Emphysematous liver abscess: Variable clinical presentations, management challenges and outcomes-a case series

Abstract

Emphysematous liver abscesses (ELAs), characterized by the presence of gas within the hepatic parenchyma, are an uncommon and potentially lifethreatening entity. ELAs with clinical presentations mimicking hollow viscus perforation pose a diagnostic conundrum for clinicians. This series highlights the diagnostic challenges posed by such atypical presentations and emphasizes the importance of considering hepatic pathology in the differential diagnosis of pneumoperitoneum. Our objective is to provide a comprehensive analysis of the diverse clinical presentations, diagnostic challenges, and therapeutic strategies employed in managing this unique subset of liver abscesses.

Keywords: Emphysematous liver abscess, liver abscess, gas under diaphragm

Introduction

Emphysematous liver abscesses (ELAs) are also known as gas-forming pyogenic liver abscesses, with 76-85% occurring in patients with uncontrolled diabetes mellitus (1). Despite its infrequent occurrence, ELA poses a formidable clinical challenge due to its propensity for rapid deterioration and life-threatening complications. Complications are reported in as many as 92% of the cases, respiratory-related complications being the most common (2). The spectrum of clinical presentations ranges from subtle symptoms like fever and abdominal pain to dreaded complications like shock, making it a diagnostic challenge. Management of acute emphysematous liver abscess requires urgent external drainage of the abscess cavity, but pneumoperitoneum on radiological imaging can pose a serious diagnostic dilemma and can misguide surgeons, leading to unnecessary laparotomies. The evolving landscape of treatment options, encompassing medical therapy, percutaneous drainage, and surgical intervention, will be scrutinized in the context of individual cases, offering valuable insights into the optimal management strategies tailored to diverse clinical scenarios.

Case Presentation

Case 1

A 22-year-old male with no comorbidities and a history of occasional alcohol intake presented with a history of on and off right upper quadrant pain for seven days with an associated low-grade fever. A chest radiograph (Figure 1A) done elsewhere showed gas under the right hemidiaphragm, suggestive of pneumoperitoneum. On examination, the patient was afebrile, hemodynamically stable, and showed no signs of peritonitis. Repeat chest radiographs revealed similar findings. Ultrasonography (USG) of the abdomen was suggestive of a liver abscess in the right lobe of the liver. Contrast enhanced computed tomography (CECT) of the abdomen and thorax (Figure 1B,C) revealed a hypodense spaceoccupying lesion with visible air fluid levels inside in the right lobe of the liver. Routine blood investigations were within normal limits, and external drainage via USG-guided pigtail catheter (PCD) insertion in the liver abscess cavity was done. Pus culture revealed the heavy growth of Klebsiella pneumoniae. The patient was discharged on oral antibiotics and was asymptomatic on three monthly follow ups.

Figure 1. . A. Chest radiograph showing pneumoperitoneum. B,C. CECT of the abdomen showing a hypodense space-occupying lesion with air specks and air-fluid levels.

Case 2

An 18-year-old heavy alcoholic and smoker male with no other comorbidities presented to the surgical emergency with complaints of severe abdominal pain, high-grade fever, and chills for seven days. On examination, the patient was febrile with tachycardia, hypotension, abdominal tenderness with guarding, and rigidity suggestive of peritonitis. An abdominal radiograph did not reveal any abnormalities. USG revealed multiple abscesses in the right lobe of the liver with no intraabdominal collection. The patient’s biochemical parameters were as follows: haemoglobin of eight, total leucocyte count of 28.000 with 85% polymorphocytes, platelet count of 35.000, urea of 180, creatinine of 3.8, INR of 3.7, and prothrombin time of 36. Liver function tests showed: total bilirubin= 3, alkaline phosphatase (ALP)= 400, SGOT= 120, and SGPT= 110, suggestive of multiorgan dysfunction syndrome. The patient was resuscitated, and CECT of the abdomen (Figure 2A, B) was done, which revealed multiple hypodense space-occupying lesions along with homogenous collection in the liver parenchyma, with specks of air noted inside the cavities in the right lobe of the liver, suggesting an emphysematous liver abscess. After initial resuscitation, the patient was managed by external drainage with multiple pigtail catheter insertions in the liver abscess cavity and empirical broad-spectrum antibiotics. Pus culture revealed K. Pneumoniae as the causative agent. The patient’s condition improved after drainage. The patient was discharged on oral antibiotics and was asymptomatic on three monthly follow ups.

Figure 2. A,B. CECT of the abdomen showing multiple hypodense space-occupying lesions with air specks.

