Acute liver abscess after non-operative management of blunt liver injury: A rare case managed with laparoscopic drainage

Highlights • Non-operative management (NOM) has today become the first treatment of choice when possible in patients with blunt liver injury.• Liver abscess as a complication after NOM of blunt liver injury is a rare entity, with an incidence rate of 1.5%.• The most common bacteria responsible for liver abscess include Klebsiella pneumoniae, Staphylococcus aureus, Streptococcus pyogenes, gram-positive cocci, Clostridium, and mixed organisms.• Laparoscopic drainage can be performed safely and effectively for the liver abscess.


Introduction
Non-operative management (NOM) has today become the first treatment of choice when possible in patients with blunt liver injury. Complications of NOM of blunt liver injury are rare, but may include biloma, hepatic artery pseudoaneurysm, liver necrosis, liver abscess, and delayed hemorrhage [1][2][3]. Liver abscess is a rare complication after NOM and management of this complication with laparoscopic approach is seldom reported. We report a case that developed liver abscess acutely after NOM of blunt liver injury and was managed successfully with laparoscopic drainage. The work has been reported in line with the SCARE guidelines [4].

Case presentation
A 36-year-old man, who was a chronic hepatitis C carrier presented at a local hospital after a motorcycle accident on November * Corresponding author.
E-mail address: linbc@cgmh.org.tw (B.-C. Lin). 28, 2017. First, resuscitation was performed and abdominal computed tomography (CT) revealed a liver injury. Then, he was transferred to our emergency department (ED) after resuscitation. At the ED, he presented a full Glasgow coma scale and his blood pressure was 118/82 mmHg, respiratory rate was 20 breaths/min, and pulse rate was 65 beats/min. Right upper abdominal tenderness was noted on physical examination, and blood tests revealed a white blood cell count of 9200/mm 3 , hemoglobin level of 13.4 gm%, serum aspartate aminotransferase level of 1165 U/L, and serum alanine aminotransferase level of 1173 U/L. On reviewing the abdomen computed tomography (CT) scan, a grade III liver injury was observed, in accordance with the American Association for the Surgery of Trauma-Organ Injury Scale for liver injury (Table 1) [5]. The segment 7/8 of the liver showed a large intraparenchymal hematoma, and there was no hemoperitoneum or contrast extravasation (Fig. 1). Thus, he was admitted to the intensive care unit (ICU) for NOM of the blunt liver injury. In the ICU, intermittent high fever up to 38.7 • C was observed, which lasted for three days, and chest radiography revealed right pleural effusion and some entrapped air over the right subphrenic space (Fig. 2). Then, repeat abdominal CT on the same day revealed a large abscess   with rupture at the previously injured liver parenchyma with air and fluid accumulation around the perihepatic space (Fig. 3). Then, laparoscopic drainage of the ruptured liver abscess was performed immediately. During the surgery, the surgeon and the camera operator stood on the patient's left side, with an assistant on the other side. Carbon dioxide pneumoperitoneum (12 mmHg) was established through an umbilical incision using Hasson technique, and a zero-degree-angled laparoscopy was introduced through an 11mm port. Then, a 5 mm port for liver access was placed at the left lateral abdomen, and a third 5 mm port was placed at the right lateral abdomen to elevate the liver. By laparoscopy, the turbid bloody fluid and necrotic tissue around the injured liver could be drained well (Fig. 4). Approximately 250 mL of infective bloody fluid was drained and sent for culture. Finally, a chest tube was placed for drainage via the right-side port wound. After laparoscopic drainage, fever subsided and the abscess culture revealed the presence of Salmonella enterica, serogroup D. According to the sensitivity test, ertapenem (Merck Sharp & Dohme, France) 1 g QD intravenously was given for 11 days. He recovered well and was discharged on December 15, 2017. Follow-up abdominal CT performed 4 months later showed a well-healed liver injury and no residual abscess (Fig. 5).

Discussion
Since few decades, non-operative management of blunt liver injuries has been a mainstream for patients who are hemodynamically stable, and the success rates for non-operative management are usually greater than 85% [1][2][3]6]. Several contributing factors have been recognized: (1) Realization that more than 50% of liver injuries stop bleeding spontaneously, (2) the precedent successful non-operative management in pediatric patients, (3) knowledge that the liver has tremendous capacity to heal after injury, (4) improvements in liver imaging with CT, and (5) use of adjunctive transarterial embolization (TAE) [7]. Many patients who undergo NOM after liver injury, especially high-grade blunt liver injury [8], have liver-related complications, including bile leaks, hemobilia, liver necrosis, liver abscess, and delayed hemorrhage [1][2][3]. According to previous data based on the same institution, liver abscess as a complication after NOM of blunt liver injury is a rare  entity, with an incidence rate of 1.5% [9]. It is usually seen in major liver injuries (grade III and above) and the abscesses take a median of 6 days (range, 1-12 days) to form and be diagnosed [9]. The most common bacteria responsible for liver abscess include Klebsiella pneumoniae, Staphylococcus aureus, Streptococcus pyogenes, gram-positive cocci, Clostridium, and mixed organisms. In the presented case, the patient developed liver abscess within 72 h of NOM, which is rare. The culture of the body fluid revealed S. enterica serogroup D, which is usually found in specific poultry [10]. The management of liver abscess may be by surgical drainage (laparotomy or laparoscopy) or percutaneous drainage. Percutaneous CT-guided drainage is regarded as first-line management in many cases, and may play a role in controlling the infection. Although laparotomy remains an option, lavage and drainage can be safely and effectively performed by laparoscopy [11,12]. Laparoscopic washout of infective blood or bile leak is gaining traction as an adjunctive therapy to non-operative management of liver trauma. Because liver abscess in this patient had already ruptured into the peritoneal cavity, surgical drainage was chosen. In this patient, we chose laparoscopy to manage the liver abscess rather than laparotomy with the expectation of benefit from a shorter hospital stay, lesser postoperative pain, and quicker recovery.

Conclusion
Acute onset of liver abscess after NOM of a blunt liver injury is rather rare, and laparoscopic drainage can be performed safely and effectively for the liver abscess. Patients may thus benefit from the lesser postoperative pain and quicker recovery.

Declaration of Competing Interest
Drs Lin BC, Lin MY, and Liao CY have no conflicts of interest or financial ties to declare.

Funding
There are no sources of funding for this case report.

Ethical approval
This study was approved by our institutional review board (IRB No.: 201801246B0).

Consent
Informed consent was obtained by the patient for the publication of this case report and images.

Author contribution
Lin MY and Liao CY analyzed the patient data and wrote the first draft of this manuscript. Lin BC contributed to the final approval of the version to be published. All authors read and approved the final manuscript.

Registration of research studies
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Provenance and peer review
Not commissioned, externally peer-reviewed.