A 21-year old male presented with upper abdominal pain for 15 days accompanied by a gradually increasing abdominal girth and swelling of the feet with low grade fever for one week. On examination, he was normo-tensive and showed pitting pedal edema. There was a tender hepatomegaly extending three fingers below the costal margin in the mid-clavicular line. Shifting dullness was positive. Hematological investigations revealed Hb level of 9 g/dL and WBC of 7,500/mm3. The biochemical investigations showed a raised BUN of 65 mg/dL and serum creatinine of 1.5 mg/dL. Urine analysis revealed slight proteinuria. Liver functions tests showed a total bilirubin of 0.6 mg/dL, serum ALP of 247 IU/L, AST 40 IU/L and ALT 80 IU/L. Ultrasonography of the abdomen showed an abscess in the right lobe of liver on its postero-superior surface measuring 1.4×1×1 cm with internal echoes and moderate ascites. Color doppler scan was done which showed patent hepatic veins with normal hepatofugal flow. Hepatic IVC was seen displaced and compressed by the large abscess cavity but the flow was normal. Infra-hepatic IVC was dilated to 1.7 cm. The Doppler findings were suggestive of IVC obstruction due to the liver abscess with proximal dilatation. A contrast enhanced CT scan confirmed the findings of thrombus in the IVC (). The patient tested positive for amoebic antibody by indirect haemagglutination test. The patient was started on intravenous metronidazole and broad spectrum antibiotics. The liver abscess was aspirated twice under ultrasonic guidance within a period of two days yielding 500 mL and 360 mL of pus. The pus was thick, creamy and brownish in color and did not grow any organisms on culture. The ascites and pedal edema disappeared rapidly after the treatment. Doppler scan repeated four days later showed a decrease in the infra-hepatic IVC dilatation. Hepatic portion of the IVC was normal in caliber and fully patent in subsequent color doppler examination performed twelve days after the aspiration of pus. The biochemical renal parameters improved and two weeks after aspiration of the liver abscess, the BUN was 32 mg/dL and serum creatinine was 1.1 mg/dL. Patient was followed up for three months, and repeat ultrasonography done was essentially normal.
A 24-year old man presented with pain in right upper abdomen with fever for five days. Physical examination revealed high grade fever and tachycardia. There was tenderness and guarding in right hypochondrium. There was bilateral pedal edema. Hematological investigations revealed a hemoglobin (Hb) level of 11.2 g/dL and white blood cell (WBC) count of 18,400/mm3 (normal range, 4,000-11,000/mm3). The biochemical investigations showed a blood urea nitrogen (BUN) of 34 mg/dL (normal range, 15-40 mg/dL), serum creatinine of 1.1 mg/dL (normal range, <1 mg/dL). Liver functions tests showed a total bilirubin of 1.5 mg/dL (normal range, <1 mg/dL), serum alkaline phosphatase (ALP) of 178 IU/L (normal range, 40-280 IU/L), aspartate aminotransferase (AST) 32 IU/L (normal range, <40 IU/L), alanine aminotransferase (ALT) 48 IU/L (normal range, <40 IU/L). Chest X-ray was normal. Ultrasound at admission showed a large (8.6×7.3×6.2 cm), volume 202 mL, heterogeneously hypoechoic lesion with internal echoes in the caudate lobe suggestive of liver abscess. On ultrasonography, the abscess was compressing the intra-hepatic IVC with abnormal color fill (slowed down) and flow pattern. Magnetic resonance imaging (MRI) with magnetic resonance cholangiopancreatography (MRCP) was performed which confirmed 6.9×6 cm abscess in the caudate lobe causing eccentric compression over the intrahepatic part of IVC (, ). There was a mass effect with compression of the main portal vein and the common hepatic duct just after the ductal confluence, however, the right and left hepatic ducts and intra-hepatic biliary radicals were not dilated. The patient tested positive for amoebic antibody by enzyme-linked immunosorbent assay (ELISA) test. The patient was started on broad spectrum antibiotics and metronidazole for two weeks. After initiating the treatment, there was a gradual amelioration in the fever and abdominal pain. Repeat ultrasound by the end of first week revealed a gradual reduction in the size of the abscess to 50% of its original size and the compression on IVC was also relieved as confirmed by doppler scan. The patient was asymptomatic. Follow-up investigations showed WBC of 8,800/mm3, and liver functions tests showed a total bilirubin of 0.5 mg/dL, serum ALP of 145 IU/L, AST 40 IU/L, ALT 45 IU/L. Patient was followed up for three months and repeat ultrasound done at the end of three months showed no residual abscess and IVC was normal in caliber, color fill and flow pattern.