Is endoscopic ultrasound a promising technique in the diagnosis and treatment of liver diseases?

Percutaneous ultrasound has been a longstanding method in the diagnostics and interventional procedures of liver diseases. In some countries, its use is restricted to radiologists, limiting access for other clinicians, such as gastroenterologists. Endoscopic ultrasound, as a novel technique, plays a crucial role in diagnosis and treatment of digestive diseases. However, its use is sometimes recommended for conditions where no clear advantage over percutaneous ultrasound exists, leaving the impression that clinicians sometimes resort to an endoscopic approach due to the unavailability of percutaneous options.

Foreign Body-Related Liver Abscess: A Case Study on Fishbone.

Foreign body-related complications are rare but possibly fatal events in clinical practice. Liver abscess as a result of gastrointestinal perforation caused by foreign bodies is even more rare. We report a case of a 63-year-old man who was admitted with fever and left epigastric pain. Further investigation revealed a liver abscess without resolution despite antibiotic therapy for several weeks. In the second admission, an enhanced computerized tomography scan revealed multiple abscesses in the left lobe of the liver, with a linear radio-dense foreign body within the collection. Open surgery was performed to extract the foreign body. The patient made a satisfactory postoperative recovery without complications and was discharged on the sixth postoperative day.

Liver abscess and tracheal fistula induced by transcatheter arterial chemoembolization for hepatocellular carcinoma: A case report.

BACKGROUND: Transarterial chemoembolization (TACE) is a standard treatment for intermediate-stage hepatocellular carcinoma (HCC). The complications of TACE include biliary tract infection, liver dysfunction, tumor lysis syndrome, biloma, partial intestinal obstruction, cerebral lipiodol embolism, etc. There are few reports about tracheal fistula induced by TACE. CASE SUMMARY: A 42-year-old man came to our hospital with cough and expectoration for 1 month after TACE for HCC. Laboratory test results showed abnormalities of albumin, hemoglobin, prothrombin time, C-reactive protein, D-dimer, and prothrombin. Culture of both phlegm and liver pus revealed growth of Citrobacter flavescens. Computed tomography showed infection in the inferior lobe of the right lung and a low-density lesion with gas in the right liver. Liver ultrasound showed that there was a big hypoechoic liquid lesion without blood flow signal. Drainage for liver abscess by needle puncture under ultrasonic guidance was performed. After 1 month of drainage and anti-infection therapy, the abscess in the liver and the infection in the lung were reduced obviously, and the symptom of expectoration was relieved. CONCLUSION: Clinicians should be alert to the possibility of complications of liver abscess and tracheal fistula after TACE for HCC. Drainage for liver abscess by needle puncture under ultrasonic guidance could relieve the liver abscess and tracheal fistula.

Alterations of Gut Microbiota in Pyogenic Liver Abscess Patients with and without Type 2 Diabetes Mellitus.

Purpose: The clinical manifestations of pyogenic liver abscess (PLA) vary between patients with and without diabetes mellitus (DM). However, the relationship between PLA and the gut microbiome remains unknown. This study analyzed the composition of gut microbiota in PLA patients with and without DM and healthy controls (HCs) with the goal of identifying potential reasons for the observed variations in clinical manifestations. Patients and Methods: Using 16S ribosomal RNA(16S rRNA) gene sequencing, we analyzed the compositions of gut microbiota in 32 PLA patients with DM, 32 PLA patients without DM, and 29 matched HCs. Results: In PLA patients with DM, the D-dimer level, fibrinogen degradation products, and thrombin time were significantly higher compared to the PLA patients without DM (P < 0.05). The abundance and diversity of intestinal flora were reduced in both groups of PLA patients compared with the HCs (P < 0.05). Specifically, the PLA patients with DM showed significant decreases in the relative abundances of Bacteroides, Blautia, Prevotella9, and Faecalibacterium, whereas Enterococcus and Escherichia-Shigella were relatively more abundant (P < 0.05). Compared to PLA patients without DM, those with DM had lower relative abundances of Lactobacillus and Klebsiella (P < 0.05) and showed different bacterial flora, including Anaerosporobacter and Megamonas. Conclusion: PLA patients with DM exhibited more severe clinical manifestations of PLA compared to patients without DM. It is important to monitor blood coagulation in PLA patients with DM to prevent the development of thrombotic diseases. Additionally, PLA patients with DM exhibit distinct differences in the composition and diversity of their intestinal flora compared to both PLA patients without DM and HCs.

