Ruptured Pyogenic Liver Abscess with Pneumoperitoneum 19 Years After Pancreatoduodenectomy

Abstract

BACKGROUND Rupture of a pyogenic liver abscess is rare but serious complication. In patients after pancreatoduodenectomy, there are some conditions causing the development of liver abscesses (e.g., chronic reflux-cholangitis, efferent jejunal loop stasis, stenosis of the biliary anastomosis, and pancreatogenic diabetes). However, the number of published cases of liver abscess after pancreatoduodenectomy is small. CASE REPORT A 42-year-old male was admitted with severe abdominal pain, fever, and jaundice. Nineteen years previously, he had undergone pancreatoduodenectomy and cholecystectomy for chronic pancreatitis with obstructive jaundice. Two years later, diabetes mellitus was diagnosed, with subsequent insulin treatment. At admission, symptoms of peritonitis were present. Plain abdominal radiography showed free gas under the right hemidiaphragm and heterogeneous liver shade with small gas-fluid levels. The rupture of a liver abscess was suspected. Laparotomy with adhesiolysis, debridement of the liver abscess cavity, and abdominal drainage were performed. The postoperative period was complicated by sepsis, right lower lobe pneumonia, and two-sided pleural effusions, on the background of insulin-dependent diabetes and malnutrition. The patient was discharged on the 40th day and the subdiaphragmatic drains were removed on the 114th day. Sixteen months after surgery, the patient's condition was satisfactory. Magnetic resonance imaging and echography showed the absence of biliary hypertension. The liver tissue had healed completely. CONCLUSIONS A unique case of ruptured liver abscess after pancreatoduodenectomy is presented. To the best of our knowledge, this is the first published case with such a long time interval (19 years) between pancreatoduodenectomy and the formation of a pyogenic liver abscess.

Figure 1.

Plain frontal radiogram of the abdomen at admission. Free gas under the right hemidiaphragm, heterogeneity of the liver shadow with small gas-fluid levels in its tissue, and signs of bowel paresis were present.

Figure 2.

CT scan of the abdomen (delay phase) on 20^th day after PLA surgical drainage. In the right lobe of the liver, residual lesion is visualized (arrows). Drainage tubes are also seen (arrowheads).

Figure 3.

Magnetic resonance imaging 16 months after surgery for PLA. The pancreas remnant (arrowheads) is very small (22×36 mm), with non-dilated Wirsung duct.