Liver abscess, due to amebic or pyogenic etiology, is a relatively common cause of right upper quadrant pain in the tropical countries. Imaging techniques, serological tests, image guided interventional procedures and appropriate therapeutic regimens have significantly reduced mortality; yet the disease is associated with many complications and can be fatal if untreated. Here we describe hepatic vein and Inferior Vena Cava (IVC) thrombosis which is one of the rarer complications of liver abscess

Venkatraman Indiran

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 Journal of Krishna Institute of Medical Sciences University 144ÓCASE REPORTAbstract:Liver abscess, due to amebic or pyogenic etiology, is a relatively common cause of right upper quadrant pain in the tropical countries. Imaging techniques, serological tests, image guided interventional procedures and appropriate therapeutic regimens have significantly reduced mortality; yet the disease is associated with many complications and can be fatal if untreated. Here we describe hepatic vein and Inferior Vena Cava (IVC) thrombosis which is one of the rarer complications of liver abscess.Keywords: Liver, Abscess, Thrombosis, ComplicationsIntroduction:Amebic liver abscess, a relatively common cause of right upper quadrant pain in the tropical countries, can be easily diagnosed on ultrasound if the clinical and imaging features are characteristic at the time of presentation. However the abscess may be complicated and can become fatal if untreated. Complications include rupture of liver abscess may into adjacent pleural, pericardial, peritoneal cavities and rarely into gastrointestinal tract [1]. Vascular involvement in the form of portal vein, hepatic vein and Inferior Vena Cava (IVC) thrombosis is also known to occur rarely [2].Case Report:A 51-year-old male presented with right upper quadrant pain and fever for 3 days. Ultrasound revealed a large hypoechoic lesion in the right lobe of liver. He had leukocytosis (21000 cells / cu.mm) and altered liver function tests (total bilirubin of 5.4 mg/dl, direct and indirect bilirubin 2.7 mg/dl, SGOT 122 U/l, SGPT 112 U/l and 240 Hepatic Vein and IVC Thrombosis in Liver AbscessVenkatraman IndiranDepartment of Radiodiagnosis, Sree Balaji Medical College and Hospital, Chromepet, Chennai -600044 (Tamil Nadu) IndiaISSN 2231-4261JKIMSU, Vol. 6, No. 3, July-September 2017 M IU /ml). Multiphasic Contrast Enhanced Multi-Phasic Computed Tomography (CECT) abdomen showed a large hypodense peripherally enhancing lesion with lobulated margins measuring ~ 8 x 7 cm in the right lobe of liver. Middle hepatic vein adjacent to the medial aspect of the lesion showed hypodense content with extension into the IVC, consistent with thrombosis (Fig. 1-3). Liver abscess with middle hepatic vein and IVC thrombosis were considered. Serology for Entamoeba histolytica was positive. About 150 ml of pus was aspirated percutaneously under ultrasound guidance. Patient was treated with Injection Metronidazole 500 mg thrice and Injection Ceftriaxone 2 g daily intravenously for 1 week. Anti coagulant therapy wasn't instituted. Patient was clinically better at the end of 1 week and followup ultrasound showed reduction in abscess size and resolution of thrombosisDiscussion:Though amoebic and pyogenic liver abscesses are commonly encountered in India, hepatic vein and IVC thrombosis secondary to liver abscess is quite rare [2]. As hepatic vein and IVC thrombosis are life threatening, it requires high clinical suspicion followed by CECT in appropriate clinical setting. Rupture of the abscess into a vascular hepatic vein / IVC, predispose to localized luminal thrombosis which may act as source of pulmonary emboli and septicemia [3, 4]. Vascular complications in hepatic abscess should be considered in patients with fever, tender liver or signs of portal  Journal of Krishna Institute of Medical Sciences University 145Óhypertension, more so in patients with diabetes. CECT is an excellent method for diagnosing hepatic abscess as well as its complications. Syed et al. in their study in 2005 identified venous thrombosis was seen in 28/67 patients (42%), involving portal vein in 16/67 (24%) and hepatic vein in 15/67 (22%); 3/67 (4%) had both portal and hepatic vein thrombosis. Thrombosis is seen as non-enhancing linear structures with or without luminal expansion [5]. Maffiolo et al. reported a case of thrombophlebitis of the hepatic veins as a complication of a Klebsiella liver abscess [6]. Wi et al. in their study of 602 cases of pyogenic liver abscesses found that the rate of complication was higher in the older age group (> 65 years) [7]. Inferior vena cava and right atrial thrombosis as a complication of pyogenic liver abscess