Endogenous Endophthalmitis: A 10-Year Review of Cases on the East Coast of Malaysia.

Purpose Our study aimed to describe the clinical profile of endogenous endophthalmitis, focusing on patient demographics, infection sources, microbial profiles, clinical outcomes, and factors affecting the final visual outcome. Methods A retrospective review was performed on data from 68 eyes of 60 patients diagnosed with endogenous endophthalmitis and hospitalized in two tertiary hospitals on the East Coast of Peninsular Malaysia from January 2011 to December 2020. The analysis encompassed evaluating patient age, gender, laterality, risk factors, infection origins, presenting and final visual acuity, microbial results, treatment responses, and factors affecting final visual outcomes. Results The average age of the patient cohort was 54.9 ± 13.3 years. Females were more likely to have endogenous endophthalmitis than males (33, 55.0% vs. 27, 45.0%). Twenty-seven patients (45.0%) presented with endogenous endophthalmitis in the left eye, while 25 patients (41.7%) had it in the right eye, and eight patients (13.3%) had bilateral involvement. Most patients had underlying predisposing conditions, predominantly diabetes mellitus (53, 88.3%). Infection sources were identified in 42 patients (70.0%), out of which urinary tract infections account for the majority (11, 18.3%). Klebsiella species(14, 22.7%) were the leading pathogens and were significantly associated with liver abscess cases. In this series, the majority of patients had poor presenting and final visual acuity of worse than 3/60 (56, 82.4% and 53, 77.9%, respectively). Thirty-six eyes (52.9%) underwent vitrectomy, resulting in only four eyes (11.11%) achieving final visual acuity better than 6/12. Presenting visual acuity was identified as the factor contributing to the blind final visual outcome (r = 0.707, p < 0.001). Conclusion Females were found to be more commonly affected by endogenous endophthalmitis than males. Klebsiella species were the most commonly isolated microorganisms and were typically associated with liver abscesses. Urinary tract infection was the most common predisposing factor. A majority of the patients had poor presenting and final visual acuity, in which poor visual acuity is a significant indicator of blind visual outcomes.

Macrophage-depleted young mice are beneficial in vivo models to assess the translocation of Klebsiella pneumonia from the gastrointestinal tract to the liver in the elderly.

Pathobionts are commensal intestinal microbiota capable of causing systemic infections under specific conditions, such as environmental changes or aging. However, it is unclear how pathobionts are recognized by the intestinal mucosal immune system under physiological conditions. This study demonstrates that the gut pathobiont Klebsiella pneumoniae causes injury to the epithelium and translocates to the liver in specific pathogen-free mice treated with clodronate-liposomes that depleted macrophages. In the clodronate-liposome-treated mice, indigenous classical K. pneumoniae (cKp) with non-K1/K2 capsular serotypes were isolated from the liver, indicating that gut commensal cKp translocated from the gastrointestinal tract to the liver due to the depletion of intestinal macrophages. Oral inoculation of isolated cKp to clodronate-liposome-treated mice significantly reduced the survival rates compared to that of non-treated mice. Our findings demonstrate that intestinal mucosal macrophages play a pivotal role in sensing commensal cKp and suppressing their translocation to the liver. This study demonstrates that clodronate-liposome-treated mouse models are effective for screening and evaluating drugs that prevent the translocation of cKp to the liver, providing new insights into the development of preventive protocols against K. pneumoniae infection.

Pyogenic liver abscess after Milligan-Morgan hemorrhoidectomy.

