2. Presentation
• 53 Y Caucasian male presented for elective
LAR
• DOA- 12/23/07
• Background- H/O IBS, depression, anxiety, N&V
since 2 years, diagnosed as having
Diverticulosis, recurrent N&V- decreased GB
EF- Pancreatitis- ERCP- Sphincterotomy-
Cholecystectomy
• Persistent recurrent N&V, many ER visits, coffee
ground emesis, no malena or BRBPR
• Endoscopies- EGD/Colonoscopy-negative
except Diverticulosis of Sigmoid, CT Scan
Abd/Head- negative
3. History
• Diagnosis- Cyclic Vomiting
Syndrome- specific therapies
not available
• May 2007- Diagnosed to have
Mallory Weiss tear due to his
vomiting about 20 times
• Oct 19th
2007- Diffuse Myalgia,
Backache, fever 101.2 with
Vomiting. ER- increased WCC
20, no abdominal pain,
hematuria or dysuria, no rigors
• CT Scan- Oct 20th
2007-
• Irrgular low-desity mass
6.2x5.1-not a simple cyst-
necrotic mass, Diverticulitis
7. 10/23/0710/23/07
Oct 22nd 2007- CT guided Drainage- 20ml purulent fluid
aspirated , 8FR pigtail catheter left in situ
•ID on board- Zosyn & Flagyl started
• Post procedure CT- abscess reduced to 3.2cms
Diverticulitis improved
8. History
• Abscess- GPC and GPB, Streptococci, Blood
Cx- no growth
• D/C on Home ABX, liver drain came out
eventually
• f/u 11/21/07- planned for Interval Colonoscopy
• Colonoscopy- Dec 13th
2008-
• Inflammation in Sigmoid Colon- resolving
Diverticulitis, no diverticula noted
• Normal Colonoscopy otherwise
• Elective Admission- 23rd
2007
9. H & P
• VITAL SIGNS: 114/72 mmHg, 97 F,
RR 20, PR 53, 100% Sao2
• The patient in no acute distress
• HEENT: EOMI, PERLA
• CHEST: CTA
• CVS- RRR
• P/A- Soft NT/ND
• Rest of the exam- normal
11. Surgery
• 24th
Dec 2008-
• Laparoscopic LAR, Hand Assisted
• Pathology- Colon Recto sigmoid resection
• -Diverticulosis and Diverticulitis, Severe
• -Peri-intestinal lymph node with reactive
hyperplasia
• -Remaining colonic mucosa with no
pathological change
12. Hospital Course
• Initial Leucocytosis which settled, Uneventful
otherwise
• Discharged on POD # 6 31st
Dec 2007
• CT Scan Abdomen- 31st
Dec 2007
14. Literature
Med Arh. 2007 ;61 (2):117-8 17629149 [Management of liver
abscess formed after asymptomatic sigmoid diverticulitis]
Predrag Jovanović , Enver Zerem , Muharem Zildzić
Liver Abscess Secondary to Sigmoid Diverticulitis A
Case Report- 2005
Department of Colon-Rectal Surgery
Department of Medicine, Kaohsiung Armed Forces General Hospital,
Kaohsiung, Taiwan, R.O.C
Pyogenic liver abscess secondary to asymptomatic sigmoid diverticulitis.
M K Wallack, A S Brown, R Austrian, and W T Fitts
Dept of Surgery , University of Pennsylvania, Philadelphia- 1976
15. Summary
Pyogenic Liver Abscess- RUQ pain (50%), Fever,
leucocytosis, Increased ALP and Bilirubin if biliary tract is
involved
Most common cause- Biliary tract Disease-30%,
Pyelephlebitis (from portal vein), Hematogenous spread,
Direct extension of intra abdominal infection
Polymicrobial
PCD/PNA & IV Abx has completely replaced Surgery but
Surgery is an important consideration for those who fail
PCD/PNA
Intestinal Evaluation to search for cause
