Pyogenic Liver Abscess Secondary to Asymptomatic Sigmoid Diverticulitis MARC K. WALLACK, M.D.,* ARTHUR S. BROWN, M.D.,* ROBERT AUSTRIAN, M.D.,t WILLIAM T. FITTS, JR., M.D.4
A patient with multiple pyogenic abscesses in both lobes of the liver secondary to asymptomatic sigmoid diverticulitis is presented. The rarity of this illness is noted. It is suggested that barium enema be performed in patients who present with pyogenic liver abscess of unknown etiology because of the association with asymptomatic sigmoid diverticulitis.
From the Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
sectioning of the specimen showed no gross evidence of pus, but microscopic examination did show both diverticula and veins filled with pyogenic material. There was no history of diverticulitis preceding the sudden onset of the liver abscess. The patient has done well for 2 years following drainage of the abscesses and resection of the mass in the sigmoid colon, and our presumption is that the liver abscesses came from the "occult" sigmoid diverticulitis.
PYOGENIC LIVER ABSCESS is now an uncommon occurrence.' Diverticulitis of the sigmoid colon as the source of hepatic abscess, moreover, is even more uncommon. Only 51 cases have been collected from the literature.2-25 We are presenting the course of a patient whose illness began with symptoms and signs consistent with severe liver infection that proved at operation to be due to multiple abscesses involving both lobes of the liver. The unusual nature of the case is due to the fact that no Case Report obvious primary site of severe infection could be found at A.S., a 53-year-old Caucasian man, entered the Hospital of the operation. There was a mass in the sigmoid colon but no signs of acute inflammation about it. Because this mass University of Pennsylvania with the chief complaint of fever, weakness "right-sided belly pain" of approximately 8 days duration. was the only abnormal finding, it was excised. Careful andEight days prior to admission, the patient developed a cold flush and
Submitted for publication February 10, *
1976. Department of Surgery, University of Pennsylvania, Philadelphia. t Department of Medicine, University of Pennsylvania, Phila-
delphia.
4: Chairman, Department of Surgery, University of Pennsylvania, Philadelphia. Reprint requests: Marc K. Wallack, M.D., Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania 19174.
malaise followed by fever to 39°. The patient was seen by his personal physician and administered broad spectrum antibiotics to combat the asymptomatic high fever. After 48 hours of drug therapy, however, the patient remained febrile. The patient was admitted to Mercer Medical Center in Trenton, N.J., complaining of fever, upper abdominal pain and loss of desire to smoke although accustomed to smoking 60 cigarettes daily. The white blood cell count was 19,600/mm3 with 81 polymorphonuclear cells and 10 band forms. Liver scan showed several hepatic defects thought to be compatible either with "multiple abscesses or metastatic carcinoma" (Fig. 1).
241
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Ann. Surg. * August 1976
On the 35th postoperative day, antibiotic therapy was discontinued. The patient remained afebrile for 3 days and then developed fever to 39°. Cultures taken from the right upper quadrant drain sites consistently grew Enterobactor aerogenes sensitive to cephalexin. The patient was treated orally with 500 mg of cephalexin 4 times a day and remained afebrile in the hospital for 14 days. On the 54th postoperative day the patient was discharged on the same cephalexin. There was no definite change in the liver scan at the time of discharge.
