Hepatic abscess in a pre-existed simple hepatic cyst as a late complication of sigmoid colon ruptured diverticula: a case report.

Abstract

Hepatic abscesses have been reported as a rare complication of diverticulitis of the bowel. This complication is recognized more commonly at the time of the diagnosis of diverticulitis, or ruptured diverticula, but also can be diagnosed prior to surgery, or postoperatively.
This report describes a man who developed an hepatic abscess within a simple hepatic cyst, two months after operation for ruptured diverticula of the sigmoid colon. The abscess was drained surgically and the patient made a complete recovery.
The development of an hepatic abscess in a pre-existing hepatic cyst, secondary to diverticulitis, is a rare complication. A high degree of clinical suspicion is required for immediate diagnosis and treatment.

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BioMed Central
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Journal of Medical Case Reports
Open Access
Case report
Hepatic abscess in a pre-existed simple hepatic cyst as a late
complication of sigmoid colon ruptured diverticula: a case report
Maria Chatzipetrou1, Efthimios Avgerinos1, Efstratios Christianakis2,
Galinos Barmparas1, Nikolaos Pashalidis2, Athanasios Stathoulopoulos1,
Panayiotis Tsatsoulis1, Dimitrios Smailis2 and Dimitrios Filippou*2,3
Address: 12ndDepartment of Surgery, "Asklepeion Voula's Hospital", Athens, Greece, 21stDepartment of General Surgery, Piraeus General
Hospital, Athens, Greece and 3Department of Anatomy, Nursing Faculty, University of Athens, Athens, Greece
Email: Maria Chatzipetrou - mchatzmed@yahoo.com; Efthimios Avgerinos - surgmaike@hotmail.com;
Efstratios Christianakis - christaina@otenet.gr; Galinos Barmparas - barbgalin@hotmail.com; Nikolaos Pashalidis - webdocgr@hotmail.com;
Athanasios Stathoulopoulos - stathan@aol.gr; Panayiotis Tsatsoulis - tsatsoulis@forthnet.gr; Dimitrios Smailis - dsmasurg@hotmail.com;
Dimitrios Filippou* - d_filippou@hotmail.com
* Corresponding author
Abstract
Introduction: Hepatic abscesses have been reported as a rare complication of diverticulitis of the
bowel. This complication is recognized more commonly at the time of the diagnosis of diverticulitis,
or ruptured diverticula, but also can be diagnosed prior to surgery, or postoperatively.
Case presentation: This report describes a man who developed an hepatic abscess within a
simple hepatic cyst, two months after operation for ruptured diverticula of the sigmoid colon. The
abscess was drained surgically and the patient made a complete recovery.
Conclusion: The development of an hepatic abscess in a pre-existing hepatic cyst, secondary to
diverticulitis, is a rare complication. A high degree of clinical suspicion is required for immediate
diagnosis and treatment.
Introduction
After the advent of antibiotics, few cases of hepatic
abscesses secondary to diverticulitis have been described.
In the past pylephlebitis, with or without hepatic abscess
formation, was a complication of abdominal sepsis more
commonly due to appendicitis. Abdominal computed
tomography (CT) scans have contributed to the early diag-
nosis of this lethal complication that had been mostly a
postmortem finding in the past. Herein, we report the case
of a man who developed an hepatic abscess within a pre-
existing simple hepatic cyst, following surgery for rup-
tured diverticula of the sigmoid colon.
Case presentation
A 66-year-old male was referred to our clinic with an acute
abdomen by the cardiology unit, where he had been
admitted three days before to be treated for paroxysmal
supraventricular tachycardia (SVT) and Right Bundle
Branch Block.
The patient was pale with tachycardia and tachypnoea.
His temperature was 38.5°C. On physical examination
there was localized tenderness at the left iliac fossa. Digital
rectal examination was normal.
Published: 14 March 2008
Journal of Medical Case Reports 2008, 2:83doi:10.1186/1752-1947-2-83
Received: 20 June 2007
Accepted: 14 March 2008
This article is available from: http://www.jmedicalcasereports.com/content/2/1/83
© 2008 Chatzipetrou et al; licensee BioMed Central Ltd.
This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0),
which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Blood tests on admission revealed: WBC: 18.200/mm3
(Seg 90%, Lymp 7%, Eos 1%, M 2%), Ht: 35.2%, Hb: 11.5
g/dl and PLT: 537.000/mm3, AST/ALT: 35/29 U/l, LDH:
116, CPK 77. Ultrasound (U/S) and CT scan of the abdo-
men demonstrated multiple simple hepatic cysts on both
lobes, the larger of those on the right lobe with a dimen-
sion of 12 cm. (Fig. 1)
After starting antibiotics (ticarcillin-clavulanic acid, ami-
cacin and metronidazole), the patient was operated on
two days later for peritonitis. At laparotomy, a small
abdominal abscess was found at the area of the sigmoid
colon caused by ruptured diverticula. The abscess was
drained and Hartmann excision of the bowel was per-
formed. The patient was admitted to the ICU for the first
four postoperative days and was discharged fully recov-
ered on the 21st day postoperatively from the clinic. Cul-
tures from the abdominal abscess grew Aerococcus viridans,
Escherichia coli and Proteus mirabilis and were negative for
anaerobes. Antibiotics were administrated for 18 days
after the operation. After discharge only dietary restric-
tions were recommended.
One month later the patient returned to the hospital with
malaise, vague abdominal pain, anorexia, poor general
condition and slightly elevated temperature (37.2–
37.5°C). Physical examination of the abdomen was nor-
mal, and the laboratory results were: WBC: 10.100/mm3
(Seg 78%, Lymp 16%, Eos 2%, M 4%), Ht: 29.1%, Hb: 9.3
g/dl and PLT: 629.000/mm3, AST/ALT: 126/37 U/l, amy-
lase 184. Abdominal ultrasound and CT scan did not
reveal any abnormal or unexpected finding, except of
course the simple hepatic cysts which were of the same
dimensions. (Fig. 2)
Three days after his admission, because of a drop of the
hematocrit to 20.9%, elevation of the patient's tempera-
ture (39°C), and worsening of his general condition,
ultrasound examination was repeated and showed that
the largest of the hepatic cysts contained opaque fluid
(Fig. 3), in contrast to the ultrasound that was performed
at the first admission, where the fluid of the cyst appeared
to be clear. Abdominal CT scan, showed the formation of
an hepatic abscess at the site of the pre-existing hepatic
cyst.
During second admission – 3 days post-admission
Figure 3
During second admission – 3 days post-admission. Ultra-
sound revealing the opaque fluid collection (abscess) inside
the previously clear right liver lobe cystic mass.
During first admission
Figure 1
During first admission. Abdominal ultrasound revealing a
sizeable right liver lobe cystic mass.
During second admission
Figure 2
During second admission. Abdominal CT scan revealing the
same clear right liver lobe cystic mass.

