UNIVERSITY OF THE EAST

Ramon Magsaysay Memorial Medical Center

Aurora Blvd., Quezon City
Department of Surgery

Greg Mikhail B. Hubo September 5, 2021

2023-B
Preceptor: Dr. Napoleon Alcedo

I. Identifying Data
The patient is a 27 year-old Filipino male from Bataan. He is single and practices Catholicism.

II. Chief Complaint

Intermittent fever and RUQ pain of 2 weeks duration

III. History of Present Illness

Two (2) weeks prior to admission (PTA), the patient noted intermittent fever highest documented
temperature at 39.2C temporarily relieved by Paracetamol 500mg/tab, 1 tab taken every 4 hours.
This was associated with myalgia, no reported abdominal pain
One (1) week PTA, patient had persistence of fever associated with noted intermittent RUQ pain.
He sought consult at a local center and was prescribed with an unrecalled antibiotic and was
maintained on paracetamol.
Day of consult, persistence of fever with a maximum body temperature of 40.0C and right upper
quadrant persisted with a pain score of 7/10, patient was now noted with generalized body
weakness and poor appetite, patient opted consult at ER.
Pertinent positives: high fever, right upper quadrant pain, body weakness, poor appetite
Pertinent negatives: diarrhea, nausea, vomiting, change in stools
Recommendation: Associated signs and symptoms should be investigated especially those
related to the RUQ abdominal symptoms such as presence of vomiting, nausea, loss of appetite,
distention. Furthermore, the history of the consultation conducted 1 week PTA should be
explored. What was the diagnosis? Were there any labs given? How was the compliance with the
antibiotic?
IV. Past Medical History
The patient has no history of Hypertension, Asthma, Allergy, Tuberculosis, Diabetes Mellitus

Recommendation: The history of why the antibiotic was given should be explored. If the drug
was unrecalled, other symptoms surrounding the previous diagnosis may be asked.
V. Family History
The patient has a positive family history of Diabetes Mellitus and breast cancer on the maternal
side and hypertension on the paternal side.

Recommendation: The family history of the patient revealed multiple risks such as malignancy,
development of diabetes.
VI. Personal/Social History
The patient is a non-smoker, occasional alcohol beverage drinker,
Recommendation: History of alcohol use should be asked. How many bottles per occasion?
How often?. HIstory of illicit drug use should also be asked. In patients presenting with jaundice
or possible liver damage, drug use via intravenous may be a suspect.
VII. Review of Systems

Recommendation: Pertinent positives for review of systems should also be established

temporally. The character and timing should be asked to help know if it is related to the current
chief complaint.
General survey  No anorexia, no fatigue, (+) fever, (+) weakness
Skin (+) jaundice, dryness, itching, changes in hair and nails, rashes
HEENT  H: No headache, No head injury;
E: No redness, pain, inability to open eye
E: No hearing impairment, otalgia, discharge, swelling of structures
N: No Nose deformity, no colds, no epistaxis
T: No gum bleeding dental carries dysphagia odynophagia, hoarseness
Respiratory No hemoptysis, wheezing rales, crackles, exertional dyspnea, DOB
Cardiovascular  No chest pain, palpitations, dyspnea orthopnea, syncope
Gastrointestinal No constipation, indigestion, heartburn, fatty food intolerance, (+) vomiting
Urinary No pain in urination, UTI, hematuria, kidney or flank pain, suprapubic pain,
increase in frequency, weak urinary stream, incomplete emptying, polyuria,
dribbling, hesitancy, (-) tea colored urine
Extremities No joint pains, no edema clubbing cyanosis varicosity, claudication
Hematopoietic No excessive bleeding/bruising, PICA, anemia
Nervous No head trauma, sensory perversions, tremors, fainting spells, seizures,
trauma, dizziness
Musculoskeletal No pain on all extremities, swelling
Endocrine No heat/cold intolerance, neck surgery/irradiation, no polydipsia, no
polyphagia, no polyuria, no thyroid problems
Psychiatric No irritation, no agitation, anxiety, depression
IX. Physical Examination
General Survey The patient is awake, conversant, not in pain, not in
cardiorespiratory distress, jaundiced
Vital signs BP: 130/80
HR 101 bpm
RR 19 cpm
Temp 38.7C
O2 Sat 99% at RA

