Persistent epigastric pain in an 80-year-old man

• Published in: Canadian Medical Association journal (CMAJ) 2011-05, Vol.183 (8), p.925-928
• Main Authors: MacFadden, Derek R, Penner, Todd P, Gold, Wayne L
• Format: Article
• Language: English
• Subjects: Abdominal Pain - etiology; Aged, 80 and over; Care and treatment; Case studies; CT imaging; Diagnosis; Foreign-Body Migration - complications; Foreign-Body Migration - diagnosis; Foreign-Body Migration - surgery; Health aspects; Humans; Laparoscopic surgery; Laparoscopy; Liver Abscess - complications; Liver Abscess - diagnosis; Liver Abscess - surgery; Liver Abscess, Pyogenic - complications; Liver Abscess, Pyogenic - diagnosis; Liver Abscess, Pyogenic - surgery; Liver diseases; Male; Medical diagnosis; Older people; Practice; Streptococcal Infections - complications; Streptococcal Infections - diagnosis; Streptococcal Infections - surgery; Streptococcus anginosus; Studies; Systematic review
• ISSN: 0820-3946; 1488-2329
• DOI: 10.1503/cmaj.101510

The annual incidence of pyogenic liver abscess has been estimated at 1.1-2.3 cases per 100 000 population.1,2 Incidence increases with age: people aged 65 years or older are 10 times more likely than younger people to develop pyogenic liver abscesses.1 This parallels the increased incidence of biliary tract disease in older populations. 3,4 Risk factors for pyogenic liver abscess include male sex, advanced age, biliary tract disease, diabetes mellitus, liver transplantation, malignancy and percutaneous treatments for hepatocellular carcinoma, including radiofrequency ablation.1,5 The most common clinical features include fever (73%), chills (45%) and right upper quadrant pain (38%). The most frequent laboratory abnormalities include hypoalbuminemia (96%), elevated γ-glutamyl transferase (81%), elevated alkaline phosphatase (71%) and leukocytosis (69%).1 Liver abscesses resulting from foreign-body migration most commonly occur in the left lobe of the liver, often as a result of perforation through the gastric antrum or proximal small bowel. Common foreign bodies include fishbones (44%), toothpicks (29%), chicken bones (8%), metallic objects (14%) and unidentified bones (5%).11 Clinical and laboratory features of liver abscess secondary to foreign-body migration are similar to those related to other mechanisms of infection.11 A systematic review of the literature that identified 60 instances of pyogenic liver abscess related to foreign-body migration suggested improved sensitivity of CT over ultrasonography for visualization of foreign bodies; however, imaging may be nondiagnostic in more than 50% of instances.11 A thickened gastrointestinal wall in contact with a liver abscess may suggest a migrated foreign body as the mechanism of infection. For instances in which a foreign-body mechanism is suspected and the foreign body is not seen on imaging, esophagogastroduodenoscopy is recommended.11 Findings at endoscopy may include direct visualization of the foreign body, mucosal inflammation and the presence of a fistulous tract. Endoscopy may assist with foreign-body removal. In some instances, exploratory laparotomy or laparoscopy may be needed to arrive at the diagnosis.11 In instances of liver abscess related to foreign- body migration, rates of cure without foreign- body removal are low (9.5%).11 Removal of the foreign body is critical to permitting resolution of the abscess and closure of fistulous tracts. Surgical drainage of the abscess at the time of rem