Comments. Diverticulitis of the sigmoid colon is an uncommon source of liver abscess. In 1906 Whyte2 first reported a case of suppurative sigmoid diverticulitis with liver abscess. In 1973, Lin24 reported 2 cases of liver abscess complicating sigmoid diverticulitis and only found 48 additional cases documented in the world's literature. Ribando and Ochsner25 further emphasized the relative infrequency of the problem when they reported that from 1951 to 1971 a total of 40 patients with primary intrahepatic abscess were treated at the Ochsner Foundation Hospital in New Orleans, Louisiana. In this period there were 203,347 hospital admissions. In only 1 of the 40 patients FIG. 1. Liver scan with hepatic defects compatible with multiple was sigmoid diverticulitis considered the cause of the liver abscesses or metastatic carcinoma. abscesses. The patient was transferred to the Hospital of the University of Pennsylvania. On admission, the patient's temperature was 39°, and the only pertinent physical finding was an extremely tender, soft liver edge palpated three finger breadths below the right costal margin. Laboratory studies were as follows: Hemoglobin 13.0 gm/100 ml; Hematocrit 40%o; W.B.C. 9.8/mm3 with 70 polymorphonuclear cells and 1 band form; Total bilirubin 2.40 mg/100 ml; with one minute index of 1.36 mg/100 ml; Alkaline Phosphatase 27 I.U./L; SGOT 75 units; SGPT 115 units. A liver scan showed the liver to be enlarged and studded with multiple spherical defects, especially in the apical portion of the right hepatic lobe, which was almost completely destroyed. Celiac arteriogram showed the liver to have multiple areas of radiolucency alternating with areas of hypervascularity compatible with either multicentric hepatoma or metastatic carcinoma. As a result of the 2 week history of continuing high fever refractory to antibiotics and a progressive course with no improvement or definitive diagnosis, the patient was taken to the operating room for an exploratory laparotomy. The liver edge extended 3 cm below the right costal margin. Multiple abscesses were identified throughout the right lobe of the liver. All the abscesses were unroofed and drained; and multiple cultures were taken. Further exploration of the abdomen revealed a mass in the rectosigmoid colon with some pericolonic inflammation. The inflammed portion of the sigmoid colon was resected. The pathologic specimens showed the liver to have numerous abscesses (Fig. 2). Sections of the sigmoid colon revealed numerous diverticula. Some ofthe diverticula showed a marked acute inflammatory reaction with abscess formation (Fig. 3). The pus cultured at surgery yielded Enterobactor aerogenes and Pseudomonas aeruginosa, both sensitive to gentamicin, carbenicillin and cephalothin. The patient was treated with all 3 antimicrobial drugs in the following doses: 70 mg of gentamicin intramuscularly every 8 hours; 2 g of carbenicillin intravenously every 3 hours and 2 g of cephalothin intravenously every 6 hours. The patient received all 3 drugs for 5 weeks. During that time, the patient's white blood cell count and liver function studies returned to normal levels, but the liver scan continued to show rather large defects in the right hepatic lobe.
FIG. 2. Liver with abscess formation in lower half of specimen.
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liver abscesses, all patients who present with the triad of fever, jaundice and an enlarged tender liver should probably have a barium enema to rule out this possibility. Once the diagnosis is considered, proper treatment should include prompt incision and drainage of the large abscesses, resection of the locally inflammed sigmoid colon and administration of high doses of antibiotics based on the cultures of pus obtained at surgery. References
0
&Fo
\
FIG. 3. Diverticula with abscess formation.
