P-L09 Pyogenic Liver Abscess: a Retrospective Study of Patients Presenting to a UK Tertiary Liver Centre

Background Pyogenic liver abscess (PLA) carries a significant mortality of between 2-12%. The incidence is higher in East Asia than in Western countries, and recent data looking at PLA in western populations is limited. Increasingly, we find that PLA is primary in the liver rather than from a secondary source, even in the western world. The aim of this retrospective study is to analyse data on presentation and outcomes of PLA at a UK tertiary liver centre. Methods Data was collected on patients diagnosed with a PLA and treated at the University Hospital of Wales, Cardiff between December 2010 and December 2020. Patients were identified by searching the Cardiff Liver Unit surgical database and Radiology database using the search term “liver abscess”. Patients with an abscess secondary to gallbladder perforation into the liver were excluded. Data was gathered using the available electronic health records, including comorbidities, mode of presentation, cause of PLA, microbiology, treatment received (surgical, radiological drainage, or antibiotic therapy), and outcomes. Results There were 86 patients with a median age of 69 (16-91), Male:Female ratio was 2:1. Main symptoms were abdominal pain and fever; 61.6% (n = 53). Treatment was surgical in 49% (n = 42), US guided drainage in 21% (n = 18) and antibiotics only in 30% (n = 26). Mortality was 9.3% (n = 8), with a median age of 76, significantly higher than survivors (p = 0.012). In this group, Male:Female ratio was 7:1; proportion with >2 co-morbidities was 62%, compared with 39% of survivors; and there was a greater delay in diagnosis (average 4 days versus 2 days in survivors), although these factors were not statistically significant. Conclusions PLA is a serious infection that can lead to mortality. Forty percent of patients can present with non-specific symptoms and early imaging in this group is essential for diagnosis. In our cohort, significant number of patients were treated with surgery compared to the literature, with good outcomes. Although the numbers are small to be statistically significant, delayed diagnosis, multiple comorbidities, and male gender confer an increased risk of mortality, as does advanced age. We conclude that early diagnosis and referral to a Liver centre for opinion or management is essential for optimal outcomes.

P-BN30 Retroperitoneal biloma: a case report of spontaneous retroperitoneal bike leak and collection

Background Retroperitoneal biloma is a rare complication of gallstone disease. Only a handful of cases have been reported in the literature with various mechanisms postulated. Here, we report a case of spontaneous retroperitoneal biloma arising from gallbladder perforation. Methods An 87-year-old female patient presented with right upper quadrant pain in the context of known gallstone disease. Inflammatory markers and liver function tests were deranged. Cross sectional imaging found acute cholecystitis and a gallbadder neck perforation with an impacted 2cm proximal common bile duct (CBD) stone. A cholecystostomy was placed and she improved clinically. However, inflammatory markers remained high, and a subsequent computed tomography (CT) found a large collection in the retroperitoneum. Results The retroperitoneal collection measured 14cm x 7cm, and there had been evidence on prior CT scans of retroperitoneal inflammation. It was urgently drained under ultrasound guidance and found to contain bilious content. Subsequent endoscopic retrograde cholangiopancreatography (ERCP) was unable to retrieve the CBD stone, but left stents either side of the stone. The patient clinically and biochemically improved. She was discharged and had an elective ERCP, which successfully retrieved the stone, with a plan for urgent elective laparoscopic cholecystectomy. Conclusions Here, we report an interesting case of retroperitoneal biloma successfully managed with ultrasound-guided drainage. Perforation of the distal CBD can result in retroperitoneal bile leak, but the proximal CBD stone in this case would have likely prevented passage of bile. A more likely cause is adhesion of the gallbladder neck to the posterior parietal peritoneum due to chronic inflammation, with subsequent perforation and release of bile into the retroperitoneum. This has previously been described in the literature. Regardless of mechanism, knowledge of the potential for this rare complication is important for anticipating and appropriately managing complications of gallbladder perforation.

Gallbladder perforation with liver abscess; laparoscopic cholecystectomy converted to open: a case report

Gallbladder disease affects more than 20 million people in the United States. Acute cholecystitis is a clinic entity characterized by the inflammation of the vesicular wall that is usually manipulated by abdominal pain, right hypochondrial sensitivity and fever. The technique of choice for the diagnosis of cholecystitis is abdominal ultrasound; gallbladder perforation is a rare complication of acute cholecystitis (2%-11%). The presence of perivesicular abscesses is infrequent, its prevalence varies between 2.1% and 19.5%. Clinical record was reviewed of a 73 years old woman who attended a second level public care unit, with a clinical picture of acute chronic lithiasis cholecystitis, who underwent surgery consisting of open converted laparoscopic cholecystectomy with a finding of vesicular perforation with liver abscess, it was initiated with laparoscopic approach, it was not possible to identify anatomical structures, so it was decided to convert to open surgery. Cholecystectomy and abdominal lavage are usually sufficient in the treatment of gallbladder perforation.

Gallstone Ileus with Resolution of Bile Leak Post-Subtotal Cholecystectomy and Spontaneous Closure of Cholecystoduodenal Fistula: Case Report and Literature Review

Gallstone ileus (GSI) is a mechanical intraluminal bowel obstruction caused by biliary calculi through the biliary-enteric fistula. This is a rare sequela of cholelithiasis occurring in 0.3 – 1.5% of patients with worrying mortality of 11.7 – 20%. This is a case of GSI in a 67-year-old woman who presented with small bowel obstruction secondary to impaction of biliary calculi at terminal ileum with underlying cholecystoduodenal fistula (CDF). Enterolithotomy with stone extraction (ES) was performed, followed by subtotal reconstituting cholecystectomy due to iatrogenic gallbladder perforation. The diagnosis of GSI is ascertained by the presence of the Rigler’s triad on abdominal X-ray, while CDF was demonstrated by post-surgery CT images. Bile leak post-operation was managed conservatively based on the SNAP (Sepsis, Nutrition, Anatomy, Plan) approach, and spontaneous closure of CDF was observed. In a nutshell, GSI should always be kept in mind as a differential diagnosis of mechanical bowel obstruction, especially among elderly female patients. Radiological findings of Rigler’s triad aid clinical diagnosis of GSI. Despite its rare incidence, early diagnosis is crucial as it is readily treatable with surgery. ES alone is the gold standard in the management of GSI.