Case 3

A 50-year-old diabetic female with poor glycaemic control presented with complaints of intermittent fever, chills, and right upper quadrant pain for 10 days. On examination, the patient was afebrile, hemodynamically stable, and tender in the right hypochondrium. Chest radiograph was suggestive of gas under the right hemidiaphragm and suggestive of pneumoperitoneum (Figure 3A). USG revealed two liver abscesses in the right lobe of the liver. The CECT of the abdomen was suggestive of two large hypodense spaces occupying lesions along with homogenous collection in the liver parenchyma, involving segments VIII, II, and III of the liver along with specks of air and visible air fluid levels inside the hypodense lesions (Figure 3B). The patient was managed by external drainage, pigtail catheter insertion in the liver abscess cavity, and glycaemic control. Pus culture was sterile. The patient was discharged on oral antibiotics and was asymptomatic on three monthly follow up.

Figure 3. A. Chest radiograph showing pneumoperitoneum. B. CECT of the abdomen showing two large hypodense space occupying lesions with air specks and air-fluid levels.

Case 4

A 32-year-old male with a history of laparoscopic cholecystectomy a month prior presented with complaints of abdominal pain and intermittent fever for seven days. The patient was hemodynamically stable with localised tenderness in the right hypochondrium. Radiograph of the chest showed gas under the right dome of the diaphragm, suggestive of pneumoperitoneum, and USG showed a 400 mL hypoechoic lesion in segment seven of the liver, suggestive of a liver abscess (Figure 4A). The CECT of the abdomen showed a hypodense lesion with a speck of air in segment seven of the liver, suggesting an emphysematous liver abscess (Figure 4B,C). The patient was managed by external drainage, pigtail catheter insertion in the liver abscess cavity, and IV antibiotics. Pus culture was sterile. The patient was discharged on oral antibiotics and was asymptomatic on three monthly follow ups.

Figure 4. A. Chest radiograph showing pneumoperitoneum. B,C. CECT of the abdomen showing a hypodense space-occupying lesion with air speck.

Case 5

A 55-year-old chronic alcoholic male with no comorbidities presented with high-grade fever, abdominal distension, and right upper quadrant pain for one week. On examination, the patient was hemodynamically stable with a distended abdomen and right upper quadrant tenderness. USG revealed two liver abscess cavities, and CECT revealed a right lobe liver abscess along with an emphysematous left lobe abscess (Figure 5A,B). After initial resuscitation, the patient was managed by external drainage with pigtail catheter insertion in the liver abscess cavity, and cultures revealed Klebsiella spp. The patient was discharged on oral antibiotics and was asymptomatic on three monthly follow ups.

Figure 5. A,B. CECT showing a right lobe liver abscess and an emphysematous left liver lobe abscess.

Case 6

A 54-year-old diabetic female with poor glycaemic control presented with upper abdominal pain and fever for one week. The patient was hemodynamically stable with right upper quadrant tenderness. USG was suggestive of emphysematous cholecystitis. Blood investigations showed hemoglobin= 6, total leukocyte count= 38.000, creatinine= 3, urea= 160, total bilirubin= 3.2, SGOT= 140, SGPT= 200, and alkaline phosphatase= 300. Non-contrast computed tomography of the abdomen showed a large liver abscess with emphysematous changes (Figures 6A,B). The patient was managed by external drainage with pigtail catheter insertion in the liver abscess cavity, glycaemic control, and broad-spectrum antibiotics. Pus culture revealed Klebsiella spp. The patient was discharged on oral antibiotics and was asymptomatic on three monthly follow ups.

Figure 6. A,B. Non-contrast CT scan showing a large liver abscess with emphysematous changes.

Case 7

A 48-year-old alcoholic and diabetic male presented with complaints of high-grade fever, abdominal distension, and right upper quadrant pain for one week. On examination, the patient was hemodynamically stable with right upper quadrant tenderness. USG revealed a single liver abscess cavity, and CECT revealed a right lobe liver abscess with emphysematous changes and pleural effusion. After initial resuscitation, the patient was managed by external drainage with pigtail catheter insertion in the liver abscess cavity and glycaemic control (Figure 7A,B). Pus culture revealed Escherichia coli spp. The patient was discharged on oral antibiotics and was asymptomatic on three monthly follow ups.

Figure 7. A, B. CECT showing emphysematous right lobe liver abscess with pleural effusion.

Case 8

A 50-year-old chronic alcoholic male with no comorbidities presented with a high-grade fever and generalised pain in the abdomen for five days. On examination, the patient was hemodynamically stable with generalised peritonitis. Abdominal radiographs showed gas under the right dome of the diaphragm, suggestive of pneumoperitoneum; USG was suggestive of liver abscess (Figure 8A). CECT revealed a liver abscess with emphysematous changes and was managed by external drainage with pigtail catheter insertion in the liver abscess cavity (Figure 8A-C). Pus culture showed E. Coli spp. The patient was discharged on oral antibiotics and was asymptomatic on three monthly follow ups.

Figure 8. A. Chest radiograph showing pneumoperitoneum. B,C. CECT showing liver abscess with emphysematous changes.