has also been reported [8, 9].Liver abscess caused by hypermucoviscous strains of Klebsiella pneumoniae is associated with thrombophlebitis of portal and hepatic veins. A retrospective study of 169 subjects with Klebsiella liver abscess to assess its natural history and role of anticoagulation found incidence of Venkatraman IndiranJKIMSU, Vol. 6, No. 3, July-September 2017 Fig. 1: Axial CECT Abdomen Images showed a Large Hypodense Peripherally Enhancing Lesion with Lobulated Margins in the Right Lobe of Liver. Middle Hepatic Vein Adjacent to the Medial Aspect of the Lesion Showed Hypodense Content (White Arrow) with Extension into the IVC (Black Arrow), Consistent with Thrombosis Journal of Krishna Institute of Medical Sciences University 146ÓVenkatraman IndiranJKIMSU, Vol. 6, No. 3, July-September 2017 Fig. 2: Coronal CECT Abdomen Images showed a Large Hypodense Peripherally Enhancing Lesion with Lobulated Margins in the Right Lobe of Liver. Middle Hepatic Vein Adjacent to the Medial Aspect of the Lesion Showed Hypodense Content (White Arrow) with Extension into the IVC (Black Arrow), Consistent with ThrombosisFig. 3: Sagittal CECT Abdomen Images showed a Large Hypodense Peripherally Enhancing Lesion with Lobulated Margins in the Right Lobe of Liver. Middle Hepatic Vein Adjacent to the Medial Aspect of the Lesion showed Hypodense Content (White Arrow) with Extension into the IVC (Black Arrow), Consistent with Thrombosis Journal of Krishna Institute of Medical Sciences University 147Óthrombophlebitis to be 31.4%. Though only one patient received therapeutic anticoagulation, almost 73 % of those showed abscess resolution, improvement or recanalization of vessels [10].Sonography may also be helpful in detection and characterization of venous extension, especially for follow-up. Echocardiography is useful in assessment in cases of intracardiac extension. Treatment includes conservative management with antibiotics, single time aspiration and catheter drainage of liver abscesses [2]. Therapeutic anticoagulation is not very essential as abscess resolution improves recanalization of thrombosed vessels. When transluminal interventional treatment such as filter insertion or venoplasty is considered, venography is important. Conclusion:Whenever a liver abscess is seen adjacent to a vascular channel or in the caudate lobe, it is imperative for the radiologist to look for vascular complications, as venous involvement may not be very symptomatic in some cases. Treatment of the abscess improves the recanalization of thrombosed vessels even without anticoagulation.Venkatraman IndiranJKIMSU, Vol. 6, No. 3, July-September 2017 References1. Lee KW, Kim HY, Kim CW, Kim YK, Kwon O, Kim MA et al. Hepatogastric fistula as a rare complication of pyogenic liver abscess. Clin Mol Hepatol 2017; 23(1): 87-90.2. Lal H, Thakral A, Sharma ML, Kumar T. Liver abscesses with venous extension- rare complication of a common problem. Turk J Gastroenterol 2014; 25 (Suppl 1): 223-8.3. Sarda AK, Mittal R, Basra BK, Mishra A, Talwar N. Three cases of amoebic liver abscess causing inferior vena cava obstruction, with a review of the literature. Korean J Hepatol 2011; 17(1): 71-5.4. Sodhi KS, Ojili V, Sakhuja V, Khandelwal N. Hepatic and inferior vena caval thrombosis: vascular complication of amebic liver abscess. J Emerg Med 2008; 34(2):155-157. 5. Syed MA, Kim TK, Jang HJ. Portal and hepatic vein thrombosis in liver abscess: CT findings. Eur J Radiol 2007; 61(3): 513-9.*Author for Correspondence: Dr. Venkatraman Indiran, Department of Radiodiagnosis, Sree Balaji Medical College and Hospital, 7 Works Road, Chromepet, Chennai-600044, Tamil Nadu Email: ivraman31@gmail.com Cell: 094430673586. Maffiolo C, Novellas S, Chevallier P, Brunner P, Mourou MY, Bruneton JN. Thrombophlebitis of the hepatic veins: complication of a Klebsiella liver abscess. Clin Imaging 2006; 30(1): 63-5. 7. Wi JW, Cho EA, Jun CH, et al. Clinical characteristics and outcomes of pyogenic liver abscess in elderly Korean patients. Korean J Gastroenterol 2015; 66(1): 27-32.8. Bagri N, Yadav D, Hemal A. Inferior vena caval and right atrial thrombosis: complicating pyogenic liver abscess. Indian Pediatr 2013; 50(7): 701-3.9. Nayak HK, Kumar K, Saraswat VA, Pandey G, Mohindra S, Singh A. An unusual complication of pyogenic liver abscess. J Clin Exp Hepatol 2016; 6(4): 337-38.10. Molton JS, Chee YL, Hennedige TP, Venkatesh SK, Archuleta S (2015) Impact of Regional Vein Thrombosis in Patients with Klebsiella pneumoniae Liver Abscess. PLoS One 10(10): e0140129.

Hepatic Vein and IVC Thrombosis in Liver Abscess

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Hepatic Vein and IVC Thrombosis in Liver Abscess

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