J Hepatobiliary Pancreat Surg (2006) 13:252255 DOI 10.

1007/s00534-005-1044-6

Case reports of interest Amebic liver abscess rupturing into the lesser omentum space
Yoichiro Nushijima1, Hideyuki Ishida1, Yasunori Watanabe1, Kazunori Nakaguchi1, Katsuaki Nakanishi2, Yoshihiko Hoshida3, and Toshiyuki Kabuto1
1 2

Department of Surgery, Osaka Seamens Insurance Hospital, 1-8-30 Chikkou, Minato-ku, Osaka 552-0021, Japan Department of Radiology, Osaka Seamens Insurance Hospital, Osaka, Japan 3 Department of Pathology, Osaka University, Suita, Japan

Abstract A case of an amebic abscess localized in the lesser omentum is reported. There was no sign of a liver abscess in the imaging examination or the operative ndings. However, it is likely that the amebic infection occurred after a liver abscess ruptured into the abdominal cavity. Early diagnosis and therapy are required when an abscess of unknown origin borders the liver, given the possibility of amebic abscess. Key words Entamoeba histolytica Amebic abscess Lesser omentum

Introduction Amebiasis is caused by Entamoeba histolytica, and infection is acquired by ingesting food or water containing the cysts of this protozoan. The adult trophozoite colonizes the large intestine and causes amebic colitis. The trophozoites often enter the circulation, where they are ltered in the liver and produce abscesses.1 Here, we present the rst case of an amebic liver abscess rupturing into the space in the lesser omentum. The imaging examinations revealed no sign of a liver abscess and therefore it was diagnosed preoperatively as a pancreatic tumor containing an abscess.

Case report A 60-year-old Japanese man presented at hospital because of abdominal distention on April 5, 2004. His family medical history was uneventful. He had been suffering from abdominal distention since March 2004

Offprint requests to: Y. Nushijima Received: May 9, 2005 / Accepted: August 3, 2005

but had experienced no other relevant symptoms, such as abnormal pain, fever, or diarrhea in the previous year. On admission, he was 162 cm tall and weighed 59 kg. His body temperature was 37.3 C and his arterial blood pressure was 112/62 mmHg. A physical examination revealed a palpable hard mass with a smooth surface in the left upper quadrant of the abdomen, which was difcult to move. Laboratory examination revealed a hematocrit of 28.7%, a white blood cell count of 7100/ mm3 with 75.0% polymorphonuclear leukocytes, and a C-reactive protein concentration of 10.2 mg/dl. Liver function and the serum levels of carcinoembryonic antigen, carbohydrate antigen 19-9 and -fetoprotein were within normal ranges. Abdominal ultrasonography (US) revealed an isoechoic mass with a hypoechoic area measuring 6.5 cm in diameter and bordering the body of the pancreas (Fig. 1). A pre-contrast computed tomography (CT) scan revealed a heterogeneous low-density mass measuring 5 cm in diameter between the body of the pancreas and the left lobe of the liver. The area contacting the mass in the left lobe of the liver had low density (Fig. 2). The early phase of the contrastenhanced CT scan revealed a strongly enhanced margin of the mass and no enhancement of the inside of the mass. The area contacting the mass in the left lobe of the liver was also shown as low density (Fig. 3). The late phase of the contrast-enhanced CT scan revealed that the inside of the mass was still not enhanced but the area contacting the mass in the left lobe of the liver was enhanced and had the same density as the surrounding normal liver (Fig. 4). T1-weighted magnetic resonance imaging (MRI) revealed a low-intensity mass (Fig. 5). T2-weighted MRI revealed a mildly high-density mass, with a high-density area contacting the mass in the left lobe of the liver (Fig. 6). Abdominal angiography showed a small shift surrounding the tumor, but no tumor stains (Fig. 7). The preoperative diagnosis was a pancreatic tumor containing an abscess. A tumor of unknown origin containing an abscess or an unknown

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Fig. 1. Abdominal ultrasonography revealed an isoechoic mass with a hypoechoic area inside measuring 6.5 cm in diameter bordering the body of the pancreas (Panc.)

