A Rare Case of Pyogenic Liver Abscess With Perforative Caecal Peritonitis

Volume 5, Issue 10, October – 2020 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
A Rare Case of Pyogenic Liver Abscess with

Perforative Caecal Peritonitis
Dr. Pratima Bisen Sanjitkumar M. Sant
Department of Pediatrics, Department of Surgery,
Grant Government Medical College & Grant Government Medical College,
Sir J.J. Group of Hospitals, Sir J.J. Group of Hospitals,
Mumbai-400008, Maharashtra, India Mumbai-400008, Maharashtra, India
Dr. Praveen Davuluri

Department of Community Medicine,
Seth G.S. Medical College & K.E.M. Hospital,
Mumbai-400012, Maharashtra, India
Abstract:- Pyogenic liver abscess (PLA) has always been 3 days and got relieved after taking medication. Since then
an important and life-threatening scenario and its the child was passing stools normally.
diagnosis has always been a challenge for physicians.
Liver abscesses are frequently encountered in pediatric On general examination, child was afebrile with pulse
population in the tropical and subtropical regions. We rate: 98/min, respiratory rate: 24/min and Blood Pressure:
present a case of pyogenic liver abscess with caecal 104/60mmHg. Pallor and icterus were present.
perforative peritonitis. Due to the critical clinical
condition caused by the sepsis and contained rupture of Abdomen was distended, umbilicus was central with
the abscess we opted for open surgical drainage, with an transverse slit. Diffuse tenderness was present with guarding.
acceptable postoperative protocol. Clinical presentation, Liver was palpable 2 cm below right costal margins along
diagnostic techniques and current management options mid-clavicular line. It was smooth, soft to firm, tender and
are discussed. both lobes were enlarged. Spleen was just palpable and firm.
Bowel sounds were present. On respiratory system
Keywords:- Pyogenic Liver Abscess, E.Coli, Caecal examination, Chest was bilaterally symmetrical; chest
Perforation. movement was slightly decreased in left lower zone with a
dull note on percussion and air entry was reduced in same
I. INTRODUCTION area. There was no other systemic abnormality. Routine
Investigations were done and the results are depicted in Table
Pyogenic liver abscess (PLA) is an important cause of 1.
morbidity and mortality. Its diagnosis is always challenging,
mainly because there is a significant clinical and radiological Sr. No. Investigation Data
overlap with other hepatic conditionssuch as amoebic
1 Haemoglobin 12.4 g%
abscess and infected hydatid cyst. The treatment options of
pyogenic liver abscess have included both 2 Total Leucocyte Count 24500/cu.mm
medical(antibiotics alone) and surgical interventions (needle 3 C-Reactive Protein 131.2 mg/L
aspiration, catheter drainage, endoscopic drainage or open 4 ESR 100 mm/hr
surgical drainage). Imaging studies [ultrasonography (USG)
and computed tomography (CT)] aid in diagnosis (1). We 5 PT; aPTT; INR 14s; 34s; 1
present a case of immunocompetant girl with pyogenic liver SGOT; SGPT; Alkaline 50U/L; 64U/L;
6
abscess with caecal perforative peritonitis. Phosphatase 104U/L
2.4 mg/dL; 6.6
7 Bilirubin; Protein; Albumin
II. CASE REPORT g/dL; 2.4 g/dL
8 HIV; HBSAg; HCV Non-reactive
The 13 year old girl had presented with the complaints Pus cells: 18-20/hpf
of fever and vomiting since 12 days along with pain in 9 Stool routine microscopy
& mucus ++
abdomen since 10 days. Fever was associated with chills and Table 1: Investigations
rigors. It was high grade, continuous in nature and increased
since last 3 days. Vomiting 3-4 episodes daily, containing Ultrasonography of Abdomen was suggestive of mild
undigested food particles usually within 30 minutes after hepatomegaly with liver abscess of 70 x 66 x 65 mm (158 ml
having food. Pain in abdomen was dull aching, initially more volume) in right lobe of liver and also a large liquefied
in the right hypochondrium and in epigastric region and since exophytic abscess arising from left lobe (89 x 77 x 70 mm)
last 3 days it was diffuse. There was also history of loose which was sub-diaphragmatic and caused mild elevation of
stools (6-8 episodes per day) 12 days back which lasted for 2- left dome of diaphragm. There was evidence of free fluid in
abdomen. Ultrasonography of thorax was suggestive of
IJISRT20OCT244 www.ijisrt.com 826

Volume 5, Issue 10, October – 2020 International Journal of Innovative Science and Research Technology
ISSN No:-2456-2165
minimal left sided pleural effusion with moderate ascites may show hepatomegaly and right upper quadrant pain
with septations within. Pleural fluid tapping was suggestive although this is seen in only about 50% of cases (4).
of normal study. No organisms were isolated on blood
culture. The most common laboratory abnormalities are
hypoalbuminemia, elevated liver enzymes, and leucocytosis
Injection pantoprazole, cefotaxime and metronidazole (5). Computed Tomography or USG aid in
were started. Surgical reference was done and emergency diagnosis.Ultrasonography is the investigation of choice and
open surgical drainage was advised. Exploratory laparotomy can detect almost 100% of abscesses (6).
was done where caecal perforation was detected which was
5mm in size. Closure of caecal perforation with loop The antibiotics are usually administered intravenously
ileostomy was done along with aspiration of liver abscess. for at least 14 days, followed by oral administration for 4
500 ml of serous fluid with pus flakes was seen in pelvis weeks (6). USG-guided percutaneous needle aspiration is
which was aspirated. usually the preferred modality of treatment as it is safe, rapid
and simple. (7). Minor complications associated with this
After the procedure, the child was kept nil by mouth. procedure are hemorrhage into the abscess cavity and
Child was gradually started on liquid feeds and as she was pericatheter leak (8). Open surgical intervention is now
tolerating it, solid food was introduced subsequently and advised for (a) Non-response to needle aspiration or catheter
drains were gradually removed one by one. drainage; (b) large size of abscess; (c) when risk of rupture
is high; (d)contained rupture and (e) presence of peritonitis.
On culture of peritoneal fluid, E. Coli was seen that was Surgical intervention is associated with complications such
sentive to amikacin, gentamycin, tigecycline and colistin. As as respiratory infection, wound infection, ileus, intra-
per culture report, antibiotics were then added. Liver abscess abdominal collections, wound dehiscence, hemorrhages,
pus was sent for microscopy which showed gram negative biliary fistula and increased mortality (9). We opted for open
E.coli bacilli. surgical drainage for our case as the patient had presented
with a contained rupture of the liver abscess. However, with
Repeat ultrasonography was done after 7 days which the introduction of antibiotic therapy, imaging studies and
showed 20 to 25 cc of hypoechoic partially liquefied liver the drainage success, mortality rates have decreased to a
abscess. Patient was discharged after completing 2 weeks of large extent.
intravenous antibiotics. She was advised oral antibiotics for
one month. After 1 month, the patient was called for follow- REFERENCES
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Volume 5, Issue 10, October – 2020 International Journal of Innovative Science and Research Technology

A Rare Case of Pyogenic Liver Abscess with

Dr. Praveen Davuluri

IJISRT20OCT244 www.ijisrt.com 826

IJISRT20OCT244 www.ijisrt.com 827

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