Acute Appendicitis with Pyogenic Liver Abscesses

Acute Appendicitis with Pyogenic Liver Abscesses. Biomed J Sci & Tech Res 41(2)-2022. BJSTR. MS.ID.006577. Objective: Acute appendicitis, although very common and well known, can present in many different ways, from asymptomatic to septic shock and every variation in between. We offer a safe management of pyogenic liver abscesses caused by acute appendicitis. Design: We present the case of a male patient with liver abscesses due to acute appendicitis. Results: Liver abscesses require a multidisciplinary approach and surgical as well as interventional treatment must be evaluated in addition to an antibiotic regimen. Conclusions: The minimally invasive management of liver abscesses with antibiotics and drainage has shown to be effective with minimal risk to the patient. in many different to and every variation in between. a


Background
Acute appendicitis is a very common surgical emergency.
The laparoscopic removal is the standard of care all around the world. Despite the discussion of conservative treatment of acute appendicitis with antibiotics, the American College of Surgeons, the European Association of Endoscopic Surgery and the World Society of Emergency Surgery all recommend the treatment by appendectomy [1,2]. In an international collaboration, researchers found that 95.7% of patients with acute appendicitis were treated operatively [1]. The lifetime risk of acute appendicitis is 8.6 percent in males and 6.9 in females [3] and the mortality in developed countries lies between 0.09 and 0.24 percent [4]. Typical complications include the perforation of the appendix (observed in 13-20% of acute appendicitis cases), which can result in peritonitis [5]. More rarely, a perityphlitic abscess can form in the proximity of the appendix. The hematogenic spread of bacteria due to an acute appendicitis is possible and has been described. This can lead to the formation of abscesses in the liver through pyemia of the portal vein [6].
Liver abscesses are relatively rare and present 2.3 cases per 100,000 people [7][8][9], but they account for 48 percent of visceral abscesses and 13% of intraabdominal abscesses [10]. In half of the cases, an underlying disease of the biliary tract can be identified, and the abscesses are often formed following a pyemia of the portal vein due to bowel leakage and peritonitis [6,7,11]. The most common pathogens are Streptococci, especially the Streptococcus milleri group (S. anginosus, S. constellatus, S. intermedius) [12].

Case Presentation
A 51-year-old male presented in our emergency department with a 4-day history of fever up to 39.0°C. He did not complain of pain, denied any nausea or diarrhea, and had no urinary symptoms.
He had no trouble breathing, no coughing and no throat pain.

Outcome and Follow-Up
The patient was seen weekly for follow-up examinations over the course of 6 weeks after discharge. During this period, the patient presented himself once with tachycardia and episodes of sweating in the emergency department. Computer tomography ruled out a pulmonary embolism but showed a thrombus of the medial hepatic vein. Oral anticoagulation with Rivaroxaban 20mg daily was established for a planned total duration of 3 months. The antibiotic treatment was continued until the abscesses could no longer be identified in the CAT scan. The patient remained afebrile and did not show any symptoms, apart from fatigue, during followup. The antibiotic treatment could be discontinued as planned, 7 weeks after initiation.

Discussion
The treatment of pyogenic liver abscesses consists of abscess drainage and antibiotic therapy [17][18][19][20]. The therapeutic approach depends on the number and size of liver abscesses. For single, unilocular abscesses smaller than 5cm in diameter, a percutaneous drainage is indicated. This can either be performed through needle aspiration or catheter placement, both bearing similar success rates [17,[21][22][23]. However, needle aspiration has to be repeated in approximately half of the cases [22][23][24]. In the case of a single, unilocular abscess bigger than 5cm in diameter, a percutaneous drainage with a catheter placement is recommended. With needle aspiration of these larger abscesses the results show slower abscess drainage, longer time to clinical improvement and more often the need for surgical intervention compared to patients with catheter placement [17]. This management should also be applied to very large abscesses (larger than 10cm in diameter), so called "giant abscesses". With a size of over 10cm in diameter, the risk of complications, including drainage failure and even sepsis leading to death, become significantly higher [8,24,25]. There have been attempts to manage these abscesses surgically, which have shown a lower rate of treatment failure.
However, no change in mortality, duration of clinical manifestation or rate of complications could be identified in the comparison between percutaneous and surgical drainage [26,27]. The therapeutic approach to multiple abscesses should be made by a multidisciplinary team according to the various capabilities and experiences. The successful percutaneous drainage of multiloculated and multiple abscesses has been described [28], which led to a shift in treatment strategy from surgical to an interventional approach. The empiric antibiotic regiment with ceftriaxone and metronidazole is recommended, such that Streptococci, enteric gram-negative bacilli and anaerobes are covered. Alternative regiments should be applied according to local resistances or probable infection pattern. Antibiotic regiments should generally be continued for a total duration of 4-6 weeks, in patients with incomplete drainage the antibiotic application should be intravenously for the whole duration, whereas patients that showed a positive response to drainage can continue the antibiotic therapy orally after 2-4 weeks of parenteral application [21,29,30].
In the case of our patient, the more caudal abscess perforated spontaneously during a laparoscopy. A drainage was inserted, and microbiological samples were taken, which helped identify the responsible pathogen. According to the stated guidelines, we initiated the antibiotic treatment and inserted a percutaneous drainage of the cranial abscess, which was left untouched during surgery. Our case shows the importance of a multidisciplinary approach and shows the efficacy of surgical as well as interventional percutaneous drainage of liver abscesses. Take Home Messages 1. Acute appendicitis is a medical chameleon: although one of the more common pathologies, it can have very diverse clinical manifestations.

The clinical findings and symptoms do not always correlate
with the gravity of an illness.

Patient's Perspective
The patient came in for follow-up as planned over a period of 6 weeks after discharge and was always compliant with the medical recommendations. He repeatedly stated that he could never have imagined having liver abscesses, especially considering he initially only experienced fever as main symptom. He stated that he was more worried about the drains than about the surgeries.