An 82-year-old man was referred to our hospital with an expanding liver cyst that
was compressing the inferior vena cava. His medical history revealed hypertension,
chronic obstructive pulmonary disease (COPD), a hip prosthesis, and surgery for varices.
At the referring hospital the patient had been treated endoscopically for upper gastrointestinal
bleeding by circumferential adrenaline injection of a duodenal ulcer with adherent
clot, using a 4 mm long and 0.2 mm thick needle, following which the bleeding stopped.
Abdominal ultrasonography had been performed because physical examination showed an
enlarged liver and the patient had developed peripheral edema suggesting inferior
vena cava compression. Ultrasound revealed multiple liver cysts, one of which, originating
from segment five of the liver, had rapidly increased in size. A contrast-enhanced
CT scan had shown a thickened wall with contrast enhancement and gas formation within
the cyst (Fig. [1]), suspicious for an infected cyst. The cyst compressed the duodenum, and inferior
vena cava. The patient’s condition deteriorated and therefore he was referred to our
hospital.
Figure 1 Contrast-enhanced computer tomography (CT) scan showing a huge cyst in segment five
of the liver with a thickened wall showing contrast enhancement and gas formation
within the cyst. The cyst is compressing the duodenum and the inferior vena cava.
The diagnosis of infected liver cyst was confirmed and the cyst was drained percutaneously.
Culture of the cyst content showed Streptococcus viridans, Escherichia coli and Bacteroides fragilis. Following drainage, the patient was transferred back to the ward and initially his
clinical condition improved and temperature dropped. Unfortunately, the drain accidentally
dislocated and fell out, following which the patient developed peritonitis and septic
shock. He was taken to the operating theatre for emergency treatment and the diagnosis
of infected liver cyst with the duodenum adherent to the medial cyst boundary was
confirmed. During the surgical procedure the patient unfortunately went into irreversible
septic shock and died 10 days after treatment of his upper gastrointestinal bleeding.
We hypothesize that the cyst became infected by transmural translocation of endoluminal
bacteria into the cyst by accidental puncture during adrenaline injection of the bleeding
ulcer.
Endoscopic adrenaline injection is an accepted treatment option for upper gastrointestinal
bleeding [1]
[2]
[3]. We are unaware of any previous reports of infected liver cysts as a complication
of this treatment.
Endoscopists using injection therapy should be aware of complications caused by the
needle’s passage through the gastrointestinal wall.
Endoscopy_UCTN_Code_CPL_1AH_2AC
