EUS-guided drainage of hepatic abscess in the right side of the liver of a patient with Chilaiditi syndrome.

Recently, the usefulness of EUS-guided hepatic abscess drainage (EUS-HAD) has been reported. However, EUS-HAD in the right lobe of the liver is not always easy and is challenging because it needs a long and angulated endoscope position, and the target is sometimes a long distance away. We describe EUS-HAD in the right side of the liver of a patient with Chilaiditi syndrome. A 65-year-old man visited our hospital because of fever and malaise for the previous 10 days. He had received a diagnosis of advanced cholangiocarcinoma 1 year previously.

CT demonstrated an abscess in the right side of the liver (Figs. 1A and B). Antibiotic therapy was administered for 7 days. However, his fever persisted, and the abscess remained. We performed EUS-HAD (Figs. 1C and D; Video 1, available online at www.VideoGIE.org) because percutaneous drainage in a patient with Chilaiditi syndrome, in which the GI tract is located between the right liver and the abdominal wall, was not possible because of the risk of puncturing the intestinal tract. The abscess was visualized with linear EUS and punctured with a 19-gauge EUS-FNA needle from the duodenum after exclusion of the interposed vascular structures by color Doppler US. A 0.025-inch guidewire was introduced through the needle and coiled within the abscess under EUS and fluoroscopic guidance. After fistula dilation with an ERCP catheter, a 5F nasocystic tube was placed in the abscess to be cut inside the stomach after the patient recovered. There were no procedure-related adverse events, and CT 6 days later revealed complete resolution of the abscess (Figs. 1E and F). The tube was then cut inside the stomach by use of a loop cutter. The patient’s clinical condition was restored immediately, and oral intake was started. Although 3 weeks later the patient died of the cancer that had already been diagnosed as terminal, the infection was under good control.

Figure 1

A, CT view showing the abscess in the right side of the liver and Chilaiditi syndrome. B, CT view showing the internal metallic stent placed into the common bile duct. C, The abscess was punctured with a 19-gauge EUS-FNA needle from the duodenum. D, Placement of a 5F nasocystic tube in the abscess and aspiration of pus from the abscess. E, F, CT view after EUS-hepatic abscess drainage showing complete disappearance of the abscess.

Disclosure

All authors disclosed no financial relationships relevant to this publication.