in the hepatic drain culture and was confirmed on the basis of 18S rRNA and 28S rRNA sequence analyses. The patient was treated successfully with hepatic drainage and amphotericin B deoxycholate.

Intravascular Hemolysis and Sepsis due to Clostridium Perfringens in a Patient with Pancreatic Cancer

Purpose: A 70 year old male with a history of pancreatic adenocarcinoma, a Whipple procedure and a recent diagnosis of liver metastasis presented to the emergency department with a 1 day history of weakness and fatigue. Physical examination was remarkable for a temperature of 94.5 degrees Fahrenheit, blood pressure of 94/58, pulse 117, marked jaundice and right sided abdominal pain. The patient was transferred to the intensive care unit. Baseline labs obtained 1 day prior to admission revealed a hemoglobin (Hb) of 11.1 g per dL, total bilirubin 0.5, AST 57, ALT 39, BUN 17, Cr. 1.3. Initial laboratory analysis upon admission demonstrated a Hb of 9.4 g per dL, total bilirubin of 10.5, AST 1019, ALT 237, BUN 57, Cr. 3.0. Of note, several attempts to measure lab tests failed because of complete hemolysis of the patient's blood samples. Repeat labs revealed a Hb of 5.7 g per dL. A direct antiglobulin test was negative x 2. The peripheral blood smear, which was reviewed by our hematologist, demonstrated many spherocytes, numerous ghost erythrocytes and toxic changes in the neutrophils with Döhle bodies. A computed tomography scan of the abdomen showed the interval development of a large complex heterogeneous low density mass lesion replacing almost the entire right hepatic lobe. The patient became progressively hypotensive and tachycardic and therapy for presumed sepsis was initiated with cefepime, vancomycin, amikacin and metronidazole. The patient was taken to interventional radiology for a percutaneous hepatic drainage catheter, and a total of 30-40 mL of brown/red serous fluid was removed. The anaerobic culture from the liver abscess grew out Clostridium perfringens. The patient's clinical status gradually improved and he was discharged 17 days after admission. Clostridium perfringens sepsis is an uncommon and frequently lethal disease that can occur in patients with underlying gastrointestinal, genitourinary and hematologic malignancies. This case illustrates that Clostridium perfringens sepsis should be in the differential diagnosis for any patient who has an underlying malignancy and presents with massive intravascular hemolysis, spherocytosis and septic shock.