Comment: The patient has elevated temperature, upper limit

respiratory rate which can be expected in someone with fever.
HEENT (+) icteric sclerae, pink palpebral conjunctivae, moist lips and oral
mucosa, no tonsillopharyngeal congestion, no palpable cervical
lymphadenopathies
Chest and Lungs Equal chest expansion, clear breath sounds, equal tactile fremitus,
clear breath sounds
Cardiovascular Adynamic precordium, tachycardic, regular rhythm, distinct s1 &
s2, (-) murmurs

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Abdomen Flabby abdomen, non tympanitic, non-distended, normoactive,
soft, (+) RUQ Tenderness

DRE: smooth, rectal mucosa, no masses palpable, no blood on

examining finger, good sphincter tone

Comment: The RUQ tenderness as an objective finding that

should be further characterized. Was it on light or deep
palpation? Was there any guarding? Was the guarding
voluntary and involuntary? In the presence of fever and pain, a
consideration of sepsis or peritonitis may be considered if the
kind of guarding was included in the PE.

Moreover, liver examination should have been noted including

its size. Presence of other organ enlargement should have been
noted, if any
Genitourinary No hematuria, no dysuria, no nocturia, no weak stream, no urgency
(-) tea colored urine
Pertinent Subjective Pertinent Objective
Patient Profile BP: 130/80 mmHg
• 27 year old, male Temp: 38.7oC
Chief Complaint RR: 19cpm
• Intermittent fever and HR: 101 bpm
RUQ pain of 2 weeks
duration Review of Systems
Personal/Social History: ● Fever
• Non-smoker ● Jaundice
• Occasional alcohol drinker ● Vomiting
History of Present Illness
• 2 weeks PTA, Comment: Pattern of fever, amount and character of vomitus
• high grade fever 39.2C should be asked.
relieved by paracetamol
• myalgia Physical Examination
• Interim- increase in size ● Jaundice
• 1 week PTA, ● Icteric Sclerae
• persistence of fever ● RUQ Tenderness
• RUQ pain
• antibiotic and Comment: Explore more the RUQ tenderness, presence of
paracetamol prescription guarding that will help assess the pace of management.
after consult
• Diagnosis not given,
medication unrecalled
• Day of Consult
• high grade fever 40.0C
• RUQ pain with a 7/10
pain score
• body weakness
• poor appetite

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 Initial Assessment
Primary Impression: Liver Abscess secondary to suspected hepatobiliary infection

Liver abscess is a pus-filled mass in the liver that may develop from disseminated
infection from the portal circulation. Liver abscess can be classified as pyogenic or amoebic
depending on the etiology. In terms of organisms that can cause the disease, amoebic infections
are usually caused by Entamoeba histolytica. On the other hand, pyogenic abscesses are usually
polymicrobial, commonly it includes E.coli, Klebsiella, Streptococcus, Staphylococcus, and gram
(-) organisms.1

In terms of history and presentation, pyogenic abscesses present with insidious onset of
RUQ pain, fever, and jaundice. It can also develop from cholangitis, hepatic artery bacteremia,
portal vein bacteremia, diverticulitis, cholecystitis, or penetrating trauma. This type of liver
abscess also happens in the background of Diabetes Mellitus.2

Meanwhile, amoebic abscesses most commonly caused by Entamoeba histolytica present

as amebic colitis with symptoms that include cramping abdominal pain, watery or bloody
diarrhea, and weight loss or anorexia. Another common finding in amoebic liver abscess is
hepatomegaly.2

