St. Joseph's Regional Medical Center Paterson, NJ, United States
Ariana R. Tagliaferri, MD, BS1, Heemani Ruparel, BS1, Gabriel Melki, MD, BS1, Walid Baddoura, MD2 1St. Joseph's Regional Medical Center, Paterson, NJ; 2St. Joseph's University Medical Center, Paterson, NJ
Introduction: We present a patient who presented with abdominal pain and fevers, and was found to have a pyogenic liver abscess biopsy proven to be secondary to Crohn's Disease (CD). This paper will discuss manifestations of CD, this unique presentation and propose a unique mechanism in which the patient may have developed this liver abscess despite having adequate control over his IBD.
Case Description/Methods: A 45 yo M with CD ileocolitis presented with abdominal pain, fevers and peri-anal fistula. He was compliant with Remicade and 6- MP. His exam was remarkable for fevers, hypotension, moderate tenderness in the RUQ. The ileostomy bag contained brown stool and there were multiple anal fistulas draining serofibrinous fluid. Labs were significant for leukocytosis, normocytic anemia, electrolyte abnormalities, and AKI. A UA was positive, with cultures growing E.Coli. Initial CT scan and MRCP demonstrated multiple liver lesions highly suspicious of liver abscess versus metastasis. He was admitted for sepsis, started on antibiotics however did not improve. He underwent a CT-guided aspiration. He was subsequently discharge, however, returned one week later with recurrent fevers and required repeat drainage. Pathology and histological findings from biopsy were consistent with CD. The patient improved and was discharged.
Discussion: The first description of a CD liver abscess was in 1946; since only 18 other cases have been reported. Studies assessing IBD patients with pyogenic abscess have demonstrated fever as the most common presenting complaint, but only 50% present with abdominal pain. Patients with CD pyogenic abscess present at a younger age and have multiple abscesses rather than solitary lesions. These patterns are consistent with our patient’s presentation. CD patients typically do not respond to medical management alone, which was also true for our patient who required repeat drainage. It is likely that given his presenting symptoms he may have had an underlying intraabdominal infection predisposing him to liver abscess formations. It is common for clinicians to mistake the diagnosis of febrile illness with or without abdominal pain as a simple reactivation of CD. It is possible that liver abscess may be underdiagnosed. Our case is also unique because he had no prior history of extra-intestinal manifestations apart from perianal disease, and his IBD was well controlled. Thus, it is imperative for clinicians to consider hepatic pyogenic abscess when CD patients present with non-specific complaints.
Figure: Figure 1: Computerized Tomography of the Abdomen and Pelvis with Intravenous Contrast. There are 2 ill-defined hypodense lesions in the right lobe of the liver measuring 6.3 x 4.4 and 5.2 by 4.7 cm and left lobe 5 x 3 cm. These are grossly stable in comparison to the earlier exam. The lesions are predominantly hypodense compared to the liver parenchyma on arterial phase and venous phase with nonenhancing central hypodensities. This may represent scar or necrosis. The lesions are predominantly isodense on delayed phase imaging. There are few nonenhancing subcentimeter hypodense lesions in the liver that are too small to characterize and may represent cysts.There is mild mesenteric congestion. Normal size mesenteric lymph nodes are evident.
Disclosures: Ariana Tagliaferri indicated no relevant financial relationships. Heemani Ruparel indicated no relevant financial relationships. Gabriel Melki indicated no relevant financial relationships. Walid Baddoura indicated no relevant financial relationships.
Ariana R. Tagliaferri, MD, BS1, Heemani Ruparel, BS1, Gabriel Melki, MD, BS1, Walid Baddoura, MD2. P2710 - A Rare Case Report of a Liver Abscess Secondary to Crohn’s Disease, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.