Liver Abscesses, Pylephlebitis, and Appendicitis in an Adolescent Male

Abstract

Case Presentation and EvolutionA 14-year-old Tongan male presented with a two-day history of tactile fevers and night sweats. He had a threeday history of dull right upper quadrant (RUQ) abdominal pain that extended to his upper back. The pain was intermittent in nature, characterized as five on a ten-point scale, occurred at least three times per day, was worse when laying on the right side, and slightly worse with eating, but not restrictive of dietary intake. The patient had no nausea or emesis or other symptoms. He had not consumed any uncooked or undercooked foods, nor had recent travel or camping. He had no prior hospitalizations, chronic medical problems or surgeries. His physical exam was only remarkable for localized and exquisite tenderness to palpation of his RUQ with no flank tenderness. The liver span was difficult to assess due to his pain, and he had no splenomegaly. There was no rebound or guarding.Laboratory tests revealed a white blood cell count of 10.2/mm 3 , hemoglobin 11.8 g/dl, and a platelet count 334,000/mm 3 . The differential included 80% neutrophils, 12% lymphocytes, and 7% monocytes. The total bilirubin was 1.6 mg/dl, direct bilirubin 0.6 mg/dl, aspartate aminotransferase 28 U/l, alanine aminotransferase 56 U/l, alkaline phosphatase 476 U/l, total protein 8.4 g/dl, albumin 2.3 g/dl, and lipase 149 U/l. His coagulation profile showed an international normalized ratio of 1.4, prothrombin time 16.3, and partial thromboplastin time 51.9. An abdominal ultrasound demonstrated multiple hypoechoic lesions in the right lobe of the liver, each measuring up to 3 cm.Given these findings, he was admitted to Lucile Packard Children's Hospital at Stanford. Tests for Entamoeba histolytica antibody, stool ova and parasites, and serology for Echinococcus were sent to the laboratory, and he was given intravenous clindamycin and cefipime for a potential bacterial process. A computed tomography (CT) scan of the abdomen demonstrated two large liver masses in the right lobe of the liver measuring 6.1 and 4.9 cm in largest diameter that were hypodense and heterogeneous in density without a well-defined capsule (Fig. 1). The distal appendix was dilated, measuring 1.4 cm in caliber, and contained an appendicolith near its tip. Given these findings, interventional radiology (IR) and surgery consultations were requested for the liver lesions and concern for acute appendicitis, respectively. The surgical team recommended observation, given his physical examination in combination with the absence of free fluid, stranding, and inflammation in the right lower quadrant on CT scan. In addition, his amebiasis evaluation was under way.A subsequent magnetic resonance imaging (MRI) scan demonstrated two pyogenic abscesses with no other hepatic lesions (Fig. 2). A branch off the anterior branch of the right portal vein demonstrated a thrombus (Fig. 3). The appendix was enlarged and hyperenhancing with an appendicolith and peri-appendiceal fluid consistent with appendicitis (Fig. 4). The same day the MRI was

Portomesenteric venous thrombosis as a rare complication of acute appendicitis in pediatric patient: a case presentation and literature review

“…Presentation of acute appendicitis with septic thrombosis can vary from days to weeks of abdominal pain, diarrhea, vomiting or fever [3,4,[6][7][8][9][10][11][12][14][15][16][17] to persistent pain or vomiting and diarrhea post-appendectomy [5,13,16]. The most common presenting symptom were fever (n = 16/18, 89%), deranged liver function (n = 13, 72%), RUQ pain (n = 10, 56%) and diarrhea (n = 8, 44%).…”

“…CT scan also allowed detection of other complications including liver abscess and bowel ischemia. Five cases developed liver abscess following the portal branches of septic thrombophlebitis [3,[9][10][11]14] However, there was no reported case developing bowel ischemia following portomesenteric thrombosis-complicating appendicitis in pediatrics. Regarding the follow-up imaging for thrombosis, there was no consensus over the modality of imaging used.…”

Sessile serrated adenoma/polyp leading to acute appendicitis with multiple pyogenic liver abscesses: A case report

“…Although acute appendicitis is a common emergency disease (7%) [8] , appendicitis with pyogenic liver abscess is rare, with an estimated incidence of less than 0.03% [1] . In most cases, liver abscess metachronously occurs after the start of treatment for a perforated, gangrenous, or phlegmonous appendicitis [2] , [9] , [10] . In a previous report, liver abscess was caused by organisms via the following three major routes: the biliary tract (60%), portal vein (6%), and hepatic artery (10%) [11] .…”

Pyogenic liver abscesses secondary to pylephlebitis complicating acute on chronic pancreatitis

“…Mortality ranges from 10–12%. However, there has been a remarkable decline in the morbidity and mortality of PLA due to the introduction and wide use of antibiotics, and to understanding and advancement of operative techniques 15 . Clinical manifestations are nonspecific, including fever, abdominal pain and emesis 2,16 .…”