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Pyogenic liver abscess complicating colonoscopic polypectomy
Brief Reports 7. Quentin V, Lermite E, Lebigot J, et al. Small bowel cavernous hemangioma: wireless capsule endoscopy diagnosis of a surgical case. Gastrointest Endosc 2007;65:550-2. 8. Calvo AM, Erce R, Monton S, et al. Cavernous haemangioma of the small bowel: an uncommon cause of intestinal obstruction [Spanish]. An Sist Sanit Navar 2003;26:437-40. 9. Morgan DR, Mylankal K, el Barghouti N, et al. Small bowel haemangioma with local lymph node involvement presenting as intussusception. J Clin Pathol 2000;53:552-3. 10. Nahon S, Hoang JM, Tuszynski T, et al. Hemangioma of the small bowel manifesting as gastrointestinal bleeding, diagnosed by pushed enteroscopy [French]. Gastroenterol Clin Biol 1999;23:1406-7. 11. Ohmiya N, Taguchi A, Shirai K, et al. Endoscopic resection of Peutz-Jeghers polyps throughout the small intestine at doubleballoon enteroscopy without laparotomy. Gastrointest Endosc 2005; 61:140-7. 12. Yamamoto H, Kita H, Sunada K, et al. Clinical outcomes of double-balloon endoscopy for the diagnosis and treatment of small-intestinal diseases. Clin Gastroenterol Hepatol 2004;2:1010-6.
13. Hsu CM, Chiu CT, Su MY, et al. The outcome assessment of double-balloon enteroscopy for diagnosing and managing patients with obscure gastrointestinal bleeding. Dig Dis Sci 2007;52:162-6. 14. May A, Nachbar L, Pohl J, et al. Endoscopic interventions in the small bowel using double balloon enteroscopy: feasibility and limitations. Am J Gastroenterol 2007;102:527-35.
Received April 11, 2007. Accepted July 31, 2007. Current affiliations: Department of Gastroenterology, Fremantle Hospital, Fremantle, Western Australia, Australia. Reprint requests: Robert P. Willert, BSc, MBChB, MRCP, PhD, Department of Gastroenterology, Fremantle Hospital, Alma St, Fremantle 6059, WA, Australia. Copyright ª 2008 by the International Council for the Exploration of the Sea 0016-5107/$32.00 doi:10.1016/j.gie.2007.07.044
Pyogenic liver abscess complicating colonoscopic polypectomy Rebekah G. Gross, MD, Bruce Reiter, MD, Mark A. Korsten, MD New York, Bronx, New York
Since its introduction in 1969,1 flexible colonoscopy has been the criterion standard for diagnosis and treatment of colorectal pathology. However, there remain serious, albeit rare, risks of this invasive procedure, especially when polypectomy is performed. Postpolypectomy injury runs the gamut from serosal burns, producing localized abdominal tenderness, to perforation with resultant peritonitis. Falling along this spectrum, ‘‘microperforation’’ involves transmural injury, potentially with escape of bowel contents, followed by spontaneous sealing of the defect by adherent omentum.2 Although less dramatic than frank perforation, microperforation, nevertheless, may have significant sequelae. Here we describe an unusual case of hepatic abscess complicating colonoscopic polypectomy, most likely from microperforation during the procedure.
CTof the abdomen and pelvis was obtained, revealing an abscess measuring 8.1 cm in maximum dimension in the posterior segment of the right hepatic lobe (Fig. 1). Blood cultures grew Escherichia coli and alpha-hemolytic streptococci. The patient was treated with intravenous antibiotics and underwent CT-guided placement of a percutaneous drainage catheter. On resolution of fever and leukocytosis, the patient underwent a right hemicolectomy for resection of the adenocarcinoma.
DISCUSSION
A 68-year-old man with coronary artery disease, congestive heart failure, and diabetes mellitus presented with a 3-day history of fever to 39 C, abdominal cramps, nausea, vomiting, and nonbloody diarrhea. The patient had undergone screening colonoscopy 1 week previously, during which a 2 3-cm pedunculated polyp at the hepatic flexure was removed by using snare cautery, and the nearby wall was tattooed with SPOT (GI Supply Inc, Camp Hill, Penn). Pathologic evaluation revealed a moderately differentiated invasive adenocarcinoma arising in a tubulovillous adenoma.