Milligan-Morgan(M-M) hemorrhoidectomy is regarded as the primary treatment option for patients diagnosed with grade III or IV hemorrhoids. Here, we present the case of a 50-year-old male who developed pyogenic liver abscesses as an unusual complication following M-M hemorrhoidectomy. Severe complications subsequent to hemorrhoid surgery are infrequent. A review of the PubMed database spanning the 30-year period between 1994 and 2024 yielded only four publications documenting patients who experienced liver abscesses following open hemorrhoidectomy. Furthermore, the patient exhibited symptoms of a liver abscess as early as the second day post-surgery, despite having no history of diabetes or liver disease, making this occurrence truly uncommon.

Concomitant Occurrence of Hepatitis A and a Pyogenic Liver Abscess: A Pediatric Case.

Pyogenic liver abscess (PLA) and hepatitis A are common in developing countries. As there is an overlap of clinical features, a diagnosis of dual infection can be missed. Here, we present the case of a five-year-old male who presented with abdominal pain, fever, and jaundice diagnosed as a complicated liver abscess with concurrent hepatitis A. To our knowledge, this is the first case where a PLA co-existed with hepatitis A. Simultaneous infection should be considered when a patient with liver abscess presents with jaundice, especially in areas where both diseases are endemic. Early diagnosis of both is crucial as PLA is a potentially fatal disease and co-infection with hepatitis A may worsen clinical outcomes.

Atypical Toxocara canis-Induced Hepatic Visceral Larva Migrans: Diagnostic Challenges and Literature Review.

Toxocariasis, a zoonotic infection transmitted by Toxocara canis (from dogs) and Toxocara cati (from cats) larvae, poses rare but severe risks to humans. We present a case of hepatic visceral larva migrans (VLM) caused by Toxocara canis in a 21-year-old male with a history of close contact with a pet dog. Initial symptoms and imaging findings mimicked a pyogenic liver abscess. The initial laboratory investigations revealed neutrophilia and elevated levels of IgE. Despite broad-spectrum antibiotics, persistent fever prompted further investigation. Subsequent serological testing for Toxocara antibodies and histopathological analysis of liver tissue demonstrating eosinophil infiltrates and Charcot-Leyden crystals led to a confirmed diagnosis of a liver abscess caused by Toxocara canis. Serological testing for Toxocara antibodies and histopathological analysis of liver tissue confirmed a Toxocara canis-induced liver abscess. Albendazole treatment yielded significant clinical improvement. This case highlights the necessity of considering toxocariasis in liver abscess differentials, particularly in high-seroprevalence regions like Vietnam. Relying solely on serological tests may be insufficient, emphasizing the need for corroborative evidence, including invasive procedures like liver biopsy, for accurate hepatic toxocariasis diagnosis.

Cardiac-to-Bronchial Fistula in Hepatocellular Carcinoma: A Case Report.

Hepatocellular carcinoma (HCC) stands as a significant contributor to cancer-related mortality globally. While the acute and often fatal manifestations of locally advanced HCC primarily present within the abdomen, it is crucial to recognize that the respiratory and circulatory systems can also fall victim due to the liver's unique anatomical position within the body. Here, we present the case of a 63-year-old male recently diagnosed with locally advanced HCC with vascular invasion. Shortly after receiving target therapy and focal radiotherapy, the patient developed repeated secondary infections and a persistent diaphragmatic defect. As the necrotic tissue invaded the pleural space, subsequent tumor-to-bronchial and tumor-to-cardiac fistulas emerged, resulting in an abnormal connection between the respiratory and cardiovascular systems, leading to massive air emboli in circulation. This report highlights the risk of supradiaphragmatic complications in HCC patients with post-treatment secondary infections, particularly in patients predisposed to developing diaphragmatic defects.

Do not stumble over the same "stone" twice: a case series of endogenous endophthalmitis secondary to severe systemic diseases.

