|Year : 2019 | Volume
| Issue : 4 | Page : 361-364
Dysphagia: An unusual complication of caudate lobe liver abscess
Department of Paediatric Surgery, Government Medical College, Kota, Rajasthan, India
|Date of Submission||02-Jun-2018|
|Date of Acceptance||02-Sep-2018|
|Date of Web Publication||8-Jul-2019|
Assistant Professor, Department of Paediatric Surgery, SMS Medical College, Jaipur, Rajasthan
Source of Support: None, Conflict of Interest: None
A 5-year-old girl presented with abdominal pain, dysphagia, respiratory distress, and fever for the past 3 weeks. The pain was dull in character; present in the epigastrium and right hypochondrium. The patient was unable to swallow solid food and there was difficulty in swallowing even semi-solids and liquids. On examination, there was decreased air entry on the right side with epigastric tenderness. The radiological evaluation suggested caudate lobe liver abscess in close relation with abdominal esophagus resulting in mild compression at gastro-esophageal junction. Pleural effusion on the right side was drained. Broad-spectrum antibiotics including amoebicidal therapy resulted in the dissolution of symptoms and rapid recovery. Caudate lobe liver abscess may result in dysphagia (as its unusual complication) due to inflammation and extraluminal compression at gastro-esophageal junction.
Keywords: Caudate lobe, compression, dysphagia, gastro-esophageal junction, liver abscess
|How to cite this article:|
Gupta R. Dysphagia: An unusual complication of caudate lobe liver abscess. Med J DY Patil Vidyapeeth 2019;12:361-4
| Introduction|| |
Liver abscess is not rare in pediatric patients. Pleural effusion may be either reactionary or rarely due to trans-diaphragmatic rupture.,,, Dysphagia associated with liver abscess is extremely rare with <10 cases reported in the literature till date.,,, We present a 5-year-old girl with liver abscess in the caudate lobe associated with dysphagia; share our experience with this unusual presentation.
| Case Report|| |
A 5-year-old girl presented to our emergency with abdominal pain, dysphagia, respiratory distress and fever for the last 3 weeks. The pain was dull in character and present in the epigastrium and right hypochondrium. There was a sense of obstruction to the passage of food during swallowing. The symptoms were gradual in onset and progressive. The patient was unable to swallow solid meals, and there was difficulty in swallowing even semi-solids and liquids. The patient had high-grade fever associated with rigors. There was loss of appetite, nausea, and upper abdominal distension.
On examination, child was febrile (100.5°F), mildly dehydrated, pale with respiratory distress; pulse rate-130/min, respiratory rate-38/min, and blood pressure −80/52 mmHg. Oropharyngeal, neck, and central nervous system examination were unremarkable. Chest examination was suggestive of decreased air entry on the right side. Abdominal signs included mild epigastric tenderness and distended upper abdomen.
Laboratory values revealed low Hb (7.3 g%), hematocrit 23.9% and raised total leukocyte count (TLC) (25,500/mm 3). Renal functions, liver function tests, and serum electrolytes were normal, but serum calcium was low (7.6 mg/dl); serum albumin and serum protein were 3.1 gm/dl and 5.5 gm/dl, respectively. Abdominal ultrasonography (USG) suggested 53 mm × 39 mm-sized abscess in the caudate lobe of the liver [Figure 1], nonaspirable and lying in close relation to the gastroesophageal junction. There was edema around the gallbladder, minimum fluid in the pelvis, and there was right-sided pleural effusion. Chest radiograph confirmed pleural effusion on the right side [Figure 1]. Contrast-enhanced computed tomography (CECT) showed large (47 mm × 52 mm) peripherally enhancing cystic lesion suggestive of liver abscess in the caudate lobe with thinned out peripheral hepatic parenchyma [Figure 2]; its close relation with abdominal esophagus and compression at the gastroesophageal junction was appreciated [Figure 3].
|Figure 1: Abdominal ultrasonography images. (a and b) Abscess in the caudate lobe of the liver; chest radiograph. (c) Right pleural effusion|
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|Figure 2: Contrast enhanced Computed tomography Abdomen coronal images showing large peripherally enhancing liver abscess, about 47 mm × 52 mm in the caudate lobe with thinned out peripheral hepatic parenchyma. Its close relation with major vessels is appreciated|
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|Figure 3: Contrast enhanced computed tomography (a-c) Abdomen transverse images showing caudate lobe liver abscess in close relation with abdominal esophagus and mild compression at gastro-esophageal junction, (d) right pleural effusion noted|
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Pleural effusion (straw colored, 250 ml) was drained with right intercostal (5th) tube drainage, following which patient had improvement in symptoms. The reactionary aspirate ceased following 24 h (procedure), and the drain was removed on the next day. Biochemical analysis of pleural fluid revealed protein-3.0 g/dl, glucose 60 mg/dl, and pleural fluid pH-7.3. Cytological evaluation of pleural fluid showed TLC-500/mm 3 (predominantly polymorphs); no bacteria or fungus was observed under microscopic examination and the aspirate was sterile on culture tests. Broad-spectrum antibiotics with amoebicidal therapy resulted in the dissolution of all symptoms including difficulty in swallowing and rapid recovery within 5 days. Repeat USG scan after 4 weeks of therapy suggested marked decrease in the size of the abscess. The patient is doing well on 6 months follow-up.
