CT Case 081

There is a heterogeneous lesion in right lobe of liver with hypoechoic areas consistent with fluid.

There is peripheral hypervascularity.

Psoas muscle haematoma can be either spontaneous or traumatic.

Spontaneous cases may be seen in patients on antiplatelet or anticoagulant therapy, with DIC, or with haemophilia, or may be see in ruptured AAA (case 84).

Traumatic causes may be iatrogenic such as post lumbar surgery or post biopsy.

Patients commonly present with groin or thigh pain. They may also have numbness or paraesthesia and occasionally will have a nerve palsy, with the femoral nerve being most commonly involved.

The incidence of psoas haematomas has slowly increased overtime with the increased use of anticoagulation and antiplatelet therapy. Haemodialysis is also a risk factor.

The incidence of psoas haematoma is 0.6% in elderly patients on anticoagulant therapy.

The mortality rate is surprisingly high (up to 30%).

This patient had a small haemoglobin drop (124 down to 110) and remained haemodynamically stable.

Management involved initial withholding of clexane. Due to ongoing risk of VTE he was then commenced on a heparin infusion as an inpatient.

As there was no further drop in his haemoglobin, clexane was recommenced, and he was discharged home on a reduced dose of clexane.

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.

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.

• Cunningham K. Abdominal Imaging Cases 026. LITFL
• Liver abscess. BMJ Best Practivce
• Davidson J. CT case 077. LITFL
• Hartung MP. Abdominal CT: Liver. LITFL