Fig. 3. The early phase of the contrast-enhanced CT scan revealed a strongly enhanced margin of the mass and no enhancement of the inside of the mass. The area contacting the mass in the left lobe of the liver was also low density

Fig. 2. A pre-contrast computed tomography (CT) scan revealed a heterogeneous low-density mass measuring 5 cm in diameter between the body of the pancreas and the left lobe of the liver. The area contacting the mass in the left lobe of the liver was low density (arrow)

Fig. 4. The late phase of the contrast-enhanced CT scan revealed that the inside of the mass was still not enhanced but the area contacting the mass in the left lobe of the liver was enhanced and had the same density as the surrounding normal liver

abdominal abscess were considered as differential diagnoses. We conducted a laparotomy on April 23, 2004. The operative ndings revealed no tumors and only an abscess. The abscess wall was composed of the left lobe of the liver, the lesser curvature of the stomach, the body of the pancreas and the second portion of the duodenum, which was considered as being in the lesser omentum (Fig. 8). Intraoperative examination of the abscess wall revealed the presence of non-specic granulomatous tissue. The patient underwent a drain-

age operation. A pathological examination on April 30, 2004, revealed that the abscess partially consisted of a granulomatous wall in the pancreatic parenchyma, and mature trophozoites of E. histolytica were detected in its exudative contents (Fig. 9). We conrmed the patients previous history, and it was revealed that he had visited Taiwan in January 2004. The patients serum was weakly positive for E. histolytica when tested with a detection kit (Amoeba-Spot IF, Biomerieux, Tokyo, Japan), but the patients stool contained no parasites or

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Y. Nushijima et al.: Amebic abscess in lesser omentum

Fig. 5. T1-weighted magnetic resonance images (MRI) show a low-intensity mass

Fig. 7. Arterial phase superior mesenteric angiogram (left) and left gastric angiogram (right) showed a small shift surrounding the tumor (arrows), but no tumor stains

Fig. 6. T2-weighted MRI revealed a mildly high-density mass and a high-density area contacting the mass in the left lobe of the liver

Fig. 8. Operative ndings revealed that the abscess wall was composed of the left lobe of the liver, the lesser curvature of the stomach, the body of the pancreas and the second portion of the duodenum

ova. The patient was treated with metronidazole and responded well. He was discharged from hospital on June 2, 2004. A contrast-enhanced CT scan 2 weeks after the operation showed that the mass had disappeared completely. The pancreatic body and left lobe of the liver were almost intact.

Discussion This is the rst report of an amebic liver abscess localized in the lesser omentum. In this case, neither the imaging examination or the operative ndings revealed an abscess in the patients liver, so there was the possi-

bility of direct amebic infection in the abdominal cavity. However, it is known that extra-intestinal infection is caused when trophozoites in amebic colitis enter the circulation. The liver is a denitive organ that lters the portal circulation, and therefore liver abscess is the most common extra-intestinal manifestation of amebiasis.1 It is likely that the abscess in this case occurred by rupture of the amebic liver abscess, which may have been small enough after rupture to evade detection. There have been many cases of an amebic liver abscess rupturing into the abdominal cavity and causing generalized peritonitis.2 Rare cases have been reported of

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In conclusion, we treated a patient with an amebic abscess localized in the lesser omentum. Early diagnosis and therapy are required when an abscess of unknown origin borders the liver given the possibility of amebic abscess.

