Clinical diagnosis
Case 27
He received tube drainage for liver abscess at the left lobe which was retained for 14 days. He was continued to be given antibiotics and drip infusion, inducing improvement liver function and returning his normal body temperature. The enterolith in periampullary diverticulum was taken out by endoscopic procedure.
【Discussion】
It is known that the common sites of gastrointestinal diverticula are colon and duodenum. Of the duodenum diverticula, periampulalary duodenal diverticulum is the most common with the incidence of 70-75% (1). Although periampullary diverticulum rarely causes complications, Lemmel syndrome initially documented a case of obstructive icterus caused by compression of periampullary duodenal diveticulum in 1934 (2). At present, Lemmel syndrome is termed as a generic name when periampullary diverticulum by itself or with food impaction compresses bile duct and/or pancreatic duct, or when ampullary dysfunction is caused by periampullary diverticulitis. Kang et al. reported a case that impacted stone (enterolith) at the orifice of the periampullary diverticulum caused dilatation of the diverticulum and icterus (3). In our case, enterolith in the periampullary diverticulum was also found in MRI (Fig. 8B). It might trigger to compress the common biliary duct.
The compression of biliary tract induces cholangitis whose symptom is known as Charcot’s triad (4): abdominal pain, icterus and fever. Cholangitis can be life-threatening, and is regarded as a medical emergency. Namely, cholangitis develops septicemia and sepsis. Reynolds' pentad includes the findings of Charcot's triad with the presence of septic shock and mental confusion (5). Further, cholangitis can be associated with pyogenic liver abscess formation. Although septic shock was not extended in our case, the symptoms of Charcot’s triad were found and CT and MRI showed multiple foci of abscess in the liver.
The most common organism of cholangitis is reported to be Escherichia coli followed by Klebsiella, Enterococcus, and Pseudomonas (6). The identification of the organism in blood culture is crucial for choice of appropriate antibiotics. In our case, tube drainage for the largest liver abscess was initially conducted accompanied with using antibiotics, leading to prevent septic shock and recovering his health.
Our patient had renal dysfunction. Then, contrast-enhanced CT or MRI was not conducted. It is sometimes difficult to differentiate liver abscess from liver cyst on non-enhanced CT. Diffusion weighted image was useful to distinct between them. Apparent diffusion coefficient (ADC) values of liver, liver abscess, metastatic liver tumor and liver cyst are reported to be 1.67 × 10−3 mm2/s, 1.47 ×10−3 mm2/s, 0.68 ×10−3 mm2/s and 2.9–3 × 10−3 mm2/sec, respectively (7, 8). Therefore, in our case, diffusion weighted image (DWI b=1000) showed high signal intensity corresponded to liver abscess with no detection of liver cyst.
【Summary】
We present a case called Lemmel syndrome of cholangitis and liver abscess caused by duodenal priampullary diveticulum dilatation probably due to enterolith at the orifice of the diverticulum. The symptoms of Charcot’s triad: abdominal pain, icterus and fever were initially found. Because of renal dysfunction, enhanced CT and MRI were avoided, diffusion weighted imaging was useful to distinct liver abscess from liver cysts. Speedy abscess drainage and antibiotics prevented the process of septic shock in our case.
【References】
1.Lobo DN, Balfour TW, Iftikhar SY, Rowlands BJ. Periampullary diverticula and pancreaticobiliary disease. Br J Surg. 1999;86:588–597. [PubMed]
2.Lemmel G. Die Klinische Bedeutung der Duodenal Divertikel. Arch Verdauungskrht. 1934;46:59–70.
3.Kang HS, et al. Lemmel's Syndrome, an Unusual Cause of Abdominal Pain and Jaundice by Impacted Intradiverticular Enterolith: Case Report
4.Charcot JM (2004) [1877]. Leçons sur les maladies du foie, des voies biliaires et des reins faites à la Faculté de médecine de Paris: Recueillies et publiées par Bourneville et Sevestre. Paris: Bureaux du Progrés Médical & Adrien Delahaye. ISBN 1-4212-1387-7.
5.Reynolds BM, Dargan EL (August 1959). "Acute obstructive cholangitis; a distinct clinical syndrome". Ann Surg.150 : 299–303.
6.Yamada T, et al. Ascending cholangitis as a cause of pyogenic liver abscesses complicated by a gastric submucosal abscess and fistula. J Clin Gastroenterol. 2000 ;30:317-320.
7.Taouli B, et al. Diffusion-weighted MR Imaging of the Liver Radiology 2010; 254: 47-66.
8.Park HJ et al. Differentiating hepatic abscess from malignant mimickers: value of diffusion-weighted imaging with an emphasis on the periphery of the lesion. J Magn Reson Imaging. 2013;38:1333-1341. doi: 10.1002/jmri.24112. Epub 2013 Apr 4.
2016.10.12
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