It can also be said that cholangitis is a possible impression because of the presence of the
Charcot’s triad which is RUQ pain, jaundice, and fever. However, it is important to note that most
cases of cholangitis especially with early intervention, like in the case of the patient, would
respond to antimicrobial therapy. In the off chance that it does not, cholangitis is included in the
differentials. Moreover, cases of liver abscess may actually develop from existing cholangitis.1,2,3,4

In the case, the patient is presenting with RUQ pain, jaundice, and an unexplained fever
that was not responsive with antibiotics. He has a family history of diabetes which may shift the
leaning on pyogenic type of liver abscess. Moreover, the patient did not present with bloody
diarrhea, weight loss, or anorexia which is included in the presentation of amoebic liver abscess.
Hepatomegaly was not noted because liver size or organ enlargement was not included in the
physical examination. The suspicion of liver abscess can change if laboratory and imaging would
show normal liver enzymes, normal inflammatory markers, normal CBC count with differentials,
absence of abscess findings in imaging study.
Differential Diagnosis
Differential
Ascending Cholangitis ● Cholangitis is a bacterial infection associated with obstruction of the
2,3,4
bile duct. Bile obstruction, usually from stones, can lead to build up
and stasis of bile which can promote bacterial infection from
Escherichia coli, Klebsiella pneumoniae, Streptococcus faecalis,
Enterobacter, and Bacteroides fragilis.
● Clinical presentation of cholangitis is the Charcot’s triad of fever,
jaundice, and epigastric or right upper quadrant paint. These can be
seen in the patient that is why it is considered a differential.
● Patients with cholangitis who do not respond to initial treatment
with antibiotics may need early and urgent surgical drainage because
it may progress to severe organ dysfunction, that is why it is
important to rule out this cause.

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 ● Rule in: Fever, RUQ, Jaundice
● Rule out: presence of another entity that may explain the etiology of
fever, pain, and jaundice; absence of biliary stasis in imaging studies
Acute Cholecystitis 5,6 ● The patient is presenting with RUQ pain which can lead to suspicion
of inflammation of the gallbladder. Acute cholecystitis can present
similarly with or without fever.
● Jaundice can be explained by probable obstruction in the
gallbladder. Bile stasis also promotes bacterial outgrowth that can
cause the fever.

Rule in: Jaundice, RUQ pain, fever,

Rule out: Normal ALT, ALP, direct and total bilirubin, normal bleeding
parameters, normal gallbladder upon imaging, postprandial pain,
transabdominal ultrasound failed to exhibit dilation of the common bile
duct (-) tea colored urine.
Viral Hepatitis 5,6 ● The patient is presenting with fever, RUQ pain, Jaundice, malaise,
● It can be viral in origin which is why it did not respond to
antimicrobials.

Rule in: Fever, RUQ pain, Jaundice

Rule out: fatigue, nausea, anorexia, dark urine, and change in stool
color.
Diagnostic Workup:
Diagnostic tests:
● CBC with differentials – to narrow down fever etiology; to see if
there is possible anemia, leukocytosis, thrombocytopenia
● Hepatic Panel – to rule out liver infection or bile obstruction;
check the pattern of the liver enzymes
● Hepatitis Serology Panel- to rule out hepatitis
● Bleeding parameters – tendency of bleeding, assess liver
inflammation
Diagnostic tests ● Creatinine – checking kidney function for further work-up or
1,2,3,,7,10
starting medications; evaluate kidney function since patient is
presenting with tea-colored urine and has history of diabetes
● BUN – checking kidney function for further work-up or starting
medications
● HBA1c – evaluate patient’s glucose control as patient has family
history of diabetes. Moreover, pyogenic liver abscess happens in
the background of DM. Patient may be undiagnosed.
● Urinalysis – patient is presenting with unexplained fever. To rule
out urinary tract infection

Imaging Tests
● Upper abdomen Ultrasound – to properly evaluate the
hepatobiliary tree and the surrounding organs for presence of
obstruction, masses, or inflammation

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 ● CT Scan (with IV contrast) - 95-100% sensitive, used to localize
the pyogenic liver abscess
● Magnetic resonance cholangiopancreatography (MRCP) - to
visualize the liver and biliary ducts which are considered as
possible sites of pathology.

