CT Case 081
A 73-year-old man presents with fevers and RUQ pain. He has had a previous recent admission with cholangitis, treated by endoscopic retrograde cholangiopancreatography (ERCP) with common bile duct (CBD) stent insertion.
Past medical history: Type 2 Diabetes and end-stage renal disease/failure on dialysis
Initially an ultrasound is performed
Describe and interpret the RUQ ultrasound images
There is a heterogeneous lesion in right lobe of liver with hypoechoic areas consistent with fluid.
There is peripheral hypervascularity.
Subsequently, the patient is sent for a CT abdomen
Describe and interpret her CT scan
There are clustered hypodense lesions coalescing to form larger lesions in segment IV and VIII of the liver which is a classical appearance for a pyogenic liver abscess.
Surrounding hypodensity in the liver parenchyma represents oedema.
The gallbladder wall is thickened and irregular with pericholecystic fat stranding representing cholecystitis.
Clinical Pearls
Patients with hepatic abscess typically present with right upper quadrant (RUQ) pain, jaundice and fever.
The most common underlying cause is contiguous spread from biliary tract disease, ascending cholangitis or cholecystitis, which was the cause in this patient.
Other causes may be haematogenous spread via portal vein or hepatic arteries. There are a number of risk factors including recent ERCP, immunocompromise and end-stage renal disease.
It is usually polymicrobial, most commonly gram negatives aerobic and anaerobic organisms.
In patients from developing countries, parasitic abscesses can be due to amoebae, protozoa, helminths and hydatid disease (see CT case 077).
Priorities in treatment are IV antibiotic administration and draining of the abscess.
Complications of hepatic abscesses include disseminated sepsis, rupture, and hepatic or portal vein thrombosis.
Management for this patient involved percutaneous drainage of the abscess and broad-spectrum IV antibiotics.
References
- Cunningham K. Abdominal Imaging Cases 026. LITFL
- Liver abscess. BMJ Best Practivce
- Davidson J. CT case 077. LITFL
- Hartung MP. Abdominal CT: Liver. LITFL
TOP 100 CT SERIES
Sydney-based Emergency Physician (MBBS, FACEM) working at Liverpool Hospital. Passionate about education, trainees and travel. Special interests include radiology, orthopaedics and trauma. Creator of the Sydney Emergency XRay interpretation day (SEXI).
Provisional fellow in emergency radiology, Liverpool hospital, Sydney. Other areas of interest include paediatric and cardiac imaging.
Emergency Medicine Education Fellow at Liverpool Hospital NSW. MBBS (Hons) Monash University. Interests in indigenous health and medical education. When not in the emergency department, can most likely be found running up some mountain training for the next ultramarathon.
Dr Leon Lam FRANZCR MBBS BSci(Med). Clinical Radiologist and Senior Staff Specialist at Liverpool Hospital, Sydney