LIVER ABSCESS WITH HEPATO PLEURAL FISTULA

A 30 years old male with liver abscess [ on medical treatment] , developed  right side chest pain with cough ,& was asked for  ultrasound examination.

By-

Dr.Subhash Tailor, MD

Bhilwara [Rajasthan]

Ultrasound showed right lobe liver abscess [ See figure - 1 ] measuring about 55 x 47

x 59 mm = 81 c.c. size & volume  with thick internal echos . Mild right pleural effusion & thickening was also noted . The outline of dome was subtle irregular & obliterated .

Pt. was then asked to perform a cough maneuver during scan , & there was a rapid gush of air echos noted from pleural cavity to liver abscess through dome defect , suggestive of Hepato - pleuro fistula . It was because of rupture of liver abscess into pleural cavity . See video clip .

There was some bright echos noted persistent in liver abscess in  the subsequent scans

[ See figure – 2 A & B]  .

Figure 1 – Shows well defined right lobe liver abscess .

Figure 2[A , B ] – Shows right lobe liver abscess with gush of  air echos from pleural cavity to liver abscess ( seen  during & subsequently after cough reflux ) .

Video – Shows rapid gush of air from pleural cavity to right lobe liver abscess on cough .

POINT TO HIGHLIGHT

-In case of right lobe liver abscess near dome ,with pleural effusion & thickening ,one must see for hepato-pleural fistula  by performing cough reflex ,& to observe  for any air gush through dome defect in real time .
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Response to this article:

Dear Editor

Dear All,

Re: Liver abscess with Hepato-pleural fistula

Allow me to make few comments regarding this case.

A fistula between the liver and pleura means there must be a communication between the liver and pleural cavity;

AIR IS NOT A PRIMARY PART OF IT, NOR IS IT ESSENTIAL FOR A H/P FISTULA TO OCCUR (unless lung is involved too).

The air was shown on video recording to be gushing from the pleural side into the abscess cavity.

This should mean a fistula which is actually pleuro-hepatic according to the direction of air-shift.

But the presenting radiologist is talking about a hepato-pleural fistula in which the air flow is pleuro-hepatic.

A hepato-pleural fistula (with air-leakage) could mean:

- Air is formed under the diaphragm (one cause may be gas-forming organisms)

- Air is expected to flow from the liver toward the pleural cavity.

- We do not even know whether there is air in the pleural spaces.

If the air flows from the pleural cavity to the liver lesion in a pleuro-hepatic fistula WE NEED A SOURCE OF AIR. What is it??

Whether it is hepato-pleural and pleuro-hepatic fistula there is breakdown of the diaphragm/pleura barrier.

(of course the peritoneal cavity may also be involved if the lesion breaks through the zones outside the bare area not covered by peritoneal reflection)

The presence of pleural fluid and adhesions should indicate involvement of the pleura but not necessarily a breakdown or actual tissue defect.

So if we rule out gas-forming infection where would the air come from?

Maybe the air-gush is initiated by a vacuum phenomenon induced by cough…or rapid movement and change of pressure-gradients.

That leads me to wonder why one would have asked the patient to cough as we, under normal working conditions, do not do this maneuver. Do we?

So I guess that the radiologist either saw the air-drifting echoes during forceful breathing or abrupt motion of diaphragm ( ? phrenic irritation ) or simply cough.

The “air “ ( or nitrogen ) is being sucked into the liver lesion just like in any other situation where a vacuum is created.

( E.g.: Caisson disease in divers, or gas seen within abducted child shoulders- on a chest x-ray or in the knees on frog-leg or von-Rosen views) ..etc.

Admittedly it is an interesting finding in this case but it sounds more like a chance observation rather than a deliberate or purposeful US technique…

but still technically smart enough for an applause.

I wish I was there with the radiologist and could have seen the patient’s records and images including chest films, abdominal films, if any etc

With best compliments

Dr. A. M. Al Tamimi

Consultant Radiologist,

MBCHB, DMRD, FRCR- UK

Canadian Specialist Hospital

Dubai

UAE