The incidence of pyogenic liver abscess ranges from 8 to 20 cases per 100,000 hospital admissions.3 Approximately three fourths of cases involve the right hepatic lobe. Routes of invasion include the biliary tree, portal vein, hepatic artery, direct extension from a contiguous focus of infection, and penetrating trauma. When the bowel is the suspected source, spread can occur via hematogenous seeding or local invasion. In the former case, a single microorganism is typically isolated, whereas in the latter, mixed flora are found, including aerobic and anaerobic species.4 Given the brief time from colonoscopy to onset of symptoms, and the fact that polypectomy was performed at the hepatic flexure, we believe the patient’s abscess was caused by a complication of his procedure, most likely arising from microperforation during polypectomy, with direct extension from the bowel lumen to the liver. The colonic wall may have been particularly susceptible to microperforation
www.giejournal.org
Volume 67, No. 4 : 2008 GASTROINTESTINAL ENDOSCOPY 767
CASE REPORT
Brief Reports
DISCLOSURE The authors report that there are no disclosures relevant to this publication. REFERENCES
Figure 1. Large, heterogeneous lesion containing fluid and air is seen within the posterior segment of the right hepatic lobe. A transhepatic drainage catheter has been deployed percutaneously.
in this case because the resection site involved invasive adenocarcinoma arising in a tubulovillous adenoma. Presence of colonic tubulovillous adenoma is understood to be a risk factor for development of hepatic abscess, presumably by causing mucosal defects that allow spontaneous microperforation.5,6 A related mechanism likely explains the 61 cases of liver abscess linked to Crohn’s disease and ulcerative colitis in the literature.7-9 Here, inflammation alters the integrity of the bowel wall, creating risk for bacterial translocation. Theoretically, hematogenous spread from the tattoo site might be considered as an alternative etiology for the abscess formation. This has never before been reported with the use of SPOT. Although ours is the first reported case of hepatic abscess arising as a complication of polypectomy, the literature describes one case of retroperitoneal abscess after polypectomy in the rectum10 and one case of liver abscess after colonoscopic removal of an impacted fish bone.11 These cases, taken collectively, should raise our consciousness of the infectious potential of therapeutic colonoscopy while not diminishing our belief in its power as a mainstay of treatment for GI pathology.
768 GASTROINTESTINAL ENDOSCOPY Volume 67, No. 4 : 2008
1. Wolff WI, Shinya H. Colonofiberoscopy. JAMA 1971;217:1509-12. 2. Christie JP, Marrazzo J. ‘‘Mini-perforation’’ of the colondnot all postpolypectomy perforations require laparotomy. Dis Colon Rectum 1991;34:132-5. 3. Johannsen EC, Sifri CD, Madoff LC. Pyogenic liver abscesses. Infect Dis Clin North Am 2000;14:547-63. 4. Zaleznik D, Kasper D. Intra-abdominal infection and abscess. In: Fauci A, Braunwald E, Isselbacher E, et al, editors. Harrison’s principles of internal medicine14th ed.. New York: McGraw-Hill; 1998. p. 794-5. 5. Leiba A, Apter S, Avni I, et al. Pyogenic liver abscessdan unusual presentation of colonic villous adenoma. Harefuah 2003;142:336-7, 399. 6. Lai HC, Chan CY, Peng CY, et al. Pyogenic liver abscess associated with large colonic tubulovillous adenoma. World J Gastroenterol 2006;12:990-2. 7. Wells CD, Balan V, Smilack JD. Pyogenic liver abscess after colonoscopy in a patient with ulcerative colitis. Clin Gastroenterol Hepatol 2005;3:xxiv. 8. Song J, Swekla M, Colorado P, et al. Liver abscess and diarrhea as initial manifestations of ulcerative colitis: case report and review of the literature. Dig Dis Sci 2003;48:417-21. 9. Margalit M, Elinav H, Ilan Y, et al. Liver abscess in inflammatory bowel disease: report of two cases and review of the literature. J Gastroenterol Hepatol 2004;19:1338-42. 10. Ostyn B, Bercoff E, Manchon ND, et al. Retroperitoneal abscess complicating colonoscopy polypectomy. Dis Colon Rectum 1987;30:201-3. 11. Paraskeva KD, Bury RW, Isaacs P. Streptococcus milleri liver abscesses: an unusual complication after colonoscopic removal of an impacted fish bone. Gastrointest Endosc 2000;51:357-8.
