Treatment of hepatic abscess by EUS-guided fine needle aspiration and lavage: case report

Case Report:

A 37-year-old woman presented with persistent right upper abdominal pain radiating to back, nausea, vomiting, chill and fever (39°C) of 7 days' duration. Other symptoms included anorexia, fatigue and mild weight loss. Physical examination revealed mid and right upper abdominal tenderness, rebound pain without muscle defense or any mass palpated, and percussion pain over hepatic region. Laboratory tests included the following: white blood cell count, 15.58×10⁹/L (normal: 4.0-10.0×10⁹/L); neutrocyte percentage, 77.5% (normal: 50%-70%); AFP, 1.54ng/ml (<20ng/ml). Biochemical tests of liver function were within normal ranges. Transabdominal B ultrasound indicated a 5.7×4.0-cm hypoechoic mass in hepatic caudate lobe while CT demonstrated a 5.0×5.5-cm, oval, low density mass with somewhat densified boarder in the hepatic caudate lobe. Enhanced scanning during arterial and portal stage exhibited circumferetial enhancement of the boarder of the low density lesion with surrounding edema. Thus hepatic abscess was considered. EUS image showed in caudate lobe of liver a 4.6×3.5cm hypoechoic mass with distinct 0.5cm even-thickness cyst wall and cyst cavity filled with evenly densified spots. The mass isn't adherent to gastric wall and was diagnosed as caudate lobe hepatic abscess. 1.0g of Prepenemtm (Imipenem and Cilastatin; Choogwae Pharma Corporation) had been intravenously administrated three times a day 1 week before aspiration and lavage.

Equipments and Pharmaceuticals: color Doppler (EUS-5500, Hitachi, Japan), endoscope main system (EPM-3500, Pentax, Japan), linear array endoscopic ultrasound (EG-3830UT, Pentax, Japan), puncture needle (EUSN-19-T, Wilson-Cook, USA), metronidazole injection (0.5% concentration, Kelun Pharmarceutical Co. Ltd, Sichuan, China.)

EUS-guided fine needle aspiration and lavage of liver abscess ( EUS-FNT ) : EUS-FNT was performed in order to provide quick elimination of the abscess. Informed consent was obtained. Routine EUS check-up finished first with short-acting intravenous anesthesia given beforehand. Under the guidance of EUS, puncture needle transgastricly accessed abscess cavity. After guiding wire withdrawal, 10ml yellowish brown sticky pus was aspirated for pathologic test. Then a total of 70ml 0.5% metronidazole was divided into 5 parts, each of which was one by one injected and then aspirated in succession so as to lavage the abscess cavity. Finally a mixture of metronidazole and pus, which gradually became thin and light-colored during lavage, was aspirated up to a sum of 93ml. The puncture needle was removed and the whole procedure took almost 30 minutes. After lavage, it's much easier for EUS to differentiate abscess wall from cavity which shrinked to a size of 1.6×6.3cm. No discomfort feedback from the patient during the procedure.

Cytopathology of the pus reported a large amount of neutrocytes, lymphocytes and necrotic substance, little epitheloid cells and no malignant tumor cells. Culture of the pus detected a small amount of Escherichia coli. Drug resistance test showed Imipenem, with its mid inhibitory concentration, MIC (mg/L) below 4, was sensitive.

Clinical prognosis: No procedure-related complication such as bleeding, peritonitis, etc. has happened, while body temperature declined to 36.3 degree centigrade and abdominal pain disappeared. Prepenemtm was continued after the procedure until it had been used totally for 25 days before discharge. One month later a follow-up B ultrasound told disappearance of the abscess. Three month later a follow-up CT revealed no abnormality.

Discussion: