A 33 year old man from Haryana,India,presented with a
history of pain abdomen and fever since one month.He
was diagnosed to havea liver abscess in another hospital
and managed with an ultrasound guided needle
aspiration on 3 separate occasions alongwith iv antibiotics
(the exact nature of the abscess couldn’t be ascertained
through his previous papers).After this treatment his fever
had subsided alongwith the pain in right hypochondrium,
but after a month he again developed fever alongwith a
swelling at the puncture site. It was diagnosed to be a
subcutaneous abscess,and was drained,following which
his fever subsided. However, he developed a persistent
bilious discharge from that site. At this point of time he
was referred to our institution. A diagnostic work-up
revealed a positive amoebic serology (Immuno-
haemagglutination titre > 1:1,600;normal < 1:128) and a
well-defined (7 x 8 cm) space occupying lesion in the left
lobe of liver,which was anechoic and had shaggy margins.
A routine haemogram, coagulogram, and liver function
tests were unremarkable. A percutaneous ultrasound
guided pigtail drainage of the large left lobe abscess was
done which produced a drain of 500 ml of bilious fluid
per day.Bile culture and sensitivity from the catheter drain
was sterile.An ERCP done soon after,demonstrated a large
biliary communication and showed adequate and free
 
block and re-instituted free flow of bile. Following this,
fever and jaundice subsided within 2 days.Atthis point of
time, an MRCP (magnetic resonance cholangio-
pancreatography) was done (Fig.2) which revealed a large
abscess in segment IV of the liver and dilatation of
intrahepatic biliary radicles in the left lobe of the liver due
to compression and inferior displacement of the left
hepatic duct by the abscess. The extra-hepatic ducts
including CBD were normal.
Few days later, a repeat ERCP with NBD placement into
the abscess cavity was done alongwith a 1 cm
sphincterotomy.The patient continued to drain bile,at first
through the NBD as well as pigtail catheter, but later on
only through the catheter (average of 100-200 ml/day).
Follow-up ultrasound showed a decrease in size of the
abscess cavity (3 x 4 cm).The catheter was removed once
drainage (Fig.1).However,after 2 daysit stopped draining
and was removed.The patient was discharged with the
external pigtail draining the abscess cavity.However, he
had to be re-admitted 2 wks.later with high-grade fever
and jaundice suggestive of cholangitis.A repeat ERCP with
nasobiliary drainage was done and revealed thick
purulent bile.A secondary infection of the abscess cavity
was suspected and intravenous cefotaxime and amikacin
instituted in appropriate doses. Bile culture sensitivity
showed growth of E.Coli sensitive to amikacin, but
resistant to cefotaxime.Fever and jaundice subsided and
NBD was again removed after 2 days, as it had stopped
draining.However,he continued to drain bile through the
initial pigtail drainage, suggestive of a persistent
intrahepatic biliary communication with the abscess
cavity.This too became blocked a week later,and he again
developed high-grade fever with further increase in
jaundice.During this period he had a total leucocyte count
of 16,800/cu. mm and a total and direct bilirubin of 5.1
mg/dl and 3.0 mg/dl respectively. Alkaline phosphatase
was 2.5 times the normal. This was again managed by
intravenous antibiotics and vigorous flushing of the
percutaneous pigtail catheter,which removed the pigtail
Fig.1: For pics see http://medind.nic.in/jac/t03/i2/jact03i2p162.pdf
Fig.2: http://medind.nic.in/jac/t03/i2/jact03i2p162.pdf
the bile output dropped to < 10 ml/day and a repeat
ultrasound showed a negligible residual cavity.There was
no recurrence of cholangitis on 6 months of follow up.
Discussion
Amoebic liver abscess is a common problem in
developing countries.In most patients drainage either by
catheter or needle aspiration is not required unless there
is a danger of imminent rupture, or if the abscess is
situated in the left lobe.Although amoebic liver abscesses
are common, a demonstrable communication between
the abscess cavity and biliary tree has been rarely
reported
1-7
. Most of these were reported in the pre-
endoscopic era and after so many years of the advent of
ERCP,there have been only a few studies mentioning this
particular complication
7-9
. Thus, the condition is either
really rare with amoebic liver abscess or not being
frequently reported.
Two aspects of this particular patient made us undertake
an ERCP though it is otherwise not essential in the
diagnostic work-up of an amoebic liver abscess.The initial
presentation of this patient was with a cutaneous
discharge of bilious fluid and percutaneous catheter
drainage too produced initially 500 ml of bilious fluid per
day.This made us suspect a biliary fistula and confirm it
on ERCP (Fig.1).
The other noteworthy features of this patient were
concerning the management of liver abscess. He was
initially treated in another hospital with multiple needle
aspirations alongwith antibiotics. However, when he
presented to us one month later, he still had a large left
lobe abscess alongwith a bilio-cutaneous fistula.Therefore,
an ultrasound guided percutaneous catheter drainage
was done to tackle the abscess. Percutaueous drainage
as such has been proven to be efficacious even in
presence of identifiable biliary fistula
9,10
. Bayratker et al
havereported a series of 15 patients,complicated in 6,by
the presence of a biliary fistula;and all of them showed a
good response to percutaneous drainage. Interestingly,
in their study, 5 patients had amoebic liver abscess, two
of whom had a demonstrable biliary communication
9
.
Another study by Huy et al reported a longer duration of
drainage (mean of 22 days) in pyogenic abscesses with
intra-hepatic biliary communications (as against 13 days
in those without) but were nevertheless successfully cured
on percutaneous drainage alone without requiring any
surgical intervention
10
. The fact that percutaneous
drainage has a demonstrated superiority over
percutaneous needle aspiration has also previously been
reported from our hospital
11
.A magnetic resonance
imaging revealed an evident compression and inferior
displacement of the left hepatic duct bythe abscess cavity
causing left lobar intrahepatic biliary dilatation and
perhaps this was the reason he developed cholangitis 2
wks.after catheter drainage and another recurrence 3 wks.
later.A secondary infection of the abscess cavity spreading
into the biliary system through the intrahepatic
communication causing suppurative cholangitis was
thought of,and a nasobiliary drainage was done with the
NBD inserted right into the abscess cavity for a more
effective drainage.There have been reports of pyogenic
liver abscesses with biliary communication treated
successfully with endoscopic stenting and drainage
12,13
.
Our case report not only describes an unusual cause of
recurrentcholangitis due to an amoebic liver abscess (with
intrahepatic biliarycommunication) causing compression
and displacement of the left hepatic duct;it also highlights
the role of percutaneous catheter drainage and
endoscopic sphincterotomy with nasobiliary drainage in
successfully managing such a challenging case.
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First published in Jl Indian Academy of Clinical medicine, JIACM 2003;4(2):162-65