Figure 1
Abdominal contrast-enhanced CT
Wedge-shaped area of high attenuation in the right hepatic lobe (arrows), air-fluid levels in the perihepatic peritoneal cavity (arrowheads) and aortic atherosclerosis.
Liver gas gangrene with spontaneous pneumoperitoneum caused by clostridium perfringens
SectionAbdominal imaging
Case TypeClinical Cases
AuthorsRomeu Vilar D, Otero Palleiro M, Méndez Díaz C
Connected authors
80 years, male
Clinical History
An 80-year-old man with poorly controlled diabetes mellitus presented with acute upper abdominal pain, chills, jaundice and high fever (39ºC), for two days. Physical examination showed a distended and tender abdomen, particularly over the right upper quadrant. Laboratory studies revealed leukocytosis and a glucose level of 555 mg/dl.
Imaging Findings
Abdominal and pelvic contrast-enhanced CT demonstrated a gas-filled cavity in the right hepatic lobe with a high attenuation wedge-shaped area in surrounding parenchyma, air-fluid levels in the perihepatic peritoneal cavity, pneumobilia and aortic atherosclerosis (Figs. 1 - 3).
Emergent exploratory laparotomy revealed a gas-forming liver necrotic cavity which had ruptured into the peritoneal cavity. Open drainage of the liver abscess necrotic cavity was performed and clostridium perfringens was identified on blood and surgical sample cultures. Three weeks later the patient had recovered completely.
Emergent exploratory laparotomy revealed a gas-forming liver necrotic cavity which had ruptured into the peritoneal cavity. Open drainage of the liver abscess necrotic cavity was performed and clostridium perfringens was identified on blood and surgical sample cultures. Three weeks later the patient had recovered completely.
Discussion
Diseases caused by clostridium perfringens include spontaneous gas gangrene and necrotising enterocolitis [1]. Spontaneous gas gangrene secondary usually occurs following delivery, surgery, or in patients with a known malignancy [2], or compromised with diabetes or liver cirrhosis [3, 4].
Classical CT findings of hepatic abscesses include clustered or septated spherical or oval pus collections and high attenuated areas around the inflamed area. Our case showed a large gas-filled cavity in liver with spontaneous pneumoperitoneum and pneumobilia. These CT features differ from the few reported cases of gas-forming pyogenic liver abscess in which usually show small air bubbles or a gas-fluid level within the fluid pus [5].
Air or gas bubbles filling a cavity also have been reported in emphysematous pyelonephritis associated with poorly controlled diabetes [6, 7]. It usually develops if there is a necrotizing gas forming infection in the presence of a glucose-rich ischaemic environment or an impaired host response to bacterial infection [6, 8]. Our patient was a poorly controlled diabetic with severe atherosclerotic disease and clostridium perfringens infection caused fulminant parenchymal necrosis of the liver without resulting exudation of pus.
Liver gas gangrene has been previously reported after orthotopic liver transplantation due to hepatic arterial thrombosis and infection of the infarcted liver with coliform bacteria [7]. Our patient was not a transplant recipient and the arterial and venous supply were intact.
Spontaneous pneumoperitoneum resulting from liver gas gangrene is an extremely rare event and very few cases have been reported in the literature [9 – 11]. Pathogens that are associated with gas formation are likely to be associated with a higher risk for abscess rupture and early mortality [9, 11] because the presence of gas increases tension within the abscess cavity [12].
Clostridium perfringens gas gangrene is one of the most fulminant bacterial infections that occur in humans. Early diagnosis is crucial for a favourable clinical outcome. Surgical debridement of all necrotic tissue should be performed immediately followed by an appropriate course of antibiotics [4, 13].
In summary, clostridium perfringens liver gas gangrene in a diabetic patient is a life-threatening necrotizing hepatic infection characterized by the presence of gas in the liver parenchyma, surrounding tissues, or both. Early diagnosis and immediate management are crucial due to increased risk of septic shock and a higher mortality.
Classical CT findings of hepatic abscesses include clustered or septated spherical or oval pus collections and high attenuated areas around the inflamed area. Our case showed a large gas-filled cavity in liver with spontaneous pneumoperitoneum and pneumobilia. These CT features differ from the few reported cases of gas-forming pyogenic liver abscess in which usually show small air bubbles or a gas-fluid level within the fluid pus [5].
Air or gas bubbles filling a cavity also have been reported in emphysematous pyelonephritis associated with poorly controlled diabetes [6, 7]. It usually develops if there is a necrotizing gas forming infection in the presence of a glucose-rich ischaemic environment or an impaired host response to bacterial infection [6, 8]. Our patient was a poorly controlled diabetic with severe atherosclerotic disease and clostridium perfringens infection caused fulminant parenchymal necrosis of the liver without resulting exudation of pus.
Liver gas gangrene has been previously reported after orthotopic liver transplantation due to hepatic arterial thrombosis and infection of the infarcted liver with coliform bacteria [7]. Our patient was not a transplant recipient and the arterial and venous supply were intact.
Spontaneous pneumoperitoneum resulting from liver gas gangrene is an extremely rare event and very few cases have been reported in the literature [9 – 11]. Pathogens that are associated with gas formation are likely to be associated with a higher risk for abscess rupture and early mortality [9, 11] because the presence of gas increases tension within the abscess cavity [12].
Clostridium perfringens gas gangrene is one of the most fulminant bacterial infections that occur in humans. Early diagnosis is crucial for a favourable clinical outcome. Surgical debridement of all necrotic tissue should be performed immediately followed by an appropriate course of antibiotics [4, 13].
In summary, clostridium perfringens liver gas gangrene in a diabetic patient is a life-threatening necrotizing hepatic infection characterized by the presence of gas in the liver parenchyma, surrounding tissues, or both. Early diagnosis and immediate management are crucial due to increased risk of septic shock and a higher mortality.
