Intravenous & Endocavitary Contrast Enhanced Ultrasound (CEUS) in Multiseptated Pyogenic Liver Abscess Drainage

1. Abstract

Pyogenic liver abscess is a potentially life-threatening pathology, while image-guided drainage is highly indicative as first-line treatment approach. We report the case of an 84-year-old woman, diagnosed with large multiseptated pyogenic liver abscess, aiming to stress out the immense contribution of both intravenous and endocavitary administration of Sonovue ™ (Bracco-Milan) in US-guided percutaneous interventional procedures

2. Key words

Liver abscess drainage; Contrast-Enhanced Ultrasound; Endocavitary CEUS; Sonovue; Image guided intervention

3. Abbreviations:

CEUS: Contrast-Enhanced Ultrasound; US: Ultrasound; CT: Computerized Tomography; MRI: Magnetic Resonance Imaging; MI: Mechanical Index; IV: Intravenous; PLA: Pyogenic Liver Abscess

4. Introduction

Throughout the last decades, an imaging revolution with the accretive use of Ultrasound Contrast agents (UCAs) and a gradual establishment of Contrast Enhanced Ultrasound (CEUS) as animaging technique, are being witnessed. Although the value of CEUS in diagnostic practice have been demonstrated by numerous studies, the utilization of UCAs in interventional procedures has been emerging the last few years, either with intravenous or endocavitary administration [1]. On the other hand, pyogenic liver abscess(PLA) is a high mortality associated pathology with a rate ranging from 10-40% [2]. Nowadays, the vast majority of etiologies of PLAs concern pathologic conditions of the biliary tract, when a certain risk factor is present [3]. Combined antibiotic therapy and image-guided percutaneous drainage have become the first-line treatment in most cases, greatly improving patients’ prognosis, hence the decrease of the mortality rate to 6.31% [3-5]. In this study, the feasibility of intravenous and intracatheterad- *Corresponding Author (s): Ortansia Doryforou, Head of Imaging Department of Ultrasound, 251 Airforce General & Veterans Hospital, 3, P. Kanellopoulou Av., 11525, Athens, Greece, E-mail: odoryforou@yahoo.gr http://www.acmcasereports.com/ ministration of Sonovue ™ as an UCA in management of a complex PLA is demonstrated, aiming to stress out Contrast Enhanced Ultrasound contribution and possibilities in ultrasound guided interventional procedures, as well as the benefits arising from the use of UCAs contrary to B-mode imaging, for daily clinical practice, in complex septic liver fluid collections needing percutaneous intervention.

5. Case Report

An 84-year-old female with no prior relevant medical history presented to the emergency department with symptoms of acute cholangitis and sepsis. Initial laboratory results demonstrated increased white blood cell (WBC) count (~14X103 ) and deranged values of hepatic enzymes and C-Reactive Protein (CRP). Imaging investigation with unenhanced abdominal US, revealed a large (~15X13 cm) hypoechoic micro cystic lesion in the right liver lobe, dilated common bile duct and choledocholithiasis, indicative of liver abscess due to ascending cholangitis. Abdominal CT and MRI scans demonstrated a large multiloculated, peripherally enhancing lesion, with low density (on CT)/hyperintense (on DWI) numerous central regions, involving multiple liver segments(IV, V, VI), confirming the diagnosis of a large multiseptated liver abscess (Figure 1).

6. Results & Discussion

Intravenous CEUS images were directly comparable to CT and MRI scans, while providing the advantage of real-time three-dimensional planning and tracking of the needle-catheter [16]. Surrounding structures and large vessels were acknowledged and avoided (Figure 2). Endocavitary administration of Sonovue ™ through puncture needle, confirmed communication between abscess cavities predisposing adequate drainage, despite the presence of multiple septae. Intracatheter Sonovue ™ administration confirmed the correct placement of drainage catheters in 3 out of 4 attempts (75%) (Figure 3). With regards the single misplaced catheter attempt, after slight retraction, a complementary Sonovue ™ injection demonstrated the accuracy of the positioning (Figure 4). No communication between the abscess and surrounding vessels or bile ducts was detected.

7. Conclusion

Pre-interventional intravenous CEUS is a useful tool, providing substantial details in PLA imaging. Abscess cavities, aslong as the surrounding structures can be distinctly depicted, in order to plan the ideal track towards the target sites [12, 14, 16, 17]. In concordance with current literature, endocavitary injection of Sonovue ™ in PLA has been an invaluable process in our case, delineating the abscess cavities, confirming inter septal communication and allowing the identification of correct positioning of drainage catheters [15, 16, 18-21]. The utilization of both intravenous and endocavitary CEUS could further assist interventional radiologists in management of complex liver abscesses, increasing the success rate in drainage, whilst lessening the complication rates and the patient-doctor radiation induced.

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Citation:

Doryforou O. Intravenous & Endocavitary Contrast Enhanced Ultrasound (CEUS) in Multiseptated Pyogenic Liver Abscess Drainage. Annals of Clinical and Medical Case Reports 2020