Our case is a 75 year old male who presented with obstructive jaundice, fever, and leukocytosis with bandemia. CT scan of the abdomen showed common bile duct and pancreatic duct dilation. There was a large pancreatic mass seen along with multiple liver lesions. Here in the abdominal CT scan the red arrows are pointing at multiple small loculated fluid collections. Here you see the distal common bile duct with a markedly thickened wall and just below the bile duct is the portal vein. As the common bile duct is followed distally it becomes obstructed by the pancreatic head mass. The mass appeared hypechoic and irregular with measurements of approximately 4 cm x 3 cm. EUS guided fine needle aspiration of this mass proved it to be an adenocarcinoma.
Here you see the sonographic imaging of the left lobe of the liver. There are multiple, anechoic spaces dispersed throughout the parenchyma. The anechoic nature of the liver lesions indicates that they are fluid filled and therefore this sonographic appearance will be consistent with microabscesses. There were also markedly dilated intrahepatic bile ducts consistent with biliary obstruction and here the arrow points towards a thickened intrahepatic bile duct wall. Again, as the liver is scanned, you can see multiple anechoic liver lesions dispersed throughout the parenchyma. These would be more consistent with microabscesses than with metastatic picture. Typically, metastatic lesions in the liver appear more solid in appearance and have a hypo, hyper or isoechoic appearance. Our patient underwent percutaneous drainage of one of the fluid collections in the liver. Purulent material was aspirated and diagnosis of hepatic abscesses was confirmed. The patient was treated with broad-spectrum intravenous antibiotics.
The annual incidence of liver abscesses is approximately 2.3 cases per 100,000 populations. There is slight predominance in males and risk factor includes diabetes, hepatobiliary or pancreatic malignancy and liver transplant. Management includes CT or US guided drainage and broad spectrum antibiotics. [Editor's note: In the management of patients with liver abscesses and cholangitis in the setting of malignant obstruction, draining the biliary tree either endoscopically or percutaneously is an important therapeutic maneuver to complement abscess drainage and antibiotics.]
Manmeet Padda, MD, Yale University
Uzma Siddiqui, M.D., Yale University