Blinkskuddet: Endoscopic ultrasound drainage of a giant liver abscess via transgrastro-hepaticic route

Tekst/bilder: Khanh Do-Cong Pham1, Øystein Wendelbo2. 1 Department of Medicine, Haukeland University Hospital, Bergen, Norway. 2 Division for infection disease, Department of Medicine, Haukeland University Hospital, Bergen, Norway.
Corresponding author: Khanh Do-Cong Pham, MD, Section of Gastroenterology, Department of Medicine, Haukeland University Hospital, Jonas Lies vei 65, 5051 Bergen, phamkdc@gmail.com

Endoscopic ultrasound guided transgastric drainage of liver abscess with a self-expanding metallic stent (SEMS) has been described [1]. Even though the idea of drainage through a short transgastric route is very tempting, the main problem seems to be migration of the stent when the abscess looses volume during drainage. We describe the first case where the liver parenchyma was used as an anchor to prevent stent migration.

A 90 year old woman with dementia was admitted with sepsis of unknown origin. One year previously, she had a liver abscess of 12 cm which was drainaged percutaneously with a pig tail catheter. Shortly after, the patient removed the catheter by herself, and was sent to a nursing home for palliative care. Without further treatment she had survived.

Figur 1.

Figur 1.

Figur 2.

Figur 2.

Figur 3.

Figur 3.

Her complaint was upper abdominal pain, and on CT the original abscess had grown to 17 cm (figur 1), in addition to few other smaller ones. In spite of antibiotic treatment, her condition rapidly deteriorated. After consent from her family, we attempted to perform EUS guided transgastric drainage. On EUS, we could find the biggest abscess in the left liver lobe. The abscess wall was adjacent to the gastric wall on the minor gastric curve. We could also recognise parenchyma of the left liver lobe from the proximal gastric body. A 19 G FNA needle was used to puncture the abscess through 2 cm of the liver parenchyma (figur 2). A guide wire was then placed under fluoroscopy into the cyst. We then performed exchange of the FNA needle with a 7 Fr cystotome, and applied current to make a tract through the liver parenchyma. A 4 mm biliary balloon was placed to dilate the tract further. Finally an 8 cm fully covered Wallstent was placed. We could observe a nice flow of pus through the stent. After 2 weeks, we performed a new gastroscopy, and saw that the stent was still in place and working (figur 3). The large opening of the stent made it possible to perform lavage with flushing endoscopically.

The patient recovered and was discharged to a nursing home.

NGF
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