Chronic appendicitis complicated by appendicular abscess, pylephlebitis and liver abscess
Patient presenting to the ER with left upper and lower quadrant pain for several weeks. Shortness of breath since the night before. The patient felt generally unwell. The lab parameter shows a septic constellation with elevated WBC, CRP and PTC. Patient has a known history of alcohol and cigarette abuse.
CT Abdomen and Pelvis
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FINDINGS: Two-phase contrast CT shows occlusion of the left main portal vein and its tributaries. Evidence of a heterogeneous hepatic lesion subcapsular in segment II, measuring 4,5 x 2,7 x 3 cm. The lesion demonstrates a hypodense center and a double ring, the thin inner ring being hyperdense and the thicker outer ring hypodense, compared to the adjacent liver parenchyma. Hyperperfusion of the left liver lobe in the arterial phase, most likely due to occluded left portal vein branch and consecutive predominant arterial supply of the left liver parenchyma via the hepatic artery.
The appendix appears mildly swollen with moderate surrounding fat stranding. There is evidence of a fluid collection medial to the tip of the appendix with a thick hyperdense wall and hypodense content alongside some gas bubbles. This formation measures 6,5 x 2 x 3 cm and abutts the urinary bladder. The right ventral bladder wall appears markedly thickened. Evidence of para-aortal lymphadenopathy.
No other acute findings. Secondary findings include hepatic steatosis, small liver cysts, advanced arteriosclerosis, reperfusion of the umbilical vein and some bilateral dystelecatic changes of the dorso-basal lung parenchyma
CONCLUSION: Clinical history, examination, lab results and CT features are in keeping with chronic appendicitis with appendicular abscess and a pyogenic spread of the intraabdominal infection via the portal venous drainage way. Consecutive pylephlebitis of the left portal vein with a superimposed hepatic abscess in the affected left liver segment II. The abscess demonstrates a double target sign which is a characteristic image feature of a hepatic abscess.
After consultation with the surgical colleagues, a primary non-surgical approach was determined and CT-guided drainage of the appendicular abscess was subsequently performed an hour after the initial CT.
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Successful CT-guided dainage of the appendicular abscess ventral of the urinary bladder.
Spontaneous discharge of foul-smelling pus, characteristic of E. coli.
No acute complications.
The patient stayed on a non-surgical regime with the abscess drainage and calculated antibiotics therapy adapted to the pathogens acquired from the abscess sample.
He soon recovered and his lab results improved significantly. The patient discharged himself prematurely but was advised to come back for ultrasound controls of the liver abscess and the pylephlebitis.
This case nicely demonstrates two rare but possible complications of an intra-abdominal infection - in this case of chronic appendicitis - that spreads via the portal venous drainage way:
- pylephlebitis, i.e. septic thrombosis of the portal vein or its tributaries, and
- a liver abscess
Additionally, this patient had an appendicular abscess, which was probably simmering for quite some time.
In the pre-computed tomography age and especially pre-antibiotics age, the above-mentioned pathologies were common complications of appendicitis. In recent years, these complications have become rare due to the advanced use of image techniques, calculated antibiotics therapy and early surgical intervention.
Like in this case, the patients presenting with pylephlebitis and/or liver abscess often have a background of alcohol/ drug abuse and/or a general reluctance to go to the doctor due to unstable social circumstances.