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• W4387249529 abstract "SESSION TITLE: Chest Infections Case Report Posters 9 SESSION TYPE: Case Report Posters PRESENTED ON: 10/09/2023 12:00 pm - 12:45 pm INTRODUCTION: Intrathoracic complications of perihepatic abscesses are potentially life-threatening if left untreated. We present a case of perihepatic abscesses resolving because of fistula formation between the abscesses and pulmonary bronchi. CASE PRESENTATION: A sixty-one-year-old previously healthy woman underwent a colectomy due to colonic perforation with course complicated by Escherichia coli posterior perihepatic subphrenic abscesses. Initial treatment of the abscesses consisted of percutaneous drainage and two weeks of intravenous meropenem. On imaging eight months later, the abscesses remained and management consisted of a 10 French pigtail drainage catheter and trimethoprim/sulfamethoxazole for seven days. Surveillance imaging showed persistence of the abscesses and development of a right sided exudative loculated pleural effusion. The pleural effusion required chest tube placement followed by intrapleural lytic therapy, resulting in resolution. Output from the perihepatic pigtail catheter dropped thus it was removed but due to persistence of the abscesses on imaging, ertapenem therapy was initiated. After four months of antibiotics, drainage of the abscesses was attempted but no fluid obtained. The cough improved and ertapenem was stopped. Over the next five weeks, she developed a worsening productive cough leading to hospital admission. Imaging revealed the perihepatic abscesses had not resolved and a new dense right lower lobe consolidation. A bronchoscopy was performed and bronchoalveolar lavage cultures grew Escherichia coli sensitive to trimethoprim/sulfamethoxazole, consistent with initial culture data from the perihepatic abscesses, and treatment initiated. The patient was scheduled for another percutaneous drainage of the abscesses three weeks later, but periprocedural computed tomography and ultrasound revealed near complete resolution of the abscesses. Antibiotics were stopped and the cough and malaise resolved. DISCUSSION: Hepatic and perihepatic abscess formation can occur as complications of abdominal infection (1). First line management of these abscesses is percutaneous drainage, with success rates of 85-90%, whereas surgical approaches are associated with a 25-30% morbidity and mortality rate (2). Complications of abdominal abscesses include sepsis, fevers, chronic infection, and in some cases intrathoracic spread (3). Pulmonary extension of a perihepatic abscess is thought to be related to the anatomic proximity of these structures and can result in serous effusion or empyema (1). Posterior perihepatic subphrenic abscesses are particularly difficult to access due to the location and depth of the pleural recess (1). In this case, attempted drainage of the perihepatic abscesses was complicated by an exudative pleural effusion. We suspect the inflammatory cascade secondary to the pleural effusion resulted in apposition of the pleural space. This pleurodesis allowed for a fistula to form between the abscess and bronchi, resulting in drainage of the abscesses directly into the bronchi. This is supported by the bronchoalveolar lavage culture which grew the same bacteria previously detected on the abscess cultures and resolution of the subphrenic abscesses with an antibiotic targeted at the right lower lobe consolidation. CONCLUSIONS: After review of current literature, this is the first reported case of a perihepatic abscess resolving as a result of the treatment of a loculated pleural effusion leading to apposition of the pleura allowing for fistula formation between the abscess and pulmonary bronchi. REFERENCE #1: BOYD DP. The intrathoracic complications of subphrenic abscess. J Thorac Cardiovasc Surg. 1959 Dec;38:771-9. PMID: 13803529. REFERENCE #2: AlGhamdi ZM, Boumarah DN, Alshammary S, Elbawab H. Pleural Empyema as a Complication of Pyogenic Liver Abscess: Can the Minimum Achieve the Optimal? A Comparison of 3 Approaches. Am J Case Rep. 2021 Dec 20;22:e935169. doi: 10.12659/AJCR.935169. PMID: 34924559; PMCID: PMC8711258. REFERENCE #3: Singhal S, Changela K, Lane D, Anand S, Duddempudi S. Endoscopic ultrasound-guided hepatic and perihepatic abscess drainage: an evolving technique. Therap Adv Gastroenterol. 2014 Mar;7(2):93-8. doi: 10.1177/1756283X13506178. PMID: 24587822; PMCID: PMC3903087. DISCLOSURES: No relevant relationships by Ajay Breen No relevant relationships by Hakim Dekkiche No relevant relationships by Emmanuel Tavan" @default.
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• W4387249529 date "2023-10-01" @default.
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• W4387249529 title "PLEURAL EFFUSION: COMPLICATION OR CURE?" @default.
• W4387249529 doi "https://doi.org/10.1016/j.chest.2023.07.879" @default.
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