Pyogenic liver abscess complicated by a hepatoduodenal fistula

Abstract

© BMJ Publishing Group Limited 2021. No commercial reuse. See rights and permissions. Published by BMJ. DESCRIPTION A 45yearold man presented with right upper abdominal pain and lowgrade fever for 2 weeks. Laboratory investigations showed polymorphonuclear leukocytosis with normal liver function tests. Ultrasound scan showed a heteroechoic lesion in the right lobe of the liver with mobile echogenic foci causing dirty acoustic shadowing, suspicious of aircontaining lesion. A contrastenhanced CT scan of the abdomen was done, which showed a welldefined 5.5 cm×6 cm hypodense peripherally enhancing lesion in the right lobe of liver with multiple air foci within, suggestive of an abscess. There was a communication of the inferomedial wall of abscess with the first part of duodenum, indicative of fistulisation (figure 1). A CTguided pigtail catheter drainage of the abscess as well as of the subcapsular collection was done. A tubogram through the pigtail catheter placed in the liver abscess showed opacification of the first part of duodenum (figure 2) confirming the diagnosis of a hepatoduodenal fistula complicating a liver abscess. Aspiration revealed frank pus, which grew Escherichia coli on culture. In addition to the catheter drainage, the patient was started on intravenous ciprofloxacin and metronidazole initially followed by meropenem for a total duration of 21 days and the symptoms resolved completely. Enterohepatic fistula is a very rare complication of liver abscess seen in 1.5% cases. Detection of air in a liver abscess cavity should raise the possibility of either a hepatobronchial fistula, hepatoenteric fistula or secondary bacterial infection by an airproducing organism. The common sites of fistulisation include stomach, colon and duodenum. 3 Contrastenhanced CT scan with positive oral contrast or instillation of contrast through the drainage catheter placed in the abscess cavity are the definitive investigations for demonstration of the fistula. There are no standard treatment guidelines for managing this complication. Although surgical management may be definitive, conservative management with catheter drainage may also help in the spontaneous closure of the fistula. It is important to remember that in addition to liver abscess, the other lesions responsible for hepatoenteric fistula may include malignant neoplasms (of gall bladder/liver/colon) as well.