CASE 2619 Published on 15.09.2003

Liver abscess with spontaneous drainage in the peritoneal cavity complicating the ethanol injection therapy of HCC

Section

Interventional radiology

Case Type

Clinical Cases

Authors

Sedati P, Telesca M, Sandolo F, Macrì R, Passariello R

Patient

72 years, female

Categories
No Area of Interest ; Imaging Technique Ultrasound, CT, Ultrasound, CT, CT, Digital radiography, CT
Clinical History
This case details the history of the effects of a percutaneous ethanol injection (PEI), which had been administered for the treatment of HCC, in a 72-year-old female patient with cirrhosis (Child-Pugh’s class C), recurring pancreatitis, gallstones, diabetes mellitus, and anxious-depressive syndrome.
Imaging Findings
A 72-year-old female patient with a history of HCV related chronic hepatitis (Child-Pugh’s class C) , recurring pancreatitis, gallstones, diabetes mellitus, and anxious-depressive syndrome had came to our observation. An ultrasound (US) examination had been done, which had shown the presence of a 2.5 cm hypoechoic nodule in segment VI of the liver. A multidetector-CT procedure had been perfomed, which had demonstrated that the nodule was hypervascular in the arterial phase with a CT appearance consistent with hepatocellular carcinoma (HCC). The patient was considered a high-risk candidate for surgery or chemoembolisation because of her performance status and clinical history. A US guided percutaneous ethanol injection (PEI) had therefore been performed with a standard multiple session technique. The nodule had been treated three times, and each time, 5–7 ml of 95% sterile ethanol had been injected using a 22-gauge Chiba needle. No antibiotic prophylaxis had been given after the administration of the PEI. Seven days after the last treatment, the patient complained of a fever (38.8 ºC), abdominal pain, elevated WBC count, elevated serum CRP, and clinical signs of peritonitis. The multidetector-CT demonstrated that the nodule had enlarged and presented an air-fluid level; the capsule of the liver was interrupted with a perihepatic fluid collection. A diagnosis of spontaneous drainage of a liver abscess in the peritoneal cavity was made and the patient was sent to surgery. Laparotomy when performed revealed a diffuse peritonitis, which was treated by abdominal lavage and the placement of two surgical drainage tubes. The culture of the peritoneal fluid grew E. coli, therefore specific antibiotic therapy was initiated. The post-operative course was complicated by a small subphrenic collection which was successfully drained through a percutaneous approach. The patient was discharged after 12 days in a good general condition.
Discussion
Percutaneous ethanol injection is widely used in the management of HCC as an alternative to surgery in patients with tumours less than 5 cm in size, or with multicentric tumours (up to three nodules, each smaller than 3 cm). The reasons for the common use of this type of treatment in clinical practice are its effectiveness, simplicity and low cost [1]. The PEI has shown relatively good long-term results at 3 and 5 years, when compared with liver surgery [5]. The common adverse effects of the PEI are mild, transient, abdominal pain and low grade fever due to tumour necrosis, which may persist for several days. Major complications occur in 1.3%–13.4% of cases and include haemoperitoneum, haemobilia, pleural effusion, jaundice, and vascular injury [1, 2]. Deaths are seldom reported [1, 2]. Septic complications are rare, but liver abscesses have been reported after the administration of the PEI [3, 4]. The treatment of such a complication includes antibiotic therapy, percutaneous drainage, and surgery. It is difficult to diagnose a liver abscess occurring within a tumour treated with PEI, because the inflammatory response to tissue necrosis may cause pain, fever, an elevation of the WBC count and CRP levels, features that are also seen in case of a liver abscess. In addition, from an imaging standpoint, it may be difficult to distinguish whether or not there is abscess formation, since at CT, intratumoural gas bubbles or a perilesional hypervascular rim are often seen after an uneventful PEI. A careful correlation between the clinical course and the findings of imaging is necessary to achieve an early diagnosis. In our case, the evidence of an air-fluid level, the interruption of the Glisson’s capsule, and the perihepatic collection clearly indicated the rupturing of an abscess in the peritoneal cavity. Liver abscess is a unique complication, because it might prove fatal. When an early diagnosis is made, antibiotic therapy or percutaneous drainage is effective. In our case, the obvious signs of peritonitis mandated a surgical approach.
Differential Diagnosis List
Liver abscess with spontaneous drainage in the peritoneal cavity.
Final Diagnosis
Liver abscess with spontaneous drainage in the peritoneal cavity.
Case information
URL: https://www.eurorad.org/case/2619
DOI: 10.1594/EURORAD/CASE.2619
ISSN: 1563-4086