Discussion

ELAs are typically characterised by gas formation within the abscess cavity. 6-24% of all bacterial liver abscesses are emphysematous in nature, with the maximum incidence in Asia, particularly Taiwan (1). The most common pathogens are K. Pneumoniae and E. Coli, with Klebsiella accounting for 82% of cases (2). ELAs have a case fatality rate of 12-40% and a mortality rate of 27-37%, as compared to only 12% in non-gas-forming liver abscesses (3,4).

The clinical presentations vary from simple fever, malaise, pain in the abdomen, and respiratory difficulty to deadly complications like septic emboli, meningitis, endophthalmitis, or even shock (1). Yang et al. have reported hepatocellular damage in 57% of ELAs and 19% of non-gas-forming liver abscesses; similar findings were noted in our series, with all the patients having deranged ALP (5). Around 6% of the patients present with intrapleural or intraperitoneal rupture and features of peritonitis mimicking those of hollow viscus perforation (6). Diabetic patients might present with milder or no pain because of diabetic neuropathy, adding an additional layer of complexity and warranting careful assessment. A similar case of pneumoperitoneum because of a ruptured liver abscess has also been reported by Maliyakkal et al. (7).

The commonly identified risk factor is poor glycaemic control, as hyperglycaemia provides a favourable condition for gas formation via the mixed acid fermentation pathway of glucose, leading to the production of formic acid, which breaks down further into carbon dioxide and hydrogen by the action of formic hydrogenylase (3). ELAs are more prone to rupture due to mass tissue damage, gas formation, and impaired transport of gas and catabolic products away from the lesion because of diabetic microangiopathy, leading to gas accumulation and a rise in internal pressure (6).

Investigations usually show a raised total leukocyte count, alkaline phosphate, and liver enzymes, with or without coagulopathy. Abdominal USG, simple radiography, and other imaging techniques might prove to be helpful for diagnosis, but computed tomography is the diagnostic tool of choice for accurate detection of gas within the abscesses, along with abscess location, size, number, and associated complications. Differential diagnoses include subphrenic abscess, emphysematous cholecystitis, right renal abscess, perinephric abscess, hepatic flexure interposed between the diaphragm and liver, and partial abdominal heterotaxia. It is often difficult to differentiate ELAs from emphysematous hepatitis. Chromatographic analysis of the formed gas has shown nitrogen (N₂ = 65.8 to 78.1%), oxygen (O₂ = 1.2 to 7.3%), carbon dioxide (CO₂ = 5.4 to 14.8%), and hydrogen (H₂ = 9.0 to 18.3%) as constituents (3).

Treatment is mainly percutaneous abscess drainage, along with antibiotic therapy and glycaemic control, with a reported success rate of 94% (8). Surgery is indicated if peritonitis and rupture are suspected, and surgery as extensive as an emergency hepatectomy might be needed (9). The summary, blood parameters, and outcome of all patients are shown in Table 1, Table 2, and Table 3.

In our study, four hemodynamically stable patients with unremarkable clinical examinations were found to have gas under the right hemidiaphragm, which was a diagnostic dilemma. Such findings can easily misguide the surgeon to perform an unnecessary laparotomy, suspecting hollow viscus perforation, especially in low-resource settings where facilities for USG and CECT are not available, as reported by Pham et al. (10). Contrastingly, another patient with signs and symptoms of acute abdomen with multiorgan dysfunction had no gas under the right hemidiaphragm and was found to have ELAs, indicating the variability in the presentations of this rarer entity.

Conclusion

To conclude, heightened awareness among clinicians, radiologists, and surgeons regarding the potential for emphysematous liver abscess to mimic other acute abdominal emergencies is warranted. A comprehensive understanding of the varied clinical presentations, particularly distinguishing ELAs from hollow viscus perforations, and the incorporation of advanced imaging techniques like contrast-enhanced computed tomography are crucial for accurate and timely diagnosis, guiding appropriate therapeutic interventions, avoiding unnecessary laparotomies, and improving patient outcomes with less invasive modalities like percutaneous drainage.

Cite this article as: Kudumallige Sudhakara S, Shiva S, Kumaran R, Chandra S, Anand A, Sonkar AA. Emphysematous liver abscess: Variable clinical presentations, management challenges and outcomes-a case series. Turk J Surg 2024; 40 (3): 247-255.

Informed consent was obtained from the all patients participating in this case.

Externally peer-reviewed.

Concept - All of authors; Design - SS, SKS, AA, AAS; Supervision - RK, SC, AA, AAS; Fundings; SC, SS, SKS, RK; Data Collection and/ or Processing - SS, SKS, RK; Analysis and/or Interpretation - SS, SKS, AA, RK, SÇ; Literature Search - SS, SK, AA, SC; Writing Manuscript - SS, SKS, AA, AAS; Critical Reviews - AAS, AA, RK.

The authors have no conflicts of interest to declare.

The authors declared that this study has received no financial support.

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