A case report and treatment considerations for pyogenic liver abscess with biliary fistula

Abstract

Introduction and importance

Pyogenic liver abscess (PLA) is a potentially life-threatening condition characterized by the formation of space-occupying lesions within the liver parenchyma. Despite advancements in diagnostic imaging and antibiotic therapies, complications such as biliary fistula formation can arise, posing challenges in management.

Case presentation

This case study presents a 23-year-old male patient with PLA complicated by a biliary fistula. Diagnostic imaging via CT scan and MRI confirmed a liver abscess and biliary dilation. The patient underwent a second drainage for ascitic fluid following the initial percutaneous liver catheter drainage.

Clinical discussion

The patient responded positively to the treatment, with reduced abscess size and fistula resolution. While endoscopic interventions offer promising results, their limited availability necessitates alternative treatment strategies, such as percutaneous drainage and appropriate antibiotics.

Conclusion

This case emphasises the importance of individualized management approaches for PLA complicated by biliary fistulas. Despite the challenges, successful outcomes can be achieved through careful management and appropriate treatment strategies.

Highlights

• •PLA is a severe liver condition with potential complications like biliary fistula, despite advancements in diagnostic imaging and antibiotic therapies.
• •A 23-year-old male patient with PLA, biliary fistula, was diagnosed with a liver abscess and biliary dilation through CT scan and MRI.
• •The patient underwent two drainage procedures: an initial percutaneous liver catheter drainage and a second drainage for ascitic fluid.
• •The patient showed a positive response with a reduction in abscess size and resolution of the fistula.
• •The case underscores the significance of personalized management for PLA involving biliary fistulas, suggesting alternative strategies like percutaneous drainage and appropriate antibiotics due to limited availability.

1. Introduction

A pyogenic liver abscess (PLA) is an infrequent but potentially life-threatening condition characterized by the formation of space-occupying lesions within the liver parenchyma [1]. It carries a significant morbidity and a mortality rate of 6.13 % of all the affected cases [1]. The prevalence of liver abscesses is estimated to be approximately 2.3 cases per 100,000 people annually, with higher rates observed in men than women (3.3 versus 1.3 per 100,000) [2]. With the emergence of antibiotics, biliary tract diseases have become the most common predisposing factor, accounting for approximately 40 % of cases [1].

Recent advancements in diagnostic imaging, the emergence of more potent antibiotics, and the introduction of less invasive techniques have greatly enhanced the efficacy of treating (PLA) [1]. However, there are instances where patients exhibit an inadequate response to pharmacological interventions, leading to the development of uncommon complications such as biliary fistula communication [3]. Pyogenic liver abscesses complicated by biliary fistulas are rarely reported in case studies based on available literature. In this case study, we are presenting a case study of a male patient who visited a tertiary teaching hospital in Mogadishu with a pyogenic liver abscess that was complicated by a biliary fistula. The diagnosis was confirmed through diagnostic imaging. The abscess and biliary fistula were treated with percutaneous catheter drainage (PCD) and antibiotics. Endoscopic retrograde cholangiopancreatography (ERCP) with a stent is the recommended treatment, but unfortunately, this option was not available at our facility.

2. Case report

A 23-year-old male patient was referred by a general practitioner to the general surgery department with a two-week history of high-grade fever and pain in the upper right quadrant of his body. The patient had no significant past medical, surgical, or social history. Upon admission, the patient was anaemic, with a haemoglobin level of 4.8 g/dL. Immediate initial resuscitation was started, with fluid therapy and blood transfusions administered after cross-matching. Additional investigations revealed a mild elevation in total bilirubin (1.5 mg/dL) and direct bilirubin (1.14 mg/dL), along with a decrease in serum albumin levels (2.7 g/dL). The complete blood count showed an unexpected rise in the number of white blood cells (17.41 × 10^9/L), primarily because of higher levels of absolute neutrophilia (13.85 × 10^9/L), which means there is still a bacterial infection going on. When the first abdominal ultrasound was done, it showed splenomegaly, mild ascites, and intrahepatic hypoechoic heterogeneous collections measuring about 82x70mm in segment VI of the right hepatic lobe. A computed tomography (CT) scan of the abdomen (Fig. 1) confirmed the presence of a liver abscess and a dilated biliary tree. After consultation with the radiology department, Percutaneous catheter drainage of the liver abscess was performed. When the (PCD) initial drainage was pus, it changed to a yellow drainage 24 h later, raising the possibility of an intestinal injury based on mild abdominal tenderness. The development of the liver abscess and the changes in the measurement were both confirmed by a triphasic CT scan with oral contrast (Fig. 2) and magnetic resonance imaging (MRI) (Fig. 3).

