A b d o m Imaging 20:452-455 (1995)

Abdominal Imaging 9 Springer-VerlagNew York Inc. 1995

Intrahepatic abscess due to gallbladder perforation A. Peer, E. Witz, H. Manor, S. Strauss Department of Radiology, Assaf Harofeh Medical Center, Zerifin 70300, Israel Received: 13 June 1994/Accepted: 26 July 1994

Abstract Background: Perforation of the gallbladder with cholecystohepatic communication is a rare cause of liver abscess. We report four cases of this condition and describe the imaging procedures related to its diagnosis and treatment. Methods: The medical and x-ray files of 39 patients with percutaneous drainage of liver abscesses were retrospectively reviewed. Four patients with hepatic abscess due to gallbladder perforation were identified. The patients presented with clinical features suggestive of cholecystitis. Results: Sonography in four patients showed a hypoechoic lesion in the liver adjacent to the gallbladder. CT in three patients showed a hypodense area in the liver, corresponding to the sonographic findings. Percutaneous abscess drainage, followed by an abscessogram, was performed in all patients. Contrast material injected throuugh the drainage catheter filled the gallbladder directly from the abscess cavity. Two patients subsequently underwent cholecystectomy, confirming perforation of the gallbladder fundus. In both cases the gallbladder was noted to be embedded in the liver and covered by adhesions. Conclusion: Perforation of the gallbladder is a rare cause of pyogenic liver abscess. We suggest, however, based on our two patients who underwent surgery, and several cases reported in the literature, that this condition may be more common when the gallbladder is partially or totally intrahepatic. Key words: Gallbladder perforation--Liver abscess-Cholecystohepatic fistula.

The etiology of pyogenic liver abscess has changed in recent years. Historically, the appendix and colon were Correspondence to: S. Strauss

the major sources of pyogenic abscesses, seeding the liver through the portal vein. Currently, biliary tract disease is the most prevalent cause of pyogenic hepatic abscesses, ranging from 31 to 45% in a recent series [1]. Biliary conditions associated with liver abscesses include acute cholecystitis, choledocholithiasis, sclerosing cholangitis, and malignant obstruction of the common bile duct [1-3]. Perforation of the gallbladder with cholecystohepatic fistula is a rare cause of liver abscess formation, and cases have been reported only sporadically in the literature [4-8]. We report our experience with four cases of hepatic abscess due to gallbladder perforation, which was diagnosed and treated initially by percutaneous abscess drainage (PAD).

Materials and Methods A review of the records and x-ray files of 39 liver abscesses drained percutaneously in our institution revealed four cases due to perforation of the gallbladder. The patients (two men, two women) ranged in age from 69 to 81 years. All four patients presented with right upper quadrant pain, fever, and leucocytosis, except for one patient who was afebrile. A history of diabetes mellitus was obtained in two patients. Liver function tests revealed elevated alkaline phosphatase levels in three of the four patients. No patients were immunosuppressed by chemotherapy or steroid treatment, and none had an underlying malignancy or were positive for h u m a n immunodeficiency virus. The four patients had no recent surgery, although gallstones were known to be present for more than 20 years in three of the patients. The radiologic diagnosis of liver abscess was made by sonography in all four patients and by CT in three. In one patient CT was not performed. All four patients underwent PAD, followed by an abscessogram. Abscesses were drained under sonographic (two patients) or CT (two patients) guidance. The Seldinger two-step technique was used [9]. An 18-gauge needle, sufficient to drain thick, viscous pus, was initially inserted. When sonography was used to direct the access route, 5 cc of sterile saline was injected into the cavity to confirm the location of the needle tip. Under fluoroscopy, a 0.38-inch safe T-J guidewire (Cook Inc., Indianapolis, IN, USA) was then introduced into the cavity and the access route dilated to the required size of the

A. Peer et al.: Liver abscess due to GB perforation

453 Fig. 1. Hypoechoic lesion in liver (black arrow) is adjacent to the gallbladder (white arrow) containing a gallstone. Fig. 2. CT of upper abdomen demonstrates gallbladder with gallstone and adjacent liver abscess (arrow). Fig. 3. A CT of right upper abdomen with tip of needle in hepatic abscess (black arrow). The gallbladder (white arrow) is distended. B CT abscessogram in same patient shows contrast in gallbladder (black arrow) connecting directly to the abscess cavity (open arrow). C Abscessogram with catheter in liver abscess cavity with direct filling of the gallbladder (arrow) and cystic duct.

drainage catheter. These were either of the Malecot type (Cook Inc.) or multipurpose pigtail type (Meditech, Watertown, MA, USA), ranging in size from 10 to 14-F.