Division of Gastroenterology (R.G.G.), Mount Sinai School of Medicine, New York, New York, Department of Radiology (B.R.), Division of Gastroenterology (M.A.K.), James J. Peters Veterans Affairs Medical Center, Bronx, New York, USA. Reprint requests: Rebekah G. Gross, MD, Division of Gastroenterology, Mount Sinai School of Medicine, 1 Gustave L. Levy Place, P.O. Box 1069, New York, NY 10029. Copyright ª 2008 by the American Society for Gastrointestinal Endoscopy 0016-5107/$32.00 doi:10.1016/j.gie.2007.08.028
www.giejournal.org
13. Hsu CM, Chiu CT, Su MY, et al. The outcome assessment of double-balloon enteroscopy for diagnosing and managing patients with obscure gastrointestinal bleeding. Dig Dis Sci 2007;52:162-6. 14. May A, Nachbar L, Pohl J, et al. Endoscopic interventions in the small bowel using double balloon enteroscopy: feasibility and limitations. Am J Gastroenterol 2007;102:527-35.
Received April 11, 2007. Accepted July 31, 2007. Current affiliations: Department of Gastroenterology, Fremantle Hospital, Fremantle, Western Australia, Australia. Reprint requests: Robert P. Willert, BSc, MBChB, MRCP, PhD, Department of Gastroenterology, Fremantle Hospital, Alma St, Fremantle 6059, WA, Australia. Copyright ª 2008 by the International Council for the Exploration of the Sea 0016-5107/$32.00 doi:10.1016/j.gie.2007.07.044
Pyogenic liver abscess complicating colonoscopic polypectomy Rebekah G. Gross, MD, Bruce Reiter, MD, Mark A. Korsten, MD New York, Bronx, New York
Since its introduction in 1969,1 flexible colonoscopy has been the criterion standard for diagnosis and treatment of colorectal pathology. However, there remain serious, albeit rare, risks of this invasive procedure, especially when polypectomy is performed. Postpolypectomy injury runs the gamut from serosal burns, producing localized abdominal tenderness, to perforation with resultant peritonitis. Falling along this spectrum, ‘‘microperforation’’ involves transmural injury, potentially with escape of bowel contents, followed by spontaneous sealing of the defect by adherent omentum.2 Although less dramatic than frank perforation, microperforation, nevertheless, may have significant sequelae. Here we describe an unusual case of hepatic abscess complicating colonoscopic polypectomy, most likely from microperforation during the procedure.
CTof the abdomen and pelvis was obtained, revealing an abscess measuring 8.1 cm in maximum dimension in the posterior segment of the right hepatic lobe (Fig. 1). Blood cultures grew Escherichia coli and alpha-hemolytic streptococci. The patient was treated with intravenous antibiotics and underwent CT-guided placement of a percutaneous drainage catheter. On resolution of fever and leukocytosis, the patient underwent a right hemicolectomy for resection of the adenocarcinoma.
DISCUSSION
A 68-year-old man with coronary artery disease, congestive heart failure, and diabetes mellitus presented with a 3-day history of fever to 39 C, abdominal cramps, nausea, vomiting, and nonbloody diarrhea. The patient had undergone screening colonoscopy 1 week previously, during which a 2 3-cm pedunculated polyp at the hepatic flexure was removed by using snare cautery, and the nearby wall was tattooed with SPOT (GI Supply Inc, Camp Hill, Penn). Pathologic evaluation revealed a moderately differentiated invasive adenocarcinoma arising in a tubulovillous adenoma.
The incidence of pyogenic liver abscess ranges from 8 to 20 cases per 100,000 hospital admissions.3 Approximately three fourths of cases involve the right hepatic lobe. Routes of invasion include the biliary tree, portal vein, hepatic artery, direct extension from a contiguous focus of infection, and penetrating trauma. When the bowel is the suspected source, spread can occur via hematogenous seeding or local invasion. In the former case, a single microorganism is typically isolated, whereas in the latter, mixed flora are found, including aerobic and anaerobic species.4 Given the brief time from colonoscopy to onset of symptoms, and the fact that polypectomy was performed at the hepatic flexure, we believe the patient’s abscess was caused by a complication of his procedure, most likely arising from microperforation during polypectomy, with direct extension from the bowel lumen to the liver. The colonic wall may have been particularly susceptible to microperforation
www.giejournal.org
Volume 67, No. 4 : 2008 GASTROINTESTINAL ENDOSCOPY 767
CASE REPORT
Brief Reports
DISCLOSURE The authors report that there are no disclosures relevant to this publication. REFERENCES
Figure 1. Large, heterogeneous lesion containing fluid and air is seen within the posterior segment of the right hepatic lobe. A transhepatic drainage catheter has been deployed percutaneously.