Laboratory Results
CBC Hemoglobin – 115 g/L (low)
Hematocrit – 35% (low)
RBC – 3.2 x 1012/L (low)
MCHC – 35
MCH – 30.2
RDW – 12.5
WBC – 19.4 (elevated)
Neutrophils – 91% (elevated)
Lymphocytes – 9% (low)
Monocytes – 0%
Eosinophil – 0%
Basophil – 0%
Platelets – 310 x 109/L

Comment: Low hematocrit, Low RBC count, normal MCHC, MCH,

RDW can be interpreted as normocytic, normochromic. Low levels of
hemoglobin with a patient presenting with jaundice may be a sign of
hemolysis. Presence of leukocytosis and neutrophilia points to possible
bacterial etiology of fever.
Bleeding Parameters Prothrombin time – 14 secs (prolonged)
Control – 12.1 secs
INR – 1.18
% Activity -64.3
APTT – 36.5 secs (prolonged)
Control – 26.8 secs

Comment: Bleeding parameters are slightly prolonged. Prothrombin

time can be used indirectly to know whether the jaundice is obstructive
in nature or if it is because of damage to the liver parenchyma.
Blood Chemistry Sodium - 132 (Low)
Potassium - 3.0 (Low)
Urea Nitrogen Substance- 3.6
Creatinine Substance - 72
Alkaline Phosphatase – 48 Iu/L (elevated)
Total bilirubin – 39 umol/L (elevated)
Direct bilirubin – 11.6 umol/L (elevated)
Indirect bilirubin – 18 umol/L
ESR- 56 mm/Hr (elevated)

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 Comment: Elevation of ALT, AST, and ALP. Total and direct bilirubin
is also elevated which may manifest as jaundice. Patient also has
hypokalemia, hyponatremia. A high ESR means that the patient has an
ongoing infection.
Urinalysis Color – Yellow
Turbidity – Turbid
Reaction – Acidic
Specific Gravity – 1.015
Protein – Trace (elevated)
Sugar – +2 (elevated)
RBC – 0-2/hpf (slightly elevated)
WBC – 18-20/hpf (elevated)
Casts – none
Bacteria – moderate
Epithelial cells – moderate
Mucus threads – none
Crystals – none
Yeast cells – few

Comment: Patient has trace proteins and glucose residues in her urine
which may be connected with kidney dysfunction - further testing
because the patient carries risk of Diabetes Mellitus.. Presence of
elevated WBC and bacteria in the urine may be interpreted as possible
urinary tract infection or ongoing bodily infection.
Liver Ultrasound Liver is normal in size. Ill defined rim enhancing hypodense foci noted
in Segment 5 and 6 of liver lobe with aggregate measurement of 4.3 x
6.2 x 3.6cm. The largest pocket seen in segment 5. Minimal fat
stranding is observed in the inferior surface of the liver lobe.

Impression: Large hepatic abscess, ill defined borders and hypodense.

Comment: Ultrasound results showing large hepatic abscess that might

be the etiology of most of the symptoms. Emergent attention should be
given.