Results Sonography demonstrated a hypoechoic lesion in the liver adjacent to the gallbladder in all cases. The lesions appeared to be fluid in nature, but contained coarse, bright echoes (Fig. 1). Although all patients had fasted for 8 h prior to the sonographic examination, the gallbladder was small and contracted in three patients, and the wall of the gallbladder was thick and irregular. The possibility of hepatic abscess, due to gallbladder perforation, was considered. In one patient the gallbladder was distended. Gallstones were demonstrated in all patients. The common bile duct was normal in caliber in all patients. A low-density lesion, corresponding to the hepatic lesion seen on sonography, was identified on CT in the three patients in whom it was performed (Fig. 2). Material aspirated from the abscess cavity revealed on culture E. coli in two patients and both Enterobacter and Streptococcus in one patient. In the fourth patient, who was also afebrile, no organisms grew. This patient

had received broad-spectrum antibiotics for several weeks prior to admission. Contrast material was instilled into the abscess cavity through the drainage catheter under fluoroscopic observati0n. In all four cases, the abscessogram showed filling of the abscess cavity, with subsequent opacification of the gallbladder. The biliary tree was outlined with contrast through the cystic duct (Fig. 3). None of the patients had common bile duct obstruction. Clinical improvement was noted in three patients after PAD. One patient continued to have a low-grade fever and underwent cholecystectomy 9 days later, the drainage catheter having been removed after 4 days. A second patient underwent elective cholecystectomy 5 months after PAD and 4 months after the catheter was withdrawn. In both cases, the gallbladder was found, at surgery, to be contracted, thick walled, partially intrahepatic, and covered by adhesions. Gallstones were present in both cases, and evidence of perforation was found in the fundal region of the gallbladder in the surgical specimens. Two patients did not undergo cholecystectomy, and both died of causes unrelated to the hepatic abscess. In neither patient was it possible to determine, on the basis of the imaging procedures performed, whether or not the gallbladder was intrahepatic. Duration of drainage in these 2 patients was 10 and 23

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days, respectively. There were no complications resulting directly from the drainage procedure.

Discussion

Perforation of the gallbladder is a significant complication of acute cholecystitis and occurs in 5-10% of cases [6]. Niemeier [10] subdivided gallbladder perforations into three types: acute free perforation into the peritoneal cavity, subacute perforation with pericholecystic abscess, and chronic perforation with cholecystoenteric fistula. Predisposing factors for gallbladder perforation include cholelithiasis, infection, malignancy, trauma, corticosteroid therapy, and impaired vascular supply [6]. The most frequent site for gallbladder perforation is the fundus because of its relatively poor blood supply [11]. Abscess formation, secondary to perforation, is usually confined to the gallbladder fossa but may spread freely throughout the peritoneal cavity, only rarely extending into the liver. Anatomic considerations may explain the rarity of this phenomenon. The peritoneum passes from the surface of the liver across the sides and posterior surface of the body and neck of the gallbladder. The anterior surface of the gallbladder is separated from the liver only by connective tissue. The fundus usually projects beyond the inferior liver margin and is completely surrounded with peritoneum [12]. However, the relative amounts of the surface in contact with the liver and covered by the peritoneum vary somewhat with the shape and location of the gallbladder. Intrahepatic gallbladder, which is associated with a higher incidence of cholelithiasis [13], is buried within the liver tissue, and perforation would result in a hepatic abscess. Teefey and Wechter [5] reported two patients with intrahepatic extension of pericholecyst abscess. In one the gallbladder was totally intrahepatic, and in the other it was partially intrahepatic. In a series of 13 patients with gallbladder perforation reported by Madrazo et al. [6], three had intrahepatic abscesses, and in one patient the gallbladder "resided within the liver, surrounded by an inflammatory mass" [6]. In our two patients who underwent surgery, the gallbladder was similarly found to be embedded in the liver and covered by adhesions. There are no classical symptoms or signs of gallbladder perforation, although symptomatology of cholecystitis is the most common clinical finding. Three of our four patients presented with high fever, whereas the fourth, an 81-year-old man, was afebrile. Right upper quadrant pain is usually present, as in our four cases, but may not be a significant part of the medical history [14]. Sudden decrease in pain intensity may occur at the time of perforation due to relief of high intracholecystic pressure [4].

A. Peer et al.: Liver abscess due to GB perforation

Sonography is usually the preferred initial examination for evaluating suspected acute cholecystitis, although CT is often employed for evaluating the extent of disease in suspected perforation. Both CT and sonography can be used to plan access routes for PAD, and, as in our cases, CT can demonstrate direct communication to the gallbladder fundus following injection of contrast. The sonographic appearance of gallbladder perforation is diverse and nonspecific. Common sonographic findings include pericholecystic fluid collections, gallstones, gallbladder wall thickening, gallbladder distention, and coarse echogenic debris in the gallbladder fossa [4-6]. Demonstration of a " h o l e " in the gallbladder wall is considered to be a more specific sign of gallbladder perforation [ 15]. Percutaneous drainage has become the preferred and often only method of treatment for collections throughout the body [16-19]. In a recent review by Lambiase et al. [17], the cure rate of intrahepatic abscesses treated by PAD was reported to be 70-90%. The purpose of this paper is to draw attention to the possibility of intrahepatic abscess formation due to gallbladder perforation, especially in cases where the gallbladder is located partially or completely within the liver. In these cases, the fundus of the gallbladder, the site of most perforations, does not project beyond the lower border of the liver, and is not covered on all four sides by peritoneum.

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