Gas-containing Liver Abscess after Transhepatic Percutaneous Cholecystostomy

Editor: Emergency cholecystectomy in critically ill patients with co-morbid factors is associated with increased mortality and poor treatment outcome. Transhepatic percutaneous cholecystostomy (PC) is a relatively safe and effective temporizing procedure in patients with cholecystitis who are at high risk for surgery and anesthesia (1–3). Herein, we describe a patient who developed a gas-containing abscess within 24 hours of PC. A 46-year-old woman had a history of perforated duodenal ulcer and had undergone subtotal gastrectomy with BII reconstruction 3 months earlier. At this time, she complained of persistent epigastric pain and was admitted for further evaluation. There was no nausea or vomiting. Abdominal computed tomography (CT) was performed with an eight-section scanner (LightSpeed Plus; GE Medical Systems, Milwaukee, WI) and revealed dilated bowel loops and a distended gallbladder with a thickened wall. Under CT guidance, PC was performed with 8-F pigtail catheter for the treatment of acute cholecystitis. The patient tolerated the procedure well. On the 2nd day, the patient developed a high fever and severe right upper quadrant abdominal pain; her abdomen became distended and physical examination revealed induration of the right upper abdominal wall with crepitus. A second abdominal CT scan showed a gascontaining liver abscess around the pigtail collection, and this was associated with extensive subcutaneous emphysema (Figure). Emergent surgical debridement was performed, and necrotizing fasciitis of the right upper abdominal wall was noted. During laparotomy, the surgeon noted that the pigtail catheter was surrounded by necrotic tissues of the right hepatic lobe and covered by a purulent exudate. At gross examination, the gallbladder was intact except for the wound created by PC. After surgical debridement, the patient was treated with Cefmetazole and gentamicin for empiric treatment; therapy was performed at the intensive care unit. Despite this therapy, the patient died of severe sepsis 7 days after the liver abscess was diagnosed. Clostridium perfringens liver abscess was subsequently confirmed by means of blood and wound cultures. The fulminant, rapid, and progressing nature of the Clostridium infection in this patient might be explained by the fact that the partially injured liver parenchyma after PC is an anaerobic environment for the growth of clostridia and a way to leave the gallbladder. A variety of virulent toxins produced by clostridia are able to induce the production of potent endogenous mediators, causing profound systemic inflammatory responses (4,5). Although C perfringens has been cultured in bile, it was isolated in only one individual in 79 patients with pyogenic