A 22-year-old male with a history of chronic alcohol abuse presented with abdominal pain, bilious vomiting, and abdominal distension for 2 days. He had been ill for 15 days with loose stools and fever. On clinical examination, the patient had abdominal distension with absent bowel sounds. His abdominal X-ray showed dilated small bowel loops with multiple air fluid levels ([Fig. 1A]). A complete hemogram suggested leukocytosis with 82,000 total leucocyte count with a neutrophilic (70%) predominance. He was admitted with a clinical suspicion of acute intestinal obstruction. He underwent computed tomography of the abdomen which showed a left lobe ruptured liver abscess ([Fig. 1B]) of size 5 cm × 4 cm × 4 cm with dilated proximal and mid jejunal loops with a smooth transition at distal jejunal and ileal junction and intra-abdominal collection ([Fig. 1C]). The patient was started on broad-spectrum antibiotics (injection piperacillin/tazobactam and injection metronidazole) for treatment of the abscess. He underwent an ultrasound-guided pigtail catheter insertion into the left paracolic gutter. The patient's condition improved with the same treatment with the resolution of fever and intestinal obstruction. The pus drained from the abscess was positive for Entamoeba histolytica polymerase chain reaction. The patient's condition again deteriorated after 6 days of in-hospital stay with the patient developing shock. A repeat ultrasound of the abdomen was done, which showed persistence of pus collection in the pelvic cavity into which a second pigtail catheter was inserted. Antibiotics were upgraded to injection meropenem and injection teicoplanin. The pus aspirated from the pelvic cavity showed growth of Escherichia coli sensitive to meropenem. The patient responded to the above therapy with a resolution of shock. He was discharged with both the pigtail catheters in situ which were removed once drainage stopped. Metronidazole was given for a total of 14 days. The therapy was shifted to oral faropenem for a total therapy of 4 weeks. An ultrasound at 4 weeks showed significant resolution of abscess with two small lesions of 1 to 2 cm with an organized appearance. The patient remains well on follow-up.
Fig. 1 (A) Abdominal X-ray (AXR) showing air fluid levels. (B) Computed tomography (CT) showing left lobe abscess with evidence of rupture. (C) CT showing intra-abdominal collection in relation to small bowel loops which are distended.
Amebic liver abscess is an important gastroenterological emergency that may present with fever, abdominal pain, and tenderness. The therapy is usually with nitroimidazole antibiotics (metronidazole or tinidazole) and drainage in certain conditions like (impending) rupture, left lobe, or multiple abscesses.[1] Although we used metronidazole, tinidazole has demonstrated more clinical efficacy and may be better tolerated.[2] We report this case for two reasons—one is the unusual occurrence of leukemoid reaction, which improved with treatment and the intestinal obstruction which precipitated the clinical presentation. We believe the obstruction was due to the pelvic collection due to the ruptured liver abscess. There are only a few prior reports of intestinal obstruction in the setting of liver abscess requiring surgery or percutaneous drainage.[3]
[4] To conclude, liver abscess can present with complications that may confuse the clinical presentation.
