Three Cases of Liver Abscesses Complicated with Colon Cancer without Liver Metastasis: Importance of Screening for Digestive Disease

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1 CASE REPORT Three Cases of Liver Abscesses Complicated with Colon Cancer without Liver Metastasis: Importance of Screening for Digestive Disease Atsushi Hiraoka 1, Yoshimasa Yamashita 1, Kazuhiro Uesugi 1, Yohei Koizumi 1, Yasunori Yamamoto 1, Hirokazu Doi 1, Aki Hasebe 1, Soichi Ichikawa 1, Makoto Yano 1, Yasunao Miyamoto 1, Tomoyuki Ninomiya 1, Bunzo Matsuura 2, Norio Horiike 2, Kojiro Michitaka 3,YoichiHiasa 2, Saburo Nishikage 4 and Morikazu Onji 2 Abstract We treated 3 patients complicated with colon cancer without liver metastasis, who were admitted to our hospital because of a high fever and diagnosed with liver abscesses. In a general screening after performing percutaneous transhepatic abscess drainage, colon cancer was detected in each, though hepatobiliary diseases were not found. Hepatobiliary diseases were the most common etiology of hepatic abscesses in our hospital in the past 41 cases from 1990 to 2005, 3 of which were due to colon cancer. If a cause is not determined, general screening, especially of the colon tract, should be performed in hepatic abscesses patients. Key words: hepatic abscess, diabetes mellitus, infection, malignant diseases, colon cancer (DOI: /internalmedicine ) Introduction The occurrence of hepatic abscesses has been reported to be very rare (0.013% to 0.02% of admissions (1-3)) and such patients are rarely encountered at our hospital. The prognosis for patients with hepatic abscesses has been improving (4), however, clinical features of the disease are severe, as various diseases are often associated, such as a hepatobiliary tumor or biliary duct stone, as well as iatrogenic complications and immunodeficiency syndrome. Thus, a concerted effort to search for the origin of the abscess condition immediately after admission is required. Recent progression in computed tomography (CT) and ultrasonography (US) techniques have made diagnosis of a hepatic abscess in the early stage much easier. Recently, percutaneous transhepatic abscess drainage (PTAD) has been used to treat patients with hepatic abscesses and the mortality rate has been improved (4). Nevertheless, it is important to search for the etiology of liver abscesses in order to provide effective treatment. Herein, we report 3 liver abscess cases associated with colon cancer without liver metastasis. Case Report A 73-year-old Japanese man felt general fatigue and developed a high fever, after which he was admitted to our hospital on April 20, Upon admission, white blood cells [12300 cells/μl (normal value: NV) <9000], C-reactive protein [15.75 mg/dl (NV <0.35)] and glyco haemoglobin A 1c [HbA1c 12.4% (NV <5.8)] were all increased. He was diagnosed with liver abscesses and diabetes mellitus. Abdominal US and CT examinations showed a liver abscess (3 rd segment; size 6.3 cm) (Fig. 1), however, there were no findings of hepatobiliary or pancreatic diseases. In a general screening, cancer in the sigmoid colon was detected during a colonoscopy procedure after PTAD and a surgical resection was performed on May 30, 2005 (Fig. 2). Department of Gastroenterology, Ehime Prefectural Central Hospital, Ehime, Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Ehime, Department of Endoscopic Medicine, Ehime University Graduate School of Medicine, Ehime and Department of Surgery, Ehime Prefectural Central Hospital, Ehime Received for publication February 3, 2007; Accepted for publication August 14, 2007 Correspondence to Dr. Atsushi Hiraoka, c-ahiraoka@eph.pref.ehime.jp 2013

2 Figure1. A.The cystic tumor was found in the leftlobe ofthe liver by abdominal ultrasonography.b(earlyphase).c (delayedphase).dynamiccomputedtomographicscanre vealedasolitaryabsces. Figure2. A.Coloncancerwasdetectedinsigmoidcolonbycolonoscopy.B.Double-contrastbarium enemashowedaapplecoresign.c.microphotographoftheresectedspecimenrevealedthetumorwhichwasmoderatelydiferentiatedadenocarcinoma. In addition, the clinical courses of 2 other cases were very similar to this case. In all cases, abscess due to metastasis was denied in their clinical course. The characteristics of the 3 patients with liver abscesses and colon cancer are shown in Table 1. Discussion From 1990 to 2005, 41 patients with hepatic abscesses were admitted to the department of Gastroenterology of Ehime Prefectural Central Hospital. The diagnosis of hepatic abscess was made by enhanced CT (5) and abdominal US (6) findings. The clinical backgrounds and outcomes for these patients are shown in Table 2. We found no significant differences between the 3 cases with colon cancer and 38 other cases. A recent report (4) found that the prognosis of patients with hepatic abscesses has improved, as along with im- 2014

3 Table1. ClinicalProfileofPatientswithLiverAbsceses Table2. ClinicalDataforAlPatientsatEntry provements in imaging techniques and image guided percutaneous drainage (eg. PTAD) as well as antibiotics, techniques such as PTAD have become popular (7). We used PTAD for diagnosis and treatment of 31 of the present cases. For most of the other 10, it could not be performed because of shock state or a large number of abscesses. Thus, early diagnosis is important, before progression to septic shock and DIC. In addition, US can be performed easily, quickly, and repeatedly at the bedside, and is useful for patients with an uncontrollable high fever or digestive symptoms to diagnose hepatic abscesses in the early stage. The most frequent reported complication was fever (80.4%). In 14.6% of the patients, shock state was observed as the first symptom (Table 3). Further, 71.9% of the patients were positive for bacteria, with Klebsiella pneumonia the most frequent (40.6%), followed by Escherichia coli 2015

4 Table3. SymptomsandComplicationsA sociatedwithhepaticabsceses Table4. BacteriaDetectedinAbscesDrainagein32CasesthatUn derwentcultivationtests Table5. DetailsRegardingBasalDiseaseAsociatedwithHepaticAbsces, Including2DiferentDiseasesin1Case (18.8%), while 1 was positive for amebae (3.1%) (Table 4). Malignant disease occurred in 29.3% of all patients, which included 3 with a cholangiocarcinoma (CCC), 3 with a hepatocellular carcinoma (HCC), 3 with colon cancer, and 1 with pancreas cancer, while 15 (36.6%) cases had an undetermined etiology. In addition, 1 (2.4%) developed an iatrogenic abscess following transcatheter arterial chemoembolization (TAE) for an HCC (Table 5). We found few reviews of liver abscess cases associated with colon cancer that studied a large number of patients. Teruya et al (8) reported 22 cases of liver abscess with colon cancer. In a series of 25 cases, which includes the present 3 cases, colon cancer was located in the rectum or sigmoid colon in 62.5%, with Borrman type 2 colon cancer the 2016

5 Figure3. A.Tumorswerelocatedintherectum orsigmoidcolonin62.5% oftheliverabsces patientswithcoloncancer. B.Borrmantype2coloncancerwasthemostprevalentinliverabscespatientswithcoloncancer.Isp:sub-pedunculatedprotrudedtype most frequently encountered (