Pyogenic hepatic abscess secondary to appendectomy. Case report

Incluido en la revista Ocronos. Vol. IV. Nº 6–Junio 2021. Pág. Inicial: Vol. IV; nº6: 167

Autor principal (primer firmante): Mildred Philippe Ponce

Fecha recepción: 24 de junio, 2021

Fecha aceptación: 28 de junio, 2021

Ref.: Ocronos. 2021;4(6): 167

Autores:

Mildred Philippe Ponce

Claudia Liliana Cervantes Nava

Rodrigo Antonio Garcia Zester

Arid Alejandro Diaz de León Rivera

Icnoti Yectiuani Martínez Reyes

Marlon Rene Terreros Contreras

Introduction

The pyogenic hepatic abscess does not represent a specific hepatic illness, but more the final result of many pathological processes. (1) (2) (3) The complication of acute appendicitis is more frequently the infection that causes the situation; surgical wounds, followed by peritonitis, and abscesses in the abdominal cavity. An infection of the portal vein and the appearance of an intrahepatic abscess is an exceptional complication, presenting low prevalence, with isolated described cases entailing a high mortality. (4) (5) (6) (7) (8)

Objective

The aim is to describe the clinical presentation and therapeutic approach of the Pyogenic Hepatic Abscess through the report of a case presented in the Hospital Pediátrico Moctezuma (Moctezuma Pediatric Hospital) in order to contribute in our way to the available information on this infrequent pathology with a high rate of morbidity and mortality.

Clinical case

Female, 12 years old, with precedence of complicated acute appendicitis occurring on 16.03.2021, which required a 4 day hospital stay, leaving for home with antibiotic therapy. Twenty-four hours prior to their re-admission, she presented colic type generalised abdominal pain degree with an intensity of 9/10, a fever quantified at 38.5° centigrade, nausea and emesis of gastrobiliary content on 6 occasions in addition to constipation with 24 hours of evolution.

Upon physical exploration: tachycardia 120 beats per minute, feverish to 38.5 degrees centigrade, algic facies, cardiopulmonary, without commitment she displayed an increase in cardiac frequency, distended abdomen with the presence of a Mcburney surgery wound with well-confronted edges, without data for bleeding or bacterial superinfection, clean wound, painful abdomen in all abdominal quadrants, without data for peritoneal irritation upon exploration, abdomen radiography in two positions which evidenced air-fluid levels and a bad distribution of distal air HB 13.1, HTO 39.9, PLA 869, LEU 21.8, NEU 85%, TP 16, INR 1.44, TTP 27.7, GLU 122, CREAT 0.5, Na 128, K 4.8, Cl 91, PCR 12.70 and PROCALCITONIN > 0.5. A diagnosis of intestinal occlusion was established, gastric decompression was carried out, replenishment for water, electrolytes, and antibiotic therapy was begun, and she was admitted for occlusive profile medical treatment. However, faced with symptomatological persistence and little response to medical treatment, an abdominal CAT scan was requested which reports: liver raised at the expense of the left hepatic lobe, regular and clear edges, heterogeneous parenchyma due to the presence of a lobulate image, with regular, defined, hypodense edges with a density of 17 UH and air component in the upper area, with approximate diametres of 63x62x58 mm on the largest axes, with an approximate volume of 118 cc, vascularity of the route, distribution, and calibre within normality, with the study being compatible with a Hepatic Abscess.

Management

It was decided to carry out percutaneous drainage guided by ultrasound, obtaining purulent liquid quantified at 110 milliliters. This was followed by irrigation, and finally transoperative ultrasound with scarce residual liquid quantified at 10 millilitres. The cultivation of the obtained liquid was carried out which reported Escherichia coli sensitive to the current antibiotic outline based in Meropenem and Vancomycin. The treatment was continued for 10 more days, central blood culture was carried out with a negative report. Upon finalising the outline a control USG was requested which reported a liver which was slightly raised at the expense of the left hepatic lobe, heterogeneous parenchyma with an oval image presence, with regular edges, defined with dimensions of 28x23x10 mm on the largest axes, a regular echogenic wall of 2 mm of thickness, hypoechoic interior, localised in the VI Couinaud segment. She was released home with antibiotic therapy and vigilance for the external consultation with laboratory studies and image study.

Discussion

The percentage of complications of acute appendicitis varies between 15 and 30 percent, above all in those that present perforation of the appendix. The hepatic abscess of a portal origin represents 16.1% of cases, with the pyogenic abscess represented even less at 0.03%. The clinical suspicion together with computed tomography are tools that allow us to carry out a timely diagnosis and offer adequate treatment for the management of hepatic abscesses.

Conclusion

The pyogenic hepatic abscess is a diagnosis challenge for the surgeon; in our case they started their approach as an occlusive profile, being the clinical presentation, the image studies, and the experience of the surgeons on this entity, the determinant that allowed a timely diagnosis and treatment.

This case manages to contribute new information to the existing literature on this entity, in addition to fomenting and contributing to the search for under-diagnosed entities.

Bibliography

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