| Discussion|| |
Liver abscess is either due to amoebiasis (extra-intestinal manifestation) or pyogenic in origin. Amoebic liver abscess is more common than pyogenic liver abscess in Indian patients. Involvement of right lobe is relatively common than left lobe (10%–15%) due to greater width and more linear course of the portal vein. Caudate lobe involvement is rare with few cases reported in the literature.,,, Its predilection for infection is rare because of its independent arterial and venous supply.
The clinical presentation of liver abscess is classical and is characterized by features of dull right upper abdominal or epigastric pain, loss of appetite, malaise, loss of weight, fever with chills and often tender hepatomegaly and sometimes intercostal tenderness on the right side., Jaundice (pressure at porta or bilio-vascular fistula) although rare, may be present. Appropriate history of exposure, supplements the diagnosis. Respiratory distress or chest pain may be present due to reactionary pleural effusion.,,, The possible causes for pleural effusion in the present case are: (a) sympathetic reaction due to diaphragmatic inflammation, (b) involvement of the pleural cavity by the involvement of the inflammatory process surrounding the abscess.
Complications of liver abscess include rupture into the peritoneal cavity, pleural cavity (empyema, pneumonia, and hepatobronchial fistula),, gastrointestinal tract, the pericardial cavity (cardiac tamponade),, and biliary tract. Vascular complications such as inferior vena cava ,,, or hepatic venous compression/thrombosis are very rare.,,,, Presentation of caudate lobe liver abscess is similar to the classical involvement.
On review of the literature, pain on swallowing when the bolus of food traverses the lower end of the esophagus was first recorded in a patient with liver abscess in 1953. Esophageal obstruction due to extraluminal compression due to left lobe liver abscess was first described in the year 1969. This patient had epigastric pain, severe dysphagia and vomiting, pain in the left shoulder (involvement of the left phrenic nerve), and moderately tender epigastric mass. The cause of dysphagia is explained by the inflammation and extraluminal compression at the gastroesophageal junction by the caudate lobe liver abscess (due to its proximity) [Figure 4]. Dysphagia has earlier been reported with left-sided liver abscess.,,,
|Figure 4: Diagrammatic representation showing inferior surface of liver with caudate lobe and its relationship with surrounding viscera. Extraluminal compression of gastro-esophageal junction by the caudate lobe liver abscess is seen|
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Laboratory investigations are suggestive of anemia, leukocytosis with an elevated neutrophil count, raised erythrocyte sedimentation rate and sometimes elevated serum alkaline phosphatase levels. Serology for amoebiasis is helpful. Chest radiograph is recommended to evaluate for raised (elevated) hemidiaphragm, pleural effusion, or pericardial involvement. Upper gastrointestinal contrast study confirmed esophageal compression in few studies., USG is a screening modality for liver abscess. CECT is an ideal investigation (sensitivity 97%) for fine anatomic details, smaller lesions, and segmental involvement and also for the evaluation of complications.,
Drug therapy with metronidazole is the treatment of choice in amebic liver abscess. The prompt symptomatic recovery is ascribed to decreased inflammation and reduction in the size of the abscess cavity with relief of compression effects as seen in our case. Pleural and pericardial collections require tube drainage.
Transcutaneous needle aspiration or percutaneous continuous catheter drainage of the abscess under USG guidance is performed if there is impending rupture on radiological evaluation, failure of medical management within 5 days, deterioration in the general condition, large abscess (6 cm). It is considered the gold standard with parenteral antibiotics. However in the case of caudate lobe liver abscess, needle aspiration is challenging as it is difficult to access because of its deep anatomic location, the risk of injury to biliary ducts and vasculature. Thus, in our case, because of prompt response to medical management, needle aspiration of caudate lobe abscess was not contemplated. Surgical intervention is contemplated in failed medical management, ruptured/multiloculated/multiple abscesses, thick pus, and nonresponding caudate lobe abscess. Laparoscopic drainage is suitable if the location is superficial. Endoscopic ultrasound-guided transgastric drainage of caudate lobe liver abscesses is another modality where the transcutaneous or surgical approach is contraindicated.
Finally, caudate lobe liver abscess may result in dysphagia (as its unusual complication) due to inflammation and extraluminal compression at the gastroesophageal junction. A high index of suspicion should be present in a pediatric patient presenting with upper abdominal pain, progressive dysphagia, high-grade fever, and other constitutional symptoms.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]