hepatic abscess following TACE procedure

The patient has septic shock and typical signs and symptoms of hepatic abscess, also known as pyogenic liver abscess. Common signs and symptoms of hepatic abscess include fever (>90%), right upper quadrant pain (50% to 60%), nausea, anorexia, weight loss, and malaise. CT of abdomen with contrast is the most sensitive test for diagnosing hepatic abscess (choice C is correct). This patient’s CT scan revealed a 6.5 × 6.5 × 3 cm-fluid collection in the dome of the liver (Figure 1), which responded to percutaneous drainage and prolonged antibiotics.

A variety of nonsurgical approaches to HCC are available, including transarterial chemoembolization (TACE), microwave ablation, radioablation, percutaneous ethanol injection, cryoablation, and hepatic artery chemotherapy infusion. Initially conceived for use in patients who are not surgical candidates, these procedures, particularly TACE and microwave ablation, are increasingly used as the primary approaches to HCC. Hepatic abscess is a potential complication of these procedures, especially in patients with biliary tract disease; it is reported as the second most common complication following TACE, with an incidence up to 5%. The hazard ratio for hepatic abscess among patients receiving sphincterotomy in treatment of their biliary obstruction is 4.5, compared with similar patients who do not receive sphincterotomy. The incidence of hepatic abscess following microwave ablation of hepatic tumors is approximately 1.5%. The exact mechanisms for abscess formation following TACE and microwave ablation are not fully understood. Sphincterotomy is conjectured to allow more direct communication between the upper biliary tract and bowel flora; this is also thought to be the case for hepatic abscess associated with biliary-enteric anastomosis. The temporal combination of sphincterotomy, TACE, and microwave ablation in this patient likely increased his risk for abscess development.

The treatment of choice for hepatic abscess is a combination of antibiotic treatment with percutaneous drainage. Most hepatic abscesses are polymicrobial, and empiric antibiotics should cover enteric gram-negative bacilli, gram-positive cocci, and anaerobic bacteria. This is often accomplished via either combination of cephalosporin with metronidazole or piperacillin-tazobactam. Amikacin provides coverage for the E coli recovered from blood cultures. However, aminoglycosides in general do not function well in the acidic environment of an abscess. Additionally, amikacin lacks the broader spectrum of activity that is necessary to treat a liver abscess, and it is important to establish the presence of abscess and ascertain its size before changing antibiotic direction (choice B is incorrect).

This patient recently had treatment for gallstones and could be at risk for acute cholecystitis, although his symptoms are not typical of acutely infected gallbladder. HIDA scan with technetium-99 labeling is used for the diagnosis of acute cholecystitis. A variety of moieties have been used, all having in common that they are processed identically with bilirubin and accumulate in the hepatobiliary tree and the gallbladder. Failure to fill the gallbladder is seen in acute, obstructive cholecystitis (this is a positive test for cholecystitis). However, gallbladder filling requires a functional sphincter of Oddi, and HIDA scans yield false-positive results in up to 30% of patients who have had sphincterotomy (choice A is incorrect). CT scan with IV contrast is the diagnostic technique of choice for hepatic abscess, as it is >95% sensitive for abscess detection (choice C is correct). However, in instances when a patient cannot receive IV contrast or cannot be moved to a CT scanner, ultrasound is 80% to 85% sensitive and can be used as a second choice. Abscesses <3 to 5 cm in diameter and in anatomic positions difficult to reach percutaneously have been successfully treated with prolonged antibiotic courses. In any patient in the ICU who is exhibiting recurrent fever and/or hypotension, removal of central vein catheters and other foreign bodies is an important consideration. However, this patient’s history, signs, and symptoms are all suggestive of hepatic abscess, and that possibility should be explored first (choice D is incorrect).12345

A 78-year-old man with hereditary hemochromatosis presented 6 weeks ago with signs and symptoms of acute biliary obstruction. CT scan of abdomen demonstrated common bile duct dilation, mild cirrhosis, and 2.4-cm lesion consistent with hepatocellular carcinoma (HCC). Endoscopic retrograde cholangiopancreatography with sphincterotomy and stone removal was performed; symptoms and increased liver function tests resolved. Four weeks ago, the patient had a combined microwave ablation and transarterial chemoembolization (TACE) of the hepatic mass. Following this procedure, he had persistent nausea, anorexia, and malaise.

He was brought last night to the emergency department with BP of 64/43 mm Hg, unresponsive to 2 L of lactated Ringer’s solution. He received 1 dose of piperacillin-tazobactam, and norepinephrine was initiated. Within 12 h, blood cultures are growing Escherichia coli. His creatinine level is 2.5 mg/dL (221 μmol/L), but urine output is adequate. 

Which of the following is the most appropriate next step in the patient’s management?

Footnotes

  1. SEEK Questionnaires ↩

  2. Bächler P, Baladron MJ, Menias C, et al. Multimodality imaging of liver infections: differential diagnosis and potential pitfalls. Radiographics. 2016;36(4):1001-1023. PubMed ↩

  3. Lv WF, Lu D, He YS, et al. Liver abscess formation following transarterial chemoembolization: clinical features, risk factors, bacteria spectrum, and percutaneous catheter drainage. Medicine (Baltimore). 2016;95(17):e3503. PubMed ↩

  4. Mavilia MG, Molina M, Wu GY. The evolving nature of hepatic abscess: a review. J Clin Transl Hepatol. 2016;4(2):158-168. PubMed ↩

  5. Peng YC, Lin CL, Sung FC. Risk of pyogenic liver abscess and endoscopic sphincterotomy: a population-based cohort study. BMJ Open. 2018;8(3):e018818. PubMed ↩