in this case because the resection site involved invasive adenocarcinoma arising in a tubulovillous adenoma. Presence of colonic tubulovillous adenoma is understood to be a risk factor for development of hepatic abscess, presumably by causing mucosal defects that allow spontaneous microperforation.5,6 A related mechanism likely explains the 61 cases of liver abscess linked to Crohn’s disease and ulcerative colitis in the literature.7-9 Here, inflammation alters the integrity of the bowel wall, creating risk for bacterial translocation. Theoretically, hematogenous spread from the tattoo site might be considered as an alternative etiology for the abscess formation. This has never before been reported with the use of SPOT. Although ours is the first reported case of hepatic abscess arising as a complication of polypectomy, the literature describes one case of retroperitoneal abscess after polypectomy in the rectum10 and one case of liver abscess after colonoscopic removal of an impacted fish bone.11 These cases, taken collectively, should raise our consciousness of the infectious potential of therapeutic colonoscopy while not diminishing our belief in its power as a mainstay of treatment for GI pathology.
768 GASTROINTESTINAL ENDOSCOPY Volume 67, No. 4 : 2008
1. Wolff WI, Shinya H. Colonofiberoscopy. JAMA 1971;217:1509-12. 2. Christie JP, Marrazzo J. ‘‘Mini-perforation’’ of the colondnot all postpolypectomy perforations require laparotomy. Dis Colon Rectum 1991;34:132-5. 3. Johannsen EC, Sifri CD, Madoff LC. Pyogenic liver abscesses. Infect Dis Clin North Am 2000;14:547-63. 4. Zaleznik D, Kasper D. Intra-abdominal infection and abscess. In: Fauci A, Braunwald E, Isselbacher E, et al, editors. Harrison’s principles of internal medicine14th ed.. New York: McGraw-Hill; 1998. p. 794-5. 5. Leiba A, Apter S, Avni I, et al. Pyogenic liver abscessdan unusual presentation of colonic villous adenoma. Harefuah 2003;142:336-7, 399. 6. Lai HC, Chan CY, Peng CY, et al. Pyogenic liver abscess associated with large colonic tubulovillous adenoma. World J Gastroenterol 2006;12:990-2. 7. Wells CD, Balan V, Smilack JD. Pyogenic liver abscess after colonoscopy in a patient with ulcerative colitis. Clin Gastroenterol Hepatol 2005;3:xxiv. 8. Song J, Swekla M, Colorado P, et al. Liver abscess and diarrhea as initial manifestations of ulcerative colitis: case report and review of the literature. Dig Dis Sci 2003;48:417-21. 9. Margalit M, Elinav H, Ilan Y, et al. Liver abscess in inflammatory bowel disease: report of two cases and review of the literature. J Gastroenterol Hepatol 2004;19:1338-42. 10. Ostyn B, Bercoff E, Manchon ND, et al. Retroperitoneal abscess complicating colonoscopy polypectomy. Dis Colon Rectum 1987;30:201-3. 11. Paraskeva KD, Bury RW, Isaacs P. Streptococcus milleri liver abscesses: an unusual complication after colonoscopic removal of an impacted fish bone. Gastrointest Endosc 2000;51:357-8.
Division of Gastroenterology (R.G.G.), Mount Sinai School of Medicine, New York, New York, Department of Radiology (B.R.), Division of Gastroenterology (M.A.K.), James J. Peters Veterans Affairs Medical Center, Bronx, New York, USA. Reprint requests: Rebekah G. Gross, MD, Division of Gastroenterology, Mount Sinai School of Medicine, 1 Gustave L. Levy Place, P.O. Box 1069, New York, NY 10029. Copyright ª 2008 by the American Society for Gastrointestinal Endoscopy 0016-5107/$32.00 doi:10.1016/j.gie.2007.08.028
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