A 33 year-old woman with no known medical history presented with one week of sharp, stabbing right upper quadrant abdominal pain along with fever to 103 degrees Fahrenheit. She had also noticed a forty pound weight loss over the past six months along with some intermittent watery diarrhea over that same time course. The patient’s exam was significant for right upper quadrant tenderness to palpation but was otherwise benign.
An initial CT scan demonstrated a 3 cm rim enhancing structure in the left lobe of the liver along with extensive diffuse fatty infiltration involving the entire colon, terminal ileum, and scattered loops of small bowel. She was initially started on antibiotics with piperacillin/tazobactam and had an amoebic serology sent. The amoebic serology was negative and the antibiotics were eventually changed to metronidazole and ciprofloxacin. A repeat CT showed an increase in size of the liver lesion and interventional radiology placed a drain but despite appropriate placement no abscess fluid was obtained. However, as a final CT scan showed some interval decrease in the size of the abscess and her fevers had abated, it was decided to continue the patient’s antibiotics and follow with repeat imaging.
During this time the patient had worsening diarrhea, and it came to light that she had a history of a perianal fistula that had been treated at another hospital. Further infectious work-up for her diarrhea was negative, and her CRP and ESR remained significantly elevated. Gastroenterology was involved in her care to further assess her newly diagnosed Crohn’s disease with a colonoscopy and to begin treatment of her Crohn’s.
Liver abscesses are among the hepatobiliary manifestations of Crohn’s disease and typically present in patients with known disease but have been seen as the initial presentation as well. Patients typically present with fever and can have abdominal pain, diarrhea, nausea and vomiting, jaundice or hepatomegally. The most common lab abnormalities are leukocytosis and elevated alkaline phosphatase. The exact mechanism of abscess formation is unclear but it has been hypothesized to be a result of either direct extension of intraabdominal abscesses or from portal vein pyemia with secondary seeding of the liver parenchyma. Treatment usually involves percutaneous drainage with appropriate antibiotic coverage as well as treatment of the underlying Crohn’s disease.
It is important for hospitalists to be aware that Crohn’s disease can be a cause of liver abscesses as successful management of these abscesses includes treatment of the underlying Crohn’s disease. Without appropriate Crohn’s therapy the liver abscess may fail to resolve or even recur. Crohn’s disease should be considered in a patient presenting with a liver abscess who is otherwise healthy and doesn’t have other explanatory circumstances.
To cite this abstract:Bell J. What’s That Eating My Liver?. Abstract published at Hospital Medicine 2015, March 29-April 1, National Harbor, Md. Abstract 454. Journal of Hospital Medicine. 2015; 10 (suppl 2). https://www.shmabstracts.com/abstract/whats-that-eating-my-liver/. Accessed July 20, 2019.