Image of the Month—Diagnosis

At laparotomy, drainage of nearly 1 L of purulent material was accomplished with excision of the capsule of the abscess and packing of the residual cavity with omentum. Drains were left in place around the treated segment. Microscopic and culture evaluation revealed that the abscess content was polymicrobial, containing Clostridium perfringens, viridans streptococci, and Staphylococcus aureus. Incidentally, the patient was also found to have positive serology for hepatitis B and C. The patient was discharged after an uncomplicated 5-day hospital course to complete 6 weeks of treatment with trimethoprim/sulfamethoxazole, levofloxacin, and metronidazole. Further investigation revealed that indeed the patient had undergone successful right hepatic arterial branch embolization to arrest hemorrhage at another institution for blunt liver injury 1 month previously.

Hepatic trauma occurs in 1% to 8% of patients following blunt abdominal trauma, with 80% of these patients successfully managed nonoperatively.¹The use of catheter-directed embolization techniques has increased the number of solid-organ injuries that can be managed without the morbidity of laparotomy. Despite the success of less invasive endovascular adjuncts to arrest hemorrhage early, delayed complications such as abscess and pseudoaneurysm have been reported. It is particularly challenging to screen for these complications in the months following injury in the often transient trauma population as in the clinical study presented here.

In an era where the use of endovascular techniques to control hemorrhage from solid-organ injury is becoming more frequent, the current case is quite germane.²Although the immediate success of catheter-directed embolic techniques is often dramatic for cessation of hemorrhage, this technique does not allow débridement of nonviable liver parenchyma or external drainage of hematomas or bilomas. As such, our clinical study emphasizes that the savvy surgeon should be mindful of the development of mid- to late-term complications following embolization of solid-organ injury. While there is no current evidence to support further intervention following embolization, the surgeon must be vigilant in assessing the patient regarding additional intervention.

Hepatic abscess in this setting is thought to result from arterial seeding of a residual hematoma or biloma with a single organism or from enteric flora from the portal circulation.³Most hepatic abscesses occur in the right lobe of the liver, with diabetes having been shown as a predisposing factor.⁴Although this has been previously reported after chemoembolization of a metastatic liver lesion, we describe, for the first time to our knowledge, a patient with a clostridial abscess following embolization used as an adjunct for nonoperative management of hepatic trauma.⁵

Management options for residual hepatic abscesses include the following: percutaneous, radiographically guided (computed tomographic or ultrasonographic) drainage; laparoscopic drainage; and laparotomy with open drainage. Because of the clinical presentation (ie, hypotension and peritonitis) and the gigantic size of the abscess, open operative management with omental packing and drainage was felt to offer the most expeditious and complete management in the current case.

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Correspondence:Brandon W. Propper, MD, Department of Surgery, Wilford Hall Medical Center, 2200 Bergquist Dr, Ste 1, Lackland AFB, TX 78236 (bpropper@me.com).

Accepted for Publication:August 3, 2009.

Author Contributions:Study concept and design: Propper, Lundy, and Rasmussen. Acquisition of data: Propper, Lundy, and Tyner. Analysis and interpretation of data: Propper, Lundy, and Rasmussen. Drafting of the manuscript: Propper, Lundy, Tyner, and Rasmussen. Critical revision of the manuscript for important intellectual content: Propper, Lundy, and Rasmussen. Statistical analysis: Propper. Study supervision: Propper, Lundy, Tyner, and Rasmussen.

Financial Disclosure:None reported.