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Due to an inability to drain the abscess under CT guidance
at our hospital, the liver abscess was drained surgically.
The cultures of the pus of the hepatic abscess grew
Escherichia coli and Enterococcus spp. The postoperative care
of the patient was uncomplicated and he recovered slowly
but fully. He was discharged one month postoperatively.
Discussion
In the pre-antibiotics era, rare but lethal cases of pylephle-
bitis and hepatic abscesses secondary to appendicitis had
been described [1,2] but after the advent of antibiotics this
complication has been observed more commonly after
diverticulitis [3]. Later in the clinical course, infection of
the liver can cause the formation of hepatic abscesses.
Only a few cases of hepatic abscesses due to diverticulitis
have been reported, with [4,5] or without coexistent pyl-
ephlebitis [6].
Our report concerns a unique case of hepatic abscess for-
mation due to diverticulitis, in an existing simple hepatic
cyst without evidence of pylephlebitis. This is the first
reported case of delayed hepatic cyst transition to abscess,
following an event of diverticular rupture. The cyst was
first detected as a random finding during an abdominal
CT scan during the first hospital admission of the patient.
Later, during his second admission, the cyst was revealed
again by U/S and was then found to have been infected
and transformed to a large abscess three days later. That
happened probably by migration of microbes via the por-
tal vein but much later than the initial infection which
took place two months earlier.
Gram negative and anaerobic organisms are most com-
monly isolated in blood cultures and specimens of
abscesses, with E. coli being the most prevalent microbe
[7,8]. That was also the case in our patient.
Hepatic abscess may precede [9], follow [10] or appear at
the same time as diverticulitis [7,8]. Abdominal CT scan
and sonography are essential diagnostic methods and one
must have always in mind this rare but serious complica-
tion when dealing with diverticulitis of the bowel. Vice
versa, one must remember the possibility of diverticulitis
in the presence of hepatic abscesses [11].
In our case, we were able to document that the abscess of
the liver appeared two months after the rupture of sig-
moid colon diverticula. In spite of the high mortality
related to this complication, our patient made a full recov-
ery following surgical drainage.
Conclusion
Hepatic abscess in a pre-existing hepatic cyst, occuring sec-
ondary to diverticulitis, is a rare complication and a high
degree of clinical suspicion is required for immediate
diagnosis and treatment.
Competing interests
The author(s) declare that they have no competing inter-
ests.
Authors' contributions
CM, BG, PN, SA, TP, FD, AE, CE were the attending physi-
cians as well as the coordinating doctors (microbiologist,
radiologist) who were responsible for the diagnosis and
treatment of the patient and who provided all the infor-
mation. CM, SD, TP, BG, helped to draft the manuscript.
CE, SA, PN, FD wrote the final manuscript. AE, SD, FD
performed the final revisions of the paper. All authors
read and approved the final manuscript.
Consent
Written informed consent was obtained from the patient
for publication of this case report and accompanying
images. A copy of the written consent is available for
review by the Editor-in-Chief of this journal.
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