BACKGROUND: Endogenous endophthalmitis (EE) is a rare but highly destructive eye emergency secondary to systemic infection. Acute endophthalmitis can lead to irreversible vision impairment or even loss of the whole eye, unless being diagnosed and treated promptly. CASE PRESENTATION: This study reports three typical EE cases of endogenous endophthalmitis secondary to different severe systemic diseases. Patients were recruited from the Department of ophthalmology at Zhongnan hospital of Wuhan University and the Department of ophthalmology at the Second Affiliated Hospital of Fujian Medical University. Patients were followed up for up to 60 days. Among these cases, the eye symptoms is the initial manifestations while secondary to original different special systemic conditions. Patients have been treated under dynamically prompt response undergoing systemic treatment and eye treatment at the same time. Best corrected visual acuity were 20/40, 20/60 and light perception during follow-up evaluation. CONCLUSIONS: Our observation suggest that prompt identification and treatment could save patients' vision from EE.

Pyogenic liver abscess caused by an atypical hypervirulent Klebsiella pneumoniae K1-ST23 in Mexico.

Hypervirulent K. pneumoniae infection has been raising worldwide and is one of the major causes of community-acquired pyogenic liver abscess. We described a case report of pyogenic liver abscess caused by an atypical hypervirulent (non-hypermucoviscous) K. pneumoniae K1 ST23 in a diabetic Asian patient who resided in Mexico. The susceptibility to antimicrobials, pathogenicity, molecular and genomic analysis were determined. A man from Guangdong (China) with a recent diagnosis of diabetes mellitus was admitted to the hospital, and he denied traveling in the last 3 months. A computed tomography revealed a right lobe liver abscess. On the third day after admission a Klebsiella pneumoniae isolate (14652) was obtained. The isolate corresponded to a susceptible K. pneumoniae with capsular type K1 and ST23 (CG23) and exhibited a non-hypermucoviscous phenotype. The isolate 14652 was genetically related to the globally distributed lineage ST23-KL1. This study describes the first case in Mexico of K. pneumoniae capsular type K1 and ST23 with an atypical hypervirulent phenotype.

Coexistence of liver abscess, hepatic cystic echinococcosis and hepatocellular carcinoma: A case report.

BACKGROUND: Human cystic echinococcosis (CE) is a life-threatening zoonosis caused by the Echinococcus granulosus (sensu lato). Hepatocellular carcinoma (HCC) is a leading cause of cancer-related mortality in the world. The coexistence of CE and HCC is exceedingly rare, and only several well-documented cases have been reported. In addition to this coexistence, there is no report of the coexistence of CE, HCC, and liver abscess to date. Herein, we aimed to report a case of coexistence of liver abscess, hepatic CE, and HCC. CASE SUMMARY: A 65-year-old herdsman presented to the department of interventional therapy with jaundice, right upper abdominal distension and pain for 10 d. Laboratory test showed that he had positive results for HBsAg, HBeAb, HBcAb, and echinococcosis IgG antibody. The test also showed an increased level of alpha fetoprotein of 3400 ng/mL. An abdominal computed tomography (CT) scan revealed an uneven enhanced lesion of the liver at the arterial phase with enhancement and was located S4/8 segment of the liver. In addition, CT scan also revealed a mass in the S6 segment of the liver with a thick calcified wall and according to current guideline and medical images, the diagnoses of hepatic CE (CE4 subtype) and HCC were established. Initially, transarterial chemoembolization was performed for HCC. In the follow-up, liver abscess occurred in addition to CE and HCC; thus, percutaneous liver puncture drainage was performed. In the next follow-up, CE and HCC were stable. The liver abscess was completely resolved, and the patient was discharged with no evidence of recurrence. CONCLUSION: This is the first reported case on the coexistence of liver abscess, hepatic CE, and HCC. Individualized treatment and multidisciplinary discussions should be performed in this setting. Therefore, treatment and diagnosis should be based on the characteristics of liver abscess, hepatic CE, and HCC, and in future clinical work, it is necessary to be aware of the possibility of this complex composition of liver diseases.

Tackling the Unyielding Challenge of Necrotic Unresectable Hepatocellular Carcinoma: A Liver Necrosectomy Approach for Intratumoral Hemorrhage and Abscess Resolution.