The major symptoms and signs of liver abscess are fever, chills, jaundice, enlarged tender liver, and leukocytosis. Symptoms and signs of the sigmoid colon disorder are infrequent, for most cases have a silent primary lesion.24 The problem is how to discover the silent sigmoid lesion. Our patient presented with the classic signs of pyogenic liver abscess but had no signs or symptoms of sigmoid diverticulitis. The evidence for the abscesses in the right lobe of the liver being secondary to sigmoid diverticulitis was good, for the only recognized possible site of primary infection was the suppurative sigmoid diverticulitis discovered at laparotomy. Therefore, it is important to be aware of sigmoid diverticulitis as a possible cause of liver abscess in patients who present with fever, jaundice, enlarged tender liver and no history of colon disorders. The liver abscess can be diagnosed by liver scanning, hepatic arteriography, percutaneous aspiration of pus and laparotomy. Furthermore, since asymptomatic sigmoid diverticulitis can cause
1. Abbruzzese, A. and Khaija, M.: Pyogenic Abscess of the Liver. Am. J. Gastroenterol, 58:288, 1972. 2. Altemeier, W. A., Schavengerdt, C. G., and Whitely, D. H.: Abscesses of the Liver: Surgical Consideration. Arch. Surg.. 101:258, 1970. 3. Bodman, F. and Taylor, A. L.: Portal Pyemia Following Diverticulitis with Report of a Case. Bristol Medic Ochiv. J., 46:131, 1929. 4. Butler, T. J. and McCarthy, C. F.: Pyogenic l iver Abscess. Gut, 10:389, 1969. 5. Cavoli, J. and Gosset, J.: La Seticemie Portale, Diverticulite Sigmoidienne, Pylephlebite Radicularie, Septicemie Colibacillaire Icterigene. Rev. Medicochir Mal. Foie., 32:11. 1957. 6. Cooke, W. T.: Diverticulitis with an Unusual Termination: Pylephlebitis Simulating Weil's Disease. Lancet, 1:84, 1937. 7. Cronin, K.: Pyogenic Abscess of Liver. Gut, 2:53. 1961. 8. Dearlave. T. P.: Diverticulitis and Diverticulosis with Report of a Rare Complication. Med. J. Aust.. 1:470, 1954. 9. Fischer. W.: Cited by Sigmund. H. Reference 23. 10. Gaisford, W. D. and Mark, J. B. D.: Surgical Management of Hepatic Abscess. Am. J. Surg.. 118:317. 1969. 11. Joseph, W. I., Kahn, A. M. and Longmire, W. P.: Pyogenic Liver Abscess, Changing Patterns in Approach. Am. J. Surg., 115:63, 1968. 12. Kinney, T. D. and Ferrebee, J. W.: Hepatic Abscess, Factors Determining Its Localization. Arch. Pathol.. 45:41, 1948. 13. Knowles, R. and Rinaldo, J. A.: Pyogenic Liver Abscess Probably Secondary to Sigmoid Diverticulitis. Report of Two Cases. Gastroenterology, 38:262. 1960. 14. Lin, C.: Suppurative Pylephlebitis and Liver Abscess Complicating Colonic Diverticulitis: Report of Two Cases and Review of Literature. Mt. Sinai J. Med.. 40:48, 1973. 15. Matheson, N. A.. Gardner. D. L. and Dudley. H. A. F.: Liver Sepsis. Br. J. Surg., 51:363, 1964. 16. Ogden, W. W., Hunter, P. R. and Rives. J. D.: ILiver Abscess. Postgrad. Med., 30:11, 1961. 17. Purtek, L. J. and Bartus, S. A.: Hepatic Pyemia. N. Engl. J. Med.. 272:511, 1965. 18. Rambo, W. M. and Black, H. C.: Intrahepatic Abscess. Am. Surg., 35: 144, 1969. 19. Ribando, J. and Ochsner, A.: Intrahepatic Abscesses: Amebic and Pyogenic. Am. J. Surg., 125:1973. 20. Robertson, R. D., Foster, J. H. and Peterson, C. G.: Pyogenic Liver Abscess Studies by Cholangiography, Case Report and 25 Years' Review. Am. Surg., 32:521, 1966. 21. Shaldon, C.: Portal Pyaemia. Br. J. Surg., 45:357, 1958. 22. Sherman, J. D. and Robbins, S. L.: Changing Trends in the Casuistics of Hepatic Abscess. Am. J. Med., 28:943, 1960. 23. Siegmund, H.: Einfache Entzundungen Des Darmrohes, Handbuch Der Speziellen Pathologischen Anatomic Und Histologie. Edited by F. Henke and D. Lubarsch. Berline Julius Springer, 1929; p. 294. 24. Weir, J. F. and Beaver, D. C.: Diseases of the Portal Vein: A Review of 127 Instances. Am. J. Dig. Nutr., 1:498, 1934. 25. Whyte, J. M.: A Case of Supparative Hepatitis Following Inflammation In An Acquired Diverticulum of the Sigmoid Flexure. Scot. Med. Surg. J., 18:120, 1906.