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 Assessment
Final Diagnosis: Pyogenic Liver Abscess secondary to suspected acute cholangitis

Based on the history, physical examination, and imaging studies, the final diagnosis would
be a Pyogenic Liver Abscess secondary to suspected acute cholangitis. Potential routes of
bacteria in pyogenic liver abscess include the biliary tree, portal vein, trauma, or extension from a
nearby site. However, based on the presentation of the patient, we can suspect an infection in the
biliary tree as the main route. Moreover, half of pyogenic liver abscesses develop by cholangitis.
The patient also presented with symptoms of cholangitis particularly the Charcot’s triad of fever,
jaundice, and RUQ pain. In addition, the laboratory was also consistent with cholangitis with
leukocytosis, hyperbilirubinemia, and elevated ALP. However, definitive diagnosis of cholangitis
can only be done if visualization of the obstruction and dilation of the CBD can be done. Thus,
further testing, particularly Magnetic Resonance cholangiopancreatography or MRCP, must be
requested. MRCP may help visualize the liver and biliary tree without possible complications
from the suspected cholangitis. Biliary obstruction, if ever present, also contributes to the
pathogenesis of pyogenic liver abscess.

In terms of deciding whether it was an amoebic type of liver abscess or a pyogenic one,
delineating the characteristics of the two was helpful. Amoebic type usually present in younger
patients, with solitary lesions only, has a history of travel to endemic areas where E. histolytica
can be found or a history of amoebiasis infection. Among which, only the younger population
fits the patient.

On the other hand, pyogenic type of liver abscess presents with multiple lesions, elevated
bilirubin and/or liver enzymes(ALP), leukocytosis, ESR, and anemia. All of which are present in
the patient. In addition, the patient has a suspected kidney dysfunction which can be caused by an
undiagnosed Diabetes Mellitus. The patient has a family history of DM that is why it must be
investigated.. It is important to note that pyogenic type of liver abscess develops around DM. A
diagnostic aspiration may be warranted to confirm the diagnosis of pyogenic liver abscess.

Management
Initial management ● Monitoring: The patient’s vital signs should be monitored closely
at least every 4 hours for possible deterioration of the patient as
the patient presents with systemic symptoms and infection of
multiple organ systems
● Treat the underlying hypokalemia and hyponatremia

Diagnostic
● Request MRCP to visualize hepatobiliary system and explore the
suspected acute cholangitis.
Definitive Plan ○ Patient should be prepared for the MRCP procedure
1,2,3,4,8,9,10,11
○ Eating, drinking and taking medications as usual.
○ Patient must wear a gown during the procedure, all
jewelry, magnetic devices, prosthetics that can interfere
with the procedure must be removed
○ Test the patient for allergy to contrast

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 ● Request for HbA1c to assess the sugar control of the patient
because of suspected kidney problems related to Diabetes
Mellitus.
● Request diagnostic aspiration to confirm pyogenic liver abscess to
be cultured
Medical
● Start IV broad spectrum antibiotics (Piperacillin-Tazobactam with
or without metronidazole) for empiric treatment of infection.
Adjust dosage or drugs according to results of culture.

Surgery is indicated if there is failure of medical therapy or if

percutaneous aspiration or drainage or coexisting intra-abdominal disease
that requires surgery.
● Catheter drainage may be done. If deemed insufficient after 7
days or catheter obstruction ensues, surgical drainage should be
done.
● If cholangitis is confirmed, emergency surgery must be done
because of possible progression into sepsis and bacterial
superinfection.
● Drainage of abscess contents is the standard therapy for liver
abscess. Make sure the patient is NPO before the procedure.
● Catheter drainage or percutaneous drainage is the recommended
management for liver abscess that are large >5 cm.
● If the abscess presents on the Left side of the liver, immediate
surgery is warranted because of possible rupture into the
pericardium.
● Surgically accessible livers can be done by laparoscopy. However,
the presence of a coexisting abdominal pathology shifts the
preference to an open surgery.
● Correction via surgery of primary cause of liver abscess.
Activity:
● Limitation of physical activity.
Post-operative Plan ● Diet as tolerated.
● Monitor for any complications or infections.

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ALGORITHM:

Figure 1: Hepatobiliary diseases with similar presentations

Figure 2: Expected findings of Primary Impression and differential diagnosis

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Figure 3: Difference of Pyogenic and Amoebic Liver Abscess

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Figure 4: Management of Pyogenic Liver Abscess

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