Question

A 45-year-old man presents with a 1-week history of high-grade fever, abdominal pain, occasional rigors, loss of appetite, malaise, nausea, and vomiting. His symptoms began about a week ago when he developed a low-grade fever for 2 days. Fever was high-grade during the last 3 - 4 days, with occasional rigors accompanied by abdominal pain predominantly in the right upper abdomen. Pain is moderate in intensity, continuous without any radiation, and is not relieved by acetaminophen (Tylenol), which he is taking on his own.

Examination reveals tender hepatomegaly. No other organs are palpable. Abdomen is slightly distended, but bowel sounds are normal.

Vital signs are as follows: temperature 40° C, pulse 108 bpm, blood pressure 136/90 mm Hg, and respiratory rate 20 per minute. The patient appears toxic. The rest of the physical examination is as follows:

Neck: supple, no stridor
Lymphatics: no lymph nodes are palpable
Lungs: decreased breath sounds at the base of the right lower lung
Cardiac: normal S1 and S2, no extra heart sounds
Back: negative
Groin: unremarkable
Genitalia: unremarkable
Neurological: normal cranial nerves, normal motor and sensory examination
Ultrasonography: multiple liver abscesses in both lobes of the liver, confirmed by similar findings from CT scan

What is the most common cause of the patient's liver abscess?

Pylephlebitis
2 Cholangitis
3 Endocarditis
4. Subphrenic abscess
5 Pyelonephritis

Answer 1

The most common cause of the patient's liver abscess is Cholangitis. The correct option is 2) Cholangitis because the patient's presentation, including high-grade fever, abdominal pain predominantly in the right upper abdomen, and tender hepatomegaly, is indicative of inflammation in the bile ducts. Cholangitis, often caused by ascending bacterial infection, can lead to liver abscesses.

Step-by-step explanation:

Cholangitis is the inflammation of the bile ducts, often associated with ascending bacterial infection. In this case, the patient's presentation with high-grade fever, abdominal pain predominantly in the right upper abdomen, and tender hepatomegaly is indicative of cholangitis leading to liver abscesses.

The absence of relief from acetaminophen, coupled with the imaging findings of multiple liver abscesses, aligns with the progression of cholangitis to hepatic involvement. The impaired drainage of bile due to inflammation facilitates the development of abscesses, contributing to the patient's clinical picture.

The patient's toxic appearance, along with the decreased breath sounds at the base of the right lower lung, suggests a potential complication of cholangitis known as ascending cholangitis with secondary liver abscesses. This can occur when there is a blockage of the bile ducts, allowing bacteria to ascend and infect the liver.

The combination of clinical symptoms, physical examination findings, and imaging results collectively points toward cholangitis as the primary cause of the liver abscesses in this patient.

In summary, the choice of cholangitis as the most common cause is substantiated by the clinical presentation, physical examination findings, and imaging results, all of which converge to highlight the ascending infection of the bile ducts leading to liver abscess formation in this 45-year-old male patient.