A patient with multiple pyogenic abscesses in both lobes of the liver secondary to asymptomatic sigmoid diverticulitis is presented. The rarity of this illness is noted. It is suggested that barium enema be performed in patients who present with pyogenic liver abscess of unknown etiology because of the association with asymptomatic sigmoid diverticulitis.
From the Department of Surgery, University of Pennsylvania, Philadelphia, Pennsylvania
sectioning of the specimen showed no gross evidence of pus, but microscopic examination did show both diverticula and veins filled with pyogenic material. There was no history of diverticulitis preceding the sudden onset of the liver abscess. The patient has done well for 2 years following drainage of the abscesses and resection of the mass in the sigmoid colon, and our presumption is that the liver abscesses came from the "occult" sigmoid diverticulitis.
PYOGENIC LIVER ABSCESS is now an uncommon occurrence.' Diverticulitis of the sigmoid colon as the source of hepatic abscess, moreover, is even more uncommon. Only 51 cases have been collected from the literature.2-25 We are presenting the course of a patient whose illness began with symptoms and signs consistent with severe liver infection that proved at operation to be due to multiple abscesses involving both lobes of the liver. The unusual nature of the case is due to the fact that no Case Report obvious primary site of severe infection could be found at A.S., a 53-year-old Caucasian man, entered the Hospital of the operation. There was a mass in the sigmoid colon but no signs of acute inflammation about it. Because this mass University of Pennsylvania with the chief complaint of fever, weakness "right-sided belly pain" of approximately 8 days duration. was the only abnormal finding, it was excised. Careful andEight days prior to admission, the patient developed a cold flush and
Submitted for publication February 10, *
1976. Department of Surgery, University of Pennsylvania, Philadelphia. t Department of Medicine, University of Pennsylvania, Phila-
delphia.
4: Chairman, Department of Surgery, University of Pennsylvania, Philadelphia. Reprint requests: Marc K. Wallack, M.D., Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania 19174.
malaise followed by fever to 39°. The patient was seen by his personal physician and administered broad spectrum antibiotics to combat the asymptomatic high fever. After 48 hours of drug therapy, however, the patient remained febrile. The patient was admitted to Mercer Medical Center in Trenton, N.J., complaining of fever, upper abdominal pain and loss of desire to smoke although accustomed to smoking 60 cigarettes daily. The white blood cell count was 19,600/mm3 with 81 polymorphonuclear cells and 10 band forms. Liver scan showed several hepatic defects thought to be compatible either with "multiple abscesses or metastatic carcinoma" (Fig. 1).
241
242
WALLACK AND OTHERS
Ann. Surg. * August 1976
On the 35th postoperative day, antibiotic therapy was discontinued. The patient remained afebrile for 3 days and then developed fever to 39°. Cultures taken from the right upper quadrant drain sites consistently grew Enterobactor aerogenes sensitive to cephalexin. The patient was treated orally with 500 mg of cephalexin 4 times a day and remained afebrile in the hospital for 14 days. On the 54th postoperative day the patient was discharged on the same cephalexin. There was no definite change in the liver scan at the time of discharge.