Differential Diagnosis List
Liver gas gangrene with spontaneous rupture into the peritoneal cavity
Hepatic infarct with secondary infection and pneumoperitoneum
Liver gas gangrene with spontaneous rupture into the peritoneal cavity
Final Diagnosis
Liver gas gangrene with spontaneous rupture into the peritoneal cavity
References
[1] Kreidl KO, Green GR, Wren SM (2002) Intravascular hemolysis from a Clostridium perfringens liver abscess. J Am Coll Surg Mar;194(3):387 (PMID: 11893140)
[2] Bodey GP, Rodriguez S, Fainstein V, Elting LS (1991) Clostridial bacteremia in cancer patients. A 12-year experience. Cancer Apr 1;67(7):1928-42 (PMID: 2004306)
[3] Chen YM, Lee HC, Chang CM, Chuang YC, Ko WC (2001) Clostridium bacteremia: emphasis on the poor prognosis in cirrhotic patients. J Microbiol Immunol Infect Jun;34(2):113-8 (PMID: 11456356)
[4] Kim JH, Jung ES, Jeong SH, Kim JS, Ku YS, Hahm KB, Kim JH, Kim YS (2012) A case of emphysematous hepatitis with spontaneous pneumoperitoneum in a patient with hilar cholangiocarcinoma. Korean J Hepatol Mar;18(1):94-7 (PMID: 22511909)
[5] Mathieu D, Vasile N, Fagniez PL, Segui S, Grably D, Lardé D (1985) Dynamic CT features of hepatic abscesses. Radiology Mar;154(3):749-52 (PMID: 3969480)
[6] Craig WD, Wagner BJ, Travis MD (2008) Pyelonephritis: radiologic-pathologic review. Radiographics Jan-Feb;28(1):255-77 (PMID: 18203942)
[7] Wan YL, Lee TY, Bullard MJ, Tsai CC (1996) Acute gas-producing bacterial renal infection: correlation between imaging findings and clinical outcome. Radiology Feb;198(2):433-8 (PMID: 8596845)
[8] Rodriguez-de-Velasquez A, Yoder IC, Velasquez PA, Papanicolaou N (1995) Imaging the effects of diabetes on the genitourinary system. Radiographics Sep;15(5):1051-68 (PMID: 7501850)
[9] Ukikusa M, Inomoto T, Kitai T, Ino K, Higashiyama H, Arimoto A, Nakajima Y, Hanafusa T, Awane H (2001) Pneumoperitoneum following the spontaneous rupture of a gas-containing pyogenic liver abscess: report of a case. Surg Today 31(1):76-9 (PMID: 11213050)
[10] Chou FF, Sheen-Chen SM, Lee TY (1995) Rupture of pyogenic liver abscess. Am J Gastroenterol May;90(5):767-70 (PMID: 7733086)
[11] Lee CH, Leu HS, Wu TS, Su LH, Liu JW (2005) Risk factors for spontaneous rupture of liver abscess caused by Klebsiella pneumoniae. Diagn Microbiol Infect Dis Jun;52(2):79-84 (PMID: 15964493)
[12] Chong VH, Yong AM, Wahab AY (2008) Gas-forming pyogenic liver abscess. Singapore Med J May;49(5):e123-5 (PMID: 18465035)
[13] Kuroda S, Okada Y, Mita M, Okamoto Y, Kato H, Ueyama S, Fujii I, Morita S, Yoshida Y (2005) Fulminant massive gas gangrene caused by Clostridium perfringens. Intern Med May;44(5):499-502 (PMID: 15942103)
Case information
| URL: | https://www.eurorad.org/case/10239 |
| DOI: | 10.1594/EURORAD/CASE.10239 |
| ISSN: | 1563-4086 |
Figure 2
Abdominal contrast-enhanced CT
Large gas-filled cavity (asterisk) without fluid in the right hepatic lobe, high attenuation area due to increased perfusion around the abscess, pneumoperitoneum (arrowhead) and pneumobilia (arrows). An incidental right adrenal adenoma also can be seen.
Figure 3
Abdominal contrast-enhanced CT image with a lung window setting
Extensive replacement of the hepatic parenchyma with interstitial gas (large arrows) without fluid, pneumoperitoneum (arrowhead) and pneumobilia (small arrows).
Abdominal contrast-enhanced CT
Wedge-shaped area of high attenuation in the right hepatic lobe (arrows), air-fluid levels in the perihepatic peritoneal cavity (arrowheads) and aortic atherosclerosis.
Department of Radiology. Complejo Hospitalario Universitario A Coruña. A Coruña (Spain)
Department of Radiology. Complejo Hospitalario Universitario A Coruña. A Coruña (Spain)
Abdominal contrast-enhanced CT
Large gas-filled cavity (asterisk) without fluid in the right hepatic lobe, high attenuation area due to increased perfusion around the abscess, pneumoperitoneum (arrowhead) and pneumobilia (arrows). An incidental right adrenal adenoma also can be seen.
Department of Radiology. Complejo Hospitalario Universitario A Coruña. A Coruña (Spain)
Department of Radiology. Complejo Hospitalario Universitario A Coruña. A Coruña (Spain)
Abdominal contrast-enhanced CT image with a lung window setting
Extensive replacement of the hepatic parenchyma with interstitial gas (large arrows) without fluid, pneumoperitoneum (arrowhead) and pneumobilia (small arrows).
Department of Radiology. Complejo Hospitalario Universitario A Coruña. A Coruña (Spain)
Department of Radiology. Complejo Hospitalario Universitario A Coruña. A Coruña (Spain)