Hepatocellular carcinoma (HCC) is one of the most common causes of gastrointestinal and hepatobiliary cancer worldwide. Chronic liver disease and cirrhosis persist as the most common risk factors, typically linked to instances of alcohol abuse or viral infections, notably hepatitis B and hepatitis C infection. Diagnosis can be made using patient history and image studies as there is no need for pathological confirmation. The only curative treatment is surgical resection, and in cases where the tumor is unresectable, as the one presented in this case, and when there are no contraindications, the only option is an orthotopic liver transplantation. This malignancy is not only associated with high mortality but also high morbidity associated with severe complications, such as hemorrhage, necrosis, and infection of the tumor. The significant relevance of this case lies in its capacity to illustrate that despite remaining in non-surgical management for months when an acute complication presented, it was timely identified and surgically treated. The emergence of complications, such as necrosis accompanied by abscess formation and intratumoral hemorrhage, represents an indication for prompt surgical management.

Disseminated Lodderomyces elongisporus and Pantoea dispersa: A Rare Dual Infection in an Immunocompromised Patient.

With the advancement of modern medicine and the prolonged survival of critically ill patients, unusual organisms are increasingly emerging. Initially found in the environment, these rare organisms started presenting as human pathogens, causing significant morbidity and mortality. Here, we present a rare case of disseminated Lodderomyces elongisporus fungemia and Pantoea dispersa bacteremia in a patient with parapneumonic effusion and ruptured liver abscess. This yeast was identified using matrix-assisted laser desorption/ionization time-of-flight (MALDI-TOF). Although this organism has no antifungal breakpoint, the isolate shows low minimum inhibitory concentration (MIC) to a wide range of antifungals. The importance of effective communication between microbiologists and clinicians and early referral to the infectious disease team was also highlighted in this case for prompt treatment.

Recurrent Pyogenic Cholangiohepatitis: A Case Report.

Recurrent pyogenic cholangitis (RPC), which is most commonly seen in Asian populations, is characterized by strictures and dilatation of both intrahepatic and extrahepatic bile ducts, along with the formation of pigmented stones inside the ducts. The most common symptoms are recurrent right upper quadrant pain, jaundice, and fever. Additionally, leukocytosis and elevated alkaline phosphatase and bilirubin levels may also be present. We report the case of a 43-year-old Bangladeshi male patient with a medical background of chronic hepatitis B infection and recurrent liver abscesses who presented to the emergency department with abdominal pain and fever lasting for two days. Given the clinical context of our patient, a diagnosis of RPC was made, and the patient was referred to a higher-level center for further management. Our case highlights the importance of considering RPC as part of the differential diagnosis in patients presenting with recurrent liver abscesses and features of ascending cholangitis.

Clinical characteristics of pyogenic liver abscess with and without biliary surgery history: a retrospective single-center experience.

BACKGROUND & AIMS: Pyogenic liver abscess (PLA) is a common hepatobiliary infection that has been shown to have an increasing incidence, with biliary surgery being identified as a trigger. Our aim was to investigate the clinical characteristics and treatments of PLA patients with and without a history of biliary surgery (BS). METHODS: The study included a total of 353 patients with PLA who received treatment at our hospital between January 2014 and February 2023. These patients were categorized into two groups: the BS group (n = 91) and the non-BS group (n = 262). In the BS group, according to the anastomosis method, they were further divided into bilioenteric anastomoses group (BEA, n = 22) and non-bilioenteric anastomoses group (non-BEA, n = 69). Clinical characteristics were recorded and analyzed. RESULTS: The percentage of PLA patients with BS history was 25.78%. The BS group exhibited elevated levels of TBIL and activated APTT abnormalities (P = 0.009 and P = 0.041, respectively). Within the BS group, the BEA subgroup had a higher prevalence of diabetes mellitus (P < 0.001) and solitary abscesses (P = 0.008) compared to the non-BEA subgroup. Escherichia coli was more frequently detected in the BS group, as evidenced by positive pus cultures (P = 0.021). The BS group exhibited reduced treatment efficacy compared to those non-BS history (P = 0.020). Intriguingly, the BS group received a higher proportion of conservative treatment (45.05% vs. 21.76%), along with reduced utilization of surgical drainage (6.59% vs. 16.41%). CONCLUSIONS: Patients with BS history, especially those who have undergone BEA, have an increased susceptibility to PLA formation without affecting prognosis.