References
1. Gutierrez Y, von Lichitenberg F. Protozoal diseases. In: Damjanov I, Linder J, editors. Andersons pathology, 10th edn. St. Louis: C.V. Mosby Company; 1996. p. 9935. 2. Sharma L, Gupta S, Soin AS, Sikora S, Kapoor V. Generalized peritonitis in India: the tropical spectrum. Jpn J Surg 1991;21:272 7. 3. Vanachayangkul V, Wattanasirichaigoon S, Letochavarit M, Charudun S, Viranuvatti V. CT and US ndings of a rare case of amoebic liver abscess rupturing into the pericardial cavity. Gastroenterol Jpn 1990;25:5037. 4. Supe AN, Sathe SS, Redkar RG, Dalvi, AN, Kulkarni BA, Shah PP. Amebic pericarditis following ruptured right liver lobe abscess. Indian J Gastroenterol 1991;10:111. 5. Mondragon-Sanchez R, Cortes-Espinoza T, Sanchez-Cisneros R, Para-Silva H, Hurtado-Andrade H. Rupture of an amebic liver abscess into the pericardium. Hepato-Gastroenterol 1994;41:585 8. 6. Perna AM, Montesi GF. Cardiac tamponade secondary to intrapericardial rupture of a hepatic amoebic abscess. Eur J Cardiothorac Surg 1994;8:1067. 7. Dusaj IS, Jaiswal A, Chokhani R. Amoebic liver abscess rupturing into the chest: ultrasonographic appearance. Indian J Chest Dis All Sci 1990;32:2439. 8. Baijal SS, Agarwal DK, Roy S, Choudhuri G. Complex ruptured amebic liver abscesses: the role of percutaneous catheter drainage. Eur J Radiol 1995;20:657. 9. Ibrarullah MD, Agarwal DK, Baijal SS, Mittal BR, Kapoor VK. Amebic liver abscess with intra-biliary rupture. HBP Surgery 1994;7:30513. 10. Sonsuz A, Basaranoglu M, Senturk H, Celik AF, Tanriover V. Amebic abscess of the caudate lobe with spontaneous rupture into the biliary tract. J Clin Gastroenterol 1998;26:3556. 11. Yanagisawa M, Kaneko M, Aizawa T, Michimata T, Takagi H, Mori M. A case of amebic liver abscess complicated by hemobilia due to rupture of hepatic artery aneurysm. Hepato-gastroenterology 2002;49:3758. 12. Tandon N, Karak PK, Mukhopadhyay S, Kumar V. Amoebic liver abscess: rupture into retroperitoneum. Gastrointest Radiol 1991; 16:2402. 13. Singh Y, Samujh R, Narasimhan KL, Rao KLN, Jayashree M, Singhi S. Amebic abscess of both liver lobes: simultaneous rupture into pleura and stomach. Indian Pediatr 1999;36:1902. 14. Ogawa T, Shimizu S, Morisaki A, Sugitani A, Nakatsuka A, Mizumoto K, et al. The role of percutaneous transhepatic abscess drainage for liver abscess. J Hepatobiliary Pancreat Surg 1999; 6:2636.

Fig. 9. Histologically, the abscess partically consisted of a granulomatous wall in the pancreatic parenchyma (H&E, 25). Inset: a mature trophozoite of E. histolytica was detected in the abscesss exudative contents (arrow) (H&E, 200)

rupture into the pericardial cavity,36 the pleural cavity,7,8 the biliary tract,9,10 a hepatic aneurysm,11 the retroperitoneum,12 the stomach,13 and the greater omentum,8 but there have been no reports of rupture into the lesser omentum producing a localized abscess. In the present case, the patient had no symptoms that were useful for making a diagnosis of amebic colitis or amebic liver abscess, for example diarrhea, abdominal pain, nausea, vomiting, abdominal malaise, appetite loss, general fatigue, body weight loss, or bloody stool with mucus. The mass was located between the liver and the pancreas, as if the mass had originated in the pancreas and was protruding into the liver. Although imaging examinations revealed signs of liver abscess in other previously reported cases,313 the present case showed no evidence of a liver abscess (Figs. 14). It is vital to consider the possibility of amebiasis when an abdominal abscess of unknown origin borders the liver. The traditional therapy for a ruptured amebic liver abscess has been immediate operative drainage and complementary drug therapy. Percutaneous catheter drainage is now a major player in the management of pyogenic hepatic abscess,14 but its role in the management of amebic abscesses remains controversial.8