Comments. Diverticulitis of the sigmoid colon is an uncommon source of liver abscess. In 1906 Whyte2 first reported a case of suppurative sigmoid diverticulitis with liver abscess. In 1973, Lin24 reported 2 cases of liver abscess complicating sigmoid diverticulitis and only found 48 additional cases documented in the world's literature. Ribando and Ochsner25 further emphasized the relative infrequency of the problem when they reported that from 1951 to 1971 a total of 40 patients with primary intrahepatic abscess were treated at the Ochsner Foundation Hospital in New Orleans, Louisiana. In this period there were 203,347 hospital admissions. In only 1 of the 40 patients FIG. 1. Liver scan with hepatic defects compatible with multiple was sigmoid diverticulitis considered the cause of the liver abscesses or metastatic carcinoma. abscesses. The patient was transferred to the Hospital of the University of Pennsylvania. On admission, the patient's temperature was 39°, and the only pertinent physical finding was an extremely tender, soft liver edge palpated three finger breadths below the right costal margin. Laboratory studies were as follows: Hemoglobin 13.0 gm/100 ml; Hematocrit 40%o; W.B.C. 9.8/mm3 with 70 polymorphonuclear cells and 1 band form; Total bilirubin 2.40 mg/100 ml; with one minute index of 1.36 mg/100 ml; Alkaline Phosphatase 27 I.U./L; SGOT 75 units; SGPT 115 units. A liver scan showed the liver to be enlarged and studded with multiple spherical defects, especially in the apical portion of the right hepatic lobe, which was almost completely destroyed. Celiac arteriogram showed the liver to have multiple areas of radiolucency alternating with areas of hypervascularity compatible with either multicentric hepatoma or metastatic carcinoma. As a result of the 2 week history of continuing high fever refractory to antibiotics and a progressive course with no improvement or definitive diagnosis, the patient was taken to the operating room for an exploratory laparotomy. The liver edge extended 3 cm below the right costal margin. Multiple abscesses were identified throughout the right lobe of the liver. All the abscesses were unroofed and drained; and multiple cultures were taken. Further exploration of the abdomen revealed a mass in the rectosigmoid colon with some pericolonic inflammation. The inflammed portion of the sigmoid colon was resected. The pathologic specimens showed the liver to have numerous abscesses (Fig. 2). Sections of the sigmoid colon revealed numerous diverticula. Some ofthe diverticula showed a marked acute inflammatory reaction with abscess formation (Fig. 3). The pus cultured at surgery yielded Enterobactor aerogenes and Pseudomonas aeruginosa, both sensitive to gentamicin, carbenicillin and cephalothin. The patient was treated with all 3 antimicrobial drugs in the following doses: 70 mg of gentamicin intramuscularly every 8 hours; 2 g of carbenicillin intravenously every 3 hours and 2 g of cephalothin intravenously every 6 hours. The patient received all 3 drugs for 5 weeks. During that time, the patient's white blood cell count and liver function studies returned to normal levels, but the liver scan continued to show rather large defects in the right hepatic lobe.
FIG. 2. Liver with abscess formation in lower half of specimen.
Vol. 184 . No. 2
243
PYOGENIC LIVER ABSCESS
liver abscesses, all patients who present with the triad of fever, jaundice and an enlarged tender liver should probably have a barium enema to rule out this possibility. Once the diagnosis is considered, proper treatment should include prompt incision and drainage of the large abscesses, resection of the locally inflammed sigmoid colon and administration of high doses of antibiotics based on the cultures of pus obtained at surgery. References
0
&Fo
\
FIG. 3. Diverticula with abscess formation.