Clinical features and risk factors for pyogenic liver abscess caused by multidrug-resistant organisms: A retrospective study.

The incidence rate of pyogenic liver abscess caused by multidrug-resistant bacteria has increased in recent years. This study aimed to identify the clinical characteristics and risk factors for pyogenic liver abscess caused by multidrug-resistant bacteria. We conducted a retrospective analysis of the clinical features, laboratory test results, and causes of pyogenic liver abscesses in 239 patients admitted to a tertiary hospital. Multivariable logistic regression was used to identify risk factors for multidrug resistance. Among patients with pyogenic liver abscesses, the rate of infection caused by multidrug-resistant organisms was observed to be 23.0% (55/239), with a polymicrobial infection rate of 14.6% (35/239). Additionally, 71 cases (29.7%) were associated with biliary tract disease. Patients with pyogenic liver abscesses caused by multidrug-resistant organisms had a significantly higher likelihood of polymicrobial infection and increased mortality (7/44 [15.9%] vs. 3/131 [2.3%]; p = .003). The Charlson Comorbidity Index (adjusted odds ratio [aOR]: 1.32, 95% confidence interval [CI]: 1.06-1.68), hospitalization (aOR: 10.34, 95% CI: 1.86-60.3) or an invasive procedure (aOR: 9.62; 95% CI: 1.66-71.7) within the past 6 months, and gas in the liver on imaging (aOR: 26.0; 95% CI: 3.29-261.3) were independent risk factors for pyogenic liver abscess caused by multidrug-resistant bacteria. A nomogram was constructed based on the risk factors identified. The nomogram showed high diagnostic accuracy (specificity, 0.878; sensitivity 0.940). Multidrug-resistant organisms causing pyogenic liver abscesses have specific characteristics. Early identification of patients at high risk of infection with multidrug-resistant organisms could help improve their management and enable personalized treatment.

Efficacy of empirical Ciprofloxacin or Cefixime plus Metronidazole therapy for the treatment of liver abscess: a randomized control clinical trial.

Liver abscess is a potentially life-threatening medical emergency. Prompt empirical antimicrobial with or without percutaneous aspiration or drainage is therapeutic. The rational for using empirical intravenous broad-spectrum antimicrobials upfront instead of oral Fluoroquinolone or Cephalosporin is contentious. In this double blind randomized control clinical trial 69 participants received Ciprofloxacin (500 mg q 12 hourly) and 71 participants received Cefixime (200 mg q 12 hourly) orally for 2 weeks. Both the group received oral Metronidazole (800 mg q 8 hourly) for 2 weeks and percutaneous drainage or aspiration of the abscess was done as per indication and followed-up for 8 weeks. Out of 140 participants, 89.3% (N = 125) achieved clinical cure, 59 (85.5%) in Ciprofloxacin group and 66 (93%) in Cefixime group (p = 0.154). Mean duration of antimicrobial therapy was 16.2 ± 4.3 days, 15.1 ± 4.5 days in Ciprofloxacin group and 16.0 ± 4.2 days in Cefixime group (p = 0.223). Total 15 (10.7%) participants had treatment failure, 10 (14.5%) in Ciprofloxacin group and 5 (7.0%) in Cefixime group (p = 0.154). The most common reason for treatment failure was need of prolong (> 4 weeks) antimicrobial therapy due to persistent hepatic collection requiring drainage, which was significantly (p = 0.036) higher in Ciprofloxacin (14.5%, N = 10) group, compared to the Cefixime (4.2%, N = 3) group. In conclusion, both, the Ciprofloxacin or Cefixime plus Metronidazole for duration of 2-3 weeks were efficacious as empirical oral antimicrobial regimen along with prompt percutaneous drainage or aspiration for the treatment of uncomplicated liver abscess with similar efficacy. Oral Cefixime was better than Ciprofloxacin in term of lesser chance of treatment failure due to persistent collection which is required to be investigated further in larger clinical trial.Trial registration: clinicaltrials.gov PRS ID: NCT03969758, 31/05/2019.