Fig. 1.

The first post-intravenous contrast MSCT abdomen axial cut shows a relatively well-defined cystic focal lesion in segment VI of the right hepatic lobe (black arrow), which is a hepatic abscess. The lesion is associated with mild biliary dilatation(white arrow).

Fig. 2.

2nd post, the MSCT scan of the abdomen with oral contrast showed an abnormal air density in segment VI of the right hepatic lobe as well as mild splenomegaly and Ascetic collection. Percutaneous drainage is visible within the collection (black arrow).

Fig. 3.

MRI abdomen T2 axial cuts show a heterogeneous focal lesion in the right hepatic lobe, mild ascites, and dilated biliary channels.

Communication with the biliary tree and decreased biliary dilatation findings led to the diagnosis of a liver abscess with a biliary fistula. Due to increasing inflammatory markers and abdominal pain of mild to moderate intensity, a second percutaneous drainage for the ascetic fluid was initiated in the most dependent part of the abdomen. The drainage predominantly contained ascitic fluid, ruling out biliary peritonitis. By the sixth day of hospitalisation, the patient's condition had stabilised, showing daily drainage of approximately 200–300 cc of abscess and biliary fluid. Subsequent culture results identified an Escherichia coli (E. coli) infection sensitive to meropenem, the antibiotic initiated upon admission. Serial abdominal ultrasounds were performed for follow-up at regular intervals every 3 to 4 days and over two months, showing a gradual reduction in abscess size, measuring 10 cm × 5.4 cm, 8.5 cm × 3 cm, and finally 6.5 cm × 3.2 cm, respectively. This led to complete abscess resolution after four months of initiating treatment.

3. Discussion

(PLA) is a severe and life-threatening condition that involves the development of a space-occupying lesion within the liver parenchyma. The bacterial agents responsible for PLA are commonly represented by gram-negative and anaerobic bacteria [1]. Similar to our case, Escherichia coli (E. coli) was identified as the etiologic agent responsible for the infection. In addition to biliary tract diseases, other etiological conditions contribute to the development of pyogenic liver abscesses; this includes disseminated haematological systemic infections, penetrating traumas, and abdominal surgical procedures, particularly in patients with compromised immune systems [4].

Malik et al. reported that several risk factors had been identified, including diabetes mellitus, underlying hepatobiliary or pancreatic diseases, liver transplant, and regular use of proton-pump inhibitors [[1], [2], [3], [4]]. Our reported case exhibited none of those indicated risk factors.

The standard technique for diagnosing liver abscesses is non-invasive radiologic imaging. Abdominal ultrasound (US) is a helpful imaging modality for diagnosis, but computed tomography (CT), with its 97 % sensitivity, is a better diagnostic tool [5]. Both a US and a CT scan were used to diagnose the liver abscess in our patient. Although hepatic abscesses and other focal hepatic lesions can be distinguished using magnetic resonance imaging (MRI) with T1- and T2-weighted and serial gadolinium-enhanced gradient-echo images, the role of the use of more advanced imaging techniques still needs to be clarified [1].

Over the past four decades, advancements in diagnostic imaging, the emergence of more effective antibiotics, and percutaneous drainage techniques have significantly enhanced the outcomes of (PLA) therapy [6,7]. (PCD) combined with antibiotic treatment became the established approach for uncomplicated hepatic abscesses in the 1980s. (PCD) has become the preferred initial treatment for PLA, reducing the need for general anaesthesia and the complications associated with open abdominal surgery [7]. Surgical intervention remains the first line of treatment for patients with abscess rupture, peritonitis, or concurrent surgical conditions, with (PCD) reserved for cases where it fails [8].