The major symptoms and signs of liver abscess are fever, chills, jaundice, enlarged tender liver, and leukocytosis. Symptoms and signs of the sigmoid colon disorder are infrequent, for most cases have a silent primary lesion.24 The problem is how to discover the silent sigmoid lesion. Our patient presented with the classic signs of pyogenic liver abscess but had no signs or symptoms of sigmoid diverticulitis. The evidence for the abscesses in the right lobe of the liver being secondary to sigmoid diverticulitis was good, for the only recognized possible site of primary infection was the suppurative sigmoid diverticulitis discovered at laparotomy. Therefore, it is important to be aware of sigmoid diverticulitis as a possible cause of liver abscess in patients who present with fever, jaundice, enlarged tender liver and no history of colon disorders. The liver abscess can be diagnosed by liver scanning, hepatic arteriography, percutaneous aspiration of pus and laparotomy. Furthermore, since asymptomatic sigmoid diverticulitis can cause
1. Abbruzzese, A. and Khaija, M.: Pyogenic Abscess of the Liver. Am. J. Gastroenterol, 58:288, 1972. 2. Altemeier, W. A., Schavengerdt, C. G., and Whitely, D. H.: Abscesses of the Liver: Surgical Consideration. Arch. Surg.. 101:258, 1970. 3. Bodman, F. and Taylor, A. L.: Portal Pyemia Following Diverticulitis with Report of a Case. Bristol Medic Ochiv. J., 46:131, 1929. 4. Butler, T. J. and McCarthy, C. F.: Pyogenic l iver Abscess. Gut, 10:389, 1969. 5. Cavoli, J. and Gosset, J.: La Seticemie Portale, Diverticulite Sigmoidienne, Pylephlebite Radicularie, Septicemie Colibacillaire Icterigene. Rev. Medicochir Mal. Foie., 32:11. 1957. 6. Cooke, W. T.: Diverticulitis with an Unusual Termination: Pylephlebitis Simulating Weil's Disease. Lancet, 1:84, 1937. 7. Cronin, K.: Pyogenic Abscess of Liver. Gut, 2:53. 1961. 8. Dearlave. T. P.: Diverticulitis and Diverticulosis with Report of a Rare Complication. Med. J. Aust.. 1:470, 1954. 9. Fischer. W.: Cited by Sigmund. H. Reference 23. 10. Gaisford, W. D. and Mark, J. B. D.: Surgical Management of Hepatic Abscess. Am. J. Surg.. 118:317. 1969. 11. Joseph, W. I., Kahn, A. M. and Longmire, W. P.: Pyogenic Liver Abscess, Changing Patterns in Approach. Am. J. Surg., 115:63, 1968. 12. Kinney, T. D. and Ferrebee, J. W.: Hepatic Abscess, Factors Determining Its Localization. Arch. Pathol.. 45:41, 1948. 13. Knowles, R. and Rinaldo, J. A.: Pyogenic Liver Abscess Probably Secondary to Sigmoid Diverticulitis. Report of Two Cases. Gastroenterology, 38:262. 1960. 14. Lin, C.: Suppurative Pylephlebitis and Liver Abscess Complicating Colonic Diverticulitis: Report of Two Cases and Review of Literature. Mt. Sinai J. Med.. 40:48, 1973. 15. Matheson, N. A.. Gardner. D. L. and Dudley. H. A. F.: Liver Sepsis. Br. J. Surg., 51:363, 1964. 16. Ogden, W. W., Hunter, P. R. and Rives. J. D.: ILiver Abscess. Postgrad. Med., 30:11, 1961. 17. Purtek, L. J. and Bartus, S. A.: Hepatic Pyemia. N. Engl. J. Med.. 272:511, 1965. 18. Rambo, W. M. and Black, H. C.: Intrahepatic Abscess. Am. Surg., 35: 144, 1969. 19. Ribando, J. and Ochsner, A.: Intrahepatic Abscesses: Amebic and Pyogenic. Am. J. Surg., 125:1973. 20. Robertson, R. D., Foster, J. H. and Peterson, C. G.: Pyogenic Liver Abscess Studies by Cholangiography, Case Report and 25 Years' Review. Am. Surg., 32:521, 1966. 21. Shaldon, C.: Portal Pyaemia. Br. J. Surg., 45:357, 1958. 22. Sherman, J. D. and Robbins, S. L.: Changing Trends in the Casuistics of Hepatic Abscess. Am. J. Med., 28:943, 1960. 23. Siegmund, H.: Einfache Entzundungen Des Darmrohes, Handbuch Der Speziellen Pathologischen Anatomic Und Histologie. Edited by F. Henke and D. Lubarsch. Berline Julius Springer, 1929; p. 294. 24. Weir, J. F. and Beaver, D. C.: Diseases of the Portal Vein: A Review of 127 Instances. Am. J. Dig. Nutr., 1:498, 1934. 25. Whyte, J. M.: A Case of Supparative Hepatitis Following Inflammation In An Acquired Diverticulum of the Sigmoid Flexure. Scot. Med. Surg. J., 18:120, 1906.
