Hepatic abscess in a pre-existed simple hepatic cyst as a late complication of sigmoid colon ruptured diverticula: a case report
© Chatzipetrou et al; licensee BioMed Central Ltd. 2008
Received: 20 June 2007
Accepted: 14 March 2008
Published: 14 March 2008
Hepatic abscesses have been reported as a rare complication of diverticulitis of the bowel. This complication is recognized more commonly at the time of the diagnosis of diverticulitis, or ruptured diverticula, but also can be diagnosed prior to surgery, or postoperatively.
This report describes a man who developed an hepatic abscess within a simple hepatic cyst, two months after operation for ruptured diverticula of the sigmoid colon. The abscess was drained surgically and the patient made a complete recovery.
The development of an hepatic abscess in a pre-existing hepatic cyst, secondary to diverticulitis, is a rare complication. A high degree of clinical suspicion is required for immediate diagnosis and treatment.
After the advent of antibiotics, few cases of hepatic abscesses secondary to diverticulitis have been described. In the past pylephlebitis, with or without hepatic abscess formation, was a complication of abdominal sepsis more commonly due to appendicitis. Abdominal computed tomography (CT) scans have contributed to the early diagnosis of this lethal complication that had been mostly a postmortem finding in the past. Herein, we report the case of a man who developed an hepatic abscess within a pre-existing simple hepatic cyst, following surgery for ruptured diverticula of the sigmoid colon.
A 66-year-old male was referred to our clinic with an acute abdomen by the cardiology unit, where he had been admitted three days before to be treated for paroxysmal supraventricular tachycardia (SVT) and Right Bundle Branch Block.
The patient was pale with tachycardia and tachypnoea. His temperature was 38.5°C. On physical examination there was localized tenderness at the left iliac fossa. Digital rectal examination was normal.
After starting antibiotics (ticarcillin-clavulanic acid, amicacin and metronidazole), the patient was operated on two days later for peritonitis. At laparotomy, a small abdominal abscess was found at the area of the sigmoid colon caused by ruptured diverticula. The abscess was drained and Hartmann excision of the bowel was performed. The patient was admitted to the ICU for the first four postoperative days and was discharged fully recovered on the 21st day postoperatively from the clinic. Cultures from the abdominal abscess grew Aerococcus viridans, Escherichia coli and Proteus mirabilis and were negative for anaerobes. Antibiotics were administrated for 18 days after the operation. After discharge only dietary restrictions were recommended.
Due to an inability to drain the abscess under CT guidance at our hospital, the liver abscess was drained surgically. The cultures of the pus of the hepatic abscess grew Escherichia coli and Enterococcus spp. The postoperative care of the patient was uncomplicated and he recovered slowly but fully. He was discharged one month postoperatively.
In the pre-antibiotics era, rare but lethal cases of pylephlebitis and hepatic abscesses secondary to appendicitis had been described [1, 2] but after the advent of antibiotics this complication has been observed more commonly after diverticulitis . Later in the clinical course, infection of the liver can cause the formation of hepatic abscesses. Only a few cases of hepatic abscesses due to diverticulitis have been reported, with [4, 5] or without coexistent pylephlebitis .
Our report concerns a unique case of hepatic abscess formation due to diverticulitis, in an existing simple hepatic cyst without evidence of pylephlebitis. This is the first reported case of delayed hepatic cyst transition to abscess, following an event of diverticular rupture. The cyst was first detected as a random finding during an abdominal CT scan during the first hospital admission of the patient. Later, during his second admission, the cyst was revealed again by U/S and was then found to have been infected and transformed to a large abscess three days later. That happened probably by migration of microbes via the portal vein but much later than the initial infection which took place two months earlier.
Gram negative and anaerobic organisms are most commonly isolated in blood cultures and specimens of abscesses, with E. coli being the most prevalent microbe [7, 8]. That was also the case in our patient.
Hepatic abscess may precede , follow  or appear at the same time as diverticulitis [7, 8]. Abdominal CT scan and sonography are essential diagnostic methods and one must have always in mind this rare but serious complication when dealing with diverticulitis of the bowel. Vice versa, one must remember the possibility of diverticulitis in the presence of hepatic abscesses .
In our case, we were able to document that the abscess of the liver appeared two months after the rupture of sigmoid colon diverticula. In spite of the high mortality related to this complication, our patient made a full recovery following surgical drainage.
Hepatic abscess in a pre-existing hepatic cyst, occuring secondary to diverticulitis, is a rare complication and a high degree of clinical suspicion is required for immediate diagnosis and treatment.
Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal.
- Bryant JH: Suppurative pylephlebitis. Guy's Hosp Report. 1897, 54: 77-112.Google Scholar
- Brown WL: Suppurative pylephlebitis. St Bart's Reports. 1901, 37: 95-135.Google Scholar
- Case records of the Massachusetts General Hospital, Case 18-1977. N Engl J Med. 1977, 296: 1051-7.Google Scholar
- Yoshida M, Mitsuo M, Kutsumi H, Fujita T, Soga T, Nishimura K, Kawabata K, Kadotani Y, Kinoshita Y, Chiba T, Kuroiwa N, Fujimoto S: A successfully treated case of multiple liver abscesses accompanied by portal venous gas. Am J Gastroentrol. 1996, 91 (11): 2423-5.Google Scholar
- Waxman BP, Cavanagh LL, Nayman J: Suppurative pylephlebitis and multiple hepatic abscesses with silent colonic diverticulitis. Med J Aust. 1979, 2 (7): 376-8.PubMedGoogle Scholar
- Liebert : Hepatic abscess resulting from asymptomatic diverticulitits of sigmoid colon. South Med J. 1981, 74 (1): 71-3.View ArticlePubMedGoogle Scholar
- Saxena R, Adolph M, Ziegler JR, Murphy W, Rutecki GW: Pylephlebitis: A case report and review of outcome in the antibiotic era. Am J Gastroentrol. 1996, 91 (6): 1251-3.Google Scholar
- Robert M, Paparel P, Arnal E, Voiglio E, Cailliot JL: [Liver abscesses secondary to sigmoid diverticulitis: about four cases]. Rev Med Interne. 2004, 25 (12): 915-9. French.View ArticlePubMedGoogle Scholar
- Niemann H, Wintzer G: [Formation of a liver abscess as the first manifestation of concealed perforated sigmoid diverticulitis]. Leber Magen Darm. 1995, 25 (1): 35-7. German.PubMedGoogle Scholar
- Steinhart AH, Simons M, Stone R, Heathcote J: Multiple hepatic abscesses: cholangiographic changes simulating sclerosing cholangitis and resolution after percutaneous drainage. Am J Gastroenterol. 1990, 85 (3): 306-8.PubMedGoogle Scholar
- Wallack MK, Brown AS, Austrian R, Fitts WT: Pyogenic liver abscess secondary to asymptomatic sigmoid diverticulitis. Ann Surg. 1976, 184 (2): 241-3. 10.1097/00000658-197608000-00018.View ArticlePubMedPubMed CentralGoogle Scholar
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