PMC8758465_01
Abdominal CT images at referral to our division. A large abscess 15.5 cm in size containing gas and fluid, forming an air-fluid level, was located in the right lobe of the liver. (A) Axial image, cephalic level. (B) Axial image, caudal level. (C) Coronal image. (D) Sagittal image.
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Abdominal CT showed a large abscess 15.5 cm in diameter that contained gas and fluid forming an air-fluid level in the right lobe of the liver (Fig. 1).
Fluoroscopic image of the abscess cavity and microscopic images of the pus with Gram staining. (A) Fluoroscopic image of the abscess with pigtail drainage catheter and injected contrast media. (B) Microscopic image of the pus with Gram staining. Large, Gram-positive, rod-shaped bacteria were detected in the pus (arrows).
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Ultrasound-guided percutaneous drainage of the abscess was performed on admission, wherein a 7.0-French pigtail catheter was inserted into the abscess cavity through a right intercostal space (Fig. 2A). A microscopic examination of the pus with Gram staining detected large Gram-positive, rod-shaped bacteria (Fig. 2B).
Clinical course. ALT: alanine aminotransferase, T-BIL: total bilirubin, CRP: C-reactive protein, BIPM: biapenem, MTZ: metronidazole, CLDM: clindamycin, CMZ: cefmetazole, SBT/ABPC: sulbactam/ampicillin, LVFX: levofloxacin
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Her jaundice was resolved, and the ALT level decreased to within the normal limit (Fig. 3); however, the cavity of the abscess remained 13.6 cm in diameter, filled with a fluid-like component and the gas forming the air-fluid level. The patient remained stable after discontinuing oral levofloxacin without a relapse of inflammation (Fig. 3).
Abdominal CT images during hemorrhaging. Mild hyperdensity substances indicating bleeding from the right inferior phrenic artery were detected in the abscess cavity (arrowheads). Cross-sections of the pigtailed drainage catheter can be seen (red arrows). (A) Axial image. (B) Coronal image.
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Inflammation spreading from the abscess cavity to the diaphragm might have damaged the artery (Fig. 4). The drainage catheter was located at the dorsal side of the abscess cavity some distance from the bleeding site (Fig. 4), so vascular damage due to contact with a long-term-placed drainage tube seemed unlikely.
Digital subtraction angiography. (A) Right inferior phrenic artery (RIPA) angiogram, early phase. (B, C) RIPA angiogram in the late phase showing contrast extravasation. A branch of the right inferior phrenic artery showed oozing hemorrhaging (yellow arrowheads) and a round, enhanced lesion, suggesting a pseudoaneurysm (red arrowhead). (D) Proper hepatic artery angiogram.
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Emergency angiography detected contrast extravasation from the right inferior phrenic artery (Fig. 5). A branch of the right inferior phrenic artery showed oozing hemorrhaging and a round, enhanced lesion, suggesting a pseudoaneurysm (Fig. 5B, C).
Abdominal CT images at the removal of the drainage catheter. The abscess cavity is filled with a substance containing small air bubbles. The gas that had formed the air-fluid level is no longer present. (A) Axial image, cephalic level. (B) Axial image, caudal level.
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Follow-up CT showed that the abscess cavity was still present in the liver, with a size of 11.7 cm, but the gas that had been forming the air-fluid level had disappeared (Fig. 6).