Pyogenic Liver Abscess Complicating Acute Cholecystitis: Different Management Options

Abstract

Acute cholecystitis, which is usually associated with gallstones is one of the most common surgical causes of emergency hospital admission and may be further complicated by mural necrosis, perforation and abscess formation. Perforation of the gallbladder is a relatively uncommon complication of acute cholecystitis (0.8-3.2% in recent reviews). The intrahepatic perforation causing a liver abscess is an extremely rare condition, anecdotally reported in the scientific literature, even in the rare types of subacute or acute perforation. Liver abscess caused by gallbladder perforation can be a life-threatening complication with a reported mortality of 5.6%. The treatment of synchronous pyogenic liver abscess and acute cholecystitis may be challenging. We reported three cases of liver abscess due to acute cholecystitis in which different therapeutical approaches were employed. The first case was treated with antibiotics and interval laparoscopic cholecystectomy; the second case was treated with emergency cholecystectomy; and the third case with percutaneous aspiration of the abscess only. The appropriate therapeutical method in these cases depends on the patient's clinical condition, the on-site expertise that is available in the hospital, and the experience of the surgeon.

Keywords: cholecystectomy; cholecystitis; percutaneous; pyogenic liver abscess.

Figure 1

Magnetic resonance imaging (MRI) image of the upper abdomen. (a) Axial T1 post contrast and (b) T2. The gall bladder mucosa shows interrupted enhancement with a localized perforation anteriorly, close to the fundus. Orange arrows: liver abscess; white arrows: gallbladder; blue arrow: gallbladder stone.

Figure 2

Magnetic Resonance Cholangiopancreatography (MRCP) images (a,b) showing gallbladder perforation (blue arrows).

Figure 3

MRI images which showed findings consistent with acute cholecystitis. (a) Coronary MRI-image T1 post contrast of a gallbladder with diffuse mural thickening and contrast enhancement; (b) T2 MRI source image showing no perforation of the gallbladder. MRCP excluded choledocholithiasis and dilatation of the common bile duct. Yellow arrows: gallbladder; blue arrows: intraluminal stone and bile.

Figure 4

Contrast-enhanced Computed Tomography (CT) and MRI images which show overdistended and inflammatory gallbladder and a nodular lesion occupying the liver. (a) Contrast-enhanced CT: nonhomogeneous, hypodense mass located in the right lobe of the liver (white arrow); (b) contrast-enhanced CT: gallbladder with wall thickening and a large stone (yellow arrow) causing gallbladder neck obstruction (white arrow: liver abscess); (c) T1 out-of-phase axial MRI image: nodular lesion (white arrow) occupying the fourth and eighth liver segments in continuation with the overdistended and inflammatory gallbladder. It also revealed diffuse mural thickening with alternating layers of abnormal signal, as well as pericholecystic and perihepatic fluid.

Figure 5

Intraoperative images. (a) Intrahepatic perforation of the gallbladder; (b) the resected gallbladder and the stone causing the neck obstruction.

Figure 6

Contrast-enhanced CT shows: (a) gallbladder associated with pericholecystic fat stranding, gallbladder wall thickening, and liver abscess (white arrow); (b) gallbladder with wall thickening and a so-called “ring sign”, without central enhancement (white arrow).

Figure 7

Ultrasound-guided percutaneous cholecystostomy with pigtail catheter inside gallbladder. (a) Gallbladder opacification through drainage catheter with occluded cystic duct; (b) after aspiration of the contrast medium, multiple small stones are seen in the gallbladder and contrast stain is also seen outside the gallbladder towards the liver parenchyma (yellow arrow) and the lower liver capsule (blue arrow).

Figure 8

Abdominal CT: mild wall thickening of the gallbladder (blue arrow) with pericholecystic inflammatory changes (yellow arrow).