Nonetheless, there exist instances where patients exhibit an inadequate response to pharmacological interventions, giving rise to complications such as the rupture of abscesses into critical anatomical regions, including the pericardium, thoracic cavity, or abdominal cavity [9]. Furthermore, the development of fistulas connecting the abscesses to the bronchial or biliary system may manifest [10]. The development of a fistula between a liver abscess and intrahepatic bile ducts is a very uncommon complication of PLA and an infrequent cause of bile leakage [[2], [3], [4], [5], [6], [7], [8], [9],11]; the infrequent occurrence of this complication is likely a result of the vasculobiliary sheath's resistance, a tough layer of fibrous tissue that encircles the segmental portal systems (bile duct, hepatic artery, and portal vein) [12]; also, the presence of biliary communication has the potential to impede the resolution of an abscess following percutaneous drainage and necessitate an extended duration of drainage compared to patients whose abscesses do not have a fistula [13,14].

Therefore, a standardised treatment protocol for liver abscess-biliary fistula remains elusive [14]. Therapeutic approaches for patients with biliary fistulas and (PLA) have broadened to include various options in recent clinical medical research. These options include the use of broad-spectrum antibiotics with or without the adjuvants of percutaneous needle aspiration or percutaneous catheter drainage, (ERCP), and finally, surgery, depending on the severity, size, and overall condition of the patient [[12], [13], [14], [15], [16]]. Though employing (PCD) combined with antibiotic therapy has been used successfully in more than a clinical research study [14,15], recent investigations have demonstrated the effectiveness of an endoscopic approach utilising (ERCP) to deploy a stent within the biliary duct proximal to the fistular connection [16]. This intervention resulted in a prompt reduction in bile output through the percutaneous catheter and an accelerated healing trajectory of the fistula [17,18].

In our case, we managed to get an efficient response utilising the combination of a culture-based broad-spectrum antibiotic (Meropenem) with the repeated (PCD) technique and the maintenance of a short-interval follow-up until the restoration of normal hepatic anatomy. Despite the superior efficacy of the ERCP + Stent technique in managing patients with PLA and biliary fistulas, it necessitates access to advanced endoscopic equipment and specialised expertise, resources that regrettably remain unavailable within our medical facility.

4. Conclusion

This case report highlights the rarity of this complication and the absence of commonly associated risk factors in our patient. Diagnostic imaging played a crucial role in confirming the diagnosis. (PCD) and antibiotic therapy effectively managed the abscess and biliary fistula. However, the endoscopic approach with (ERCP) and stent deployment is considered a superior option; it was a limitation for us due to its non-availability in our facility. Our case emphasises the importance of individualising treatment strategies based on the severity, size, and patient's condition, and it also highlights the need for further research and standardised treatment protocols for PLA with biliary fistula.

Consent

Written consent for the publication of this case report and its accompanying images has been acquired from the patient (or their guardian or next of kin). There is no information in submitted manuscript that can be used to identify the patient. Written informed consent was obtained from the patient for publication and any accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal on request.

Methods

The work has been reported in line with the SCARE criteria [19].

Ethical approval

As per our institution's research ethics committee, ethical clearance is unnecessary for this case report. The committee has thoroughly examined the report and ensured it conforms to standard clinical practices. Additionally, the report doesn't involve any experimental interventions or require further data collection.

Funding

The author(s) received NO financial support for the preparation, research, authorship, and/or publication of this manuscript.

Author contribution

Conceptualization: ismail ahmed ali/Abdirahman ahmed omar alasso.

Data Curation: Abdirahman ahmed omar alasso.

Formal Analysis: Abdirahman ahmed omar alasso/Mohamed rage ahmed.

Funding Acquisition: Not aplicable.

Investigation: Abdirahman ahmed omar alasso/Ismail gedi ibrahim.

Project Administration: Abdirahman ahmed omar alasso.

Resources: Mohamed rage ahmed.

Software: Abdirahman ahmed omar alasso.

Supervision: Abdirahman ahmed omar alasso.

Validation: Abdirahman ahmed omar alasso.

Visualization: Abdirahman ahmed omar alasso.

Writing-original draft preparation: Abdirahman ahmed omar alasso.

Writing-review and editing: Abdirahman ahmed omar alasso.

Guarantor

Abdirahman Ahmed Omar Alasso.

Research registration number

This case report is not a first-in-man case.

Conflict of interest statement

The author(s) do NOT have any potential conflicts of interest with respect to this manuscript.