Hepatogastric Fistula in One Patient With Liver Abscess
Article Outline
- Answer to the Clinical Challenges and Images in GI Question: Image 4: Hepatogastric Fistula
- References
- Copyright
Question: An 86-year-old man with no relevant medical history visited our hospital for chronic constipation for 2 years. Colonoscopy and computed tomography (CT) showed adenocarcinoma of ascending colon and a 3.7-cm solitary liver metastasis at the lateral segment of left lobe. Right hemicolectomy and liver lateral segmentectomy were performed. Two weeks after the operation, he complained of dull epigastric pain, fever, and nausea. Physical examination revealed epigastric knocking pain with vague radiation to back, and decreased bowel sound. Laboratory studies disclosed total white blood cell of 3600/mm3 (normal, 4800–10,800/mm3), and C-reactive protein 6.3 mg/dL (normal, <1.0 mg/dL). CT scan of abdomen showed one 6.5-cm hypodense, cystic lesion with bubble formation in left lobe of liver (Figure A), which was compatible with abscess formation. Percutaneous pigtail insertion was performed smoothly and Klebsiella pneumoniae was cultured in the aspirated pus. Seven days after pigtail drainage tube insertion, upper gastrointestinal endoscopy for acid regurgitation found 1 oval-shaped ulcer about 1.0 cm in size at the anterior wall of upper lesser curvature (Figure B). One week later, after upper gastrointestinal endoscopy, dramatically diminished drain amount from pigtail was found. At the moment, there was no new-onset abdominal pain, ascites formation, anemia, or coffee ground material from nasogastric tube. Pigtail malposition was suspected and contrast injection for pigtail position revision revealed the image (Figure C). What is the possible complicating etiology?
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Answer to the Clinical Challenges and Images in GI Question: Image 4: Hepatogastric Fistula
This patient presented with dramatically decreased drainage amount of liver abscess of left lobe liver, etiologies such as recovery of liver abscess, malposition of drainage tube, and occlusion of drainage tube were suspected. Figure A shows the adjacent position of liver abscess and the stomach and suspicious vicinal gastric wall inflammation. Figure B reveals an uncommon gastric ulcer without evidence of perforation. Figure C discloses contrast media in the stomach under the left diaphragm. In addition, contrast media was drained out from nasogastric tube immediately after injection. There was no evidence of free air accumulation or ascites formation in abdominal cavity. The possibility of sonography-guided pigtail insertion–related puncture through the liver was also excluded owing to the absence of perforation revealed by gastrointestinal endoscope and a well-functioning drainage tube for 2 weeks.
Liver abscess may rupture into adjacent thoracic, pericardial, and peritoneal cavities; however, fistulization into gastrointestinal tract is extremely rare; only a few cases of hepatogastric fistula have been reported.1, 2 CT scan, upper gastrointestinal barium study, and endoscopy establish the diagnosis in most cases.3 Nasojejunal tube insertion, antibiotics, and revised pigtail drainage were suggested. The patient recovered well.
References
Conflicts of interest The authors disclose no conflicts.
PII: S0016-5085(09)00188-7
doi:10.1053/j.gastro.2009.02.009
© 2009 AGA Institute. Published by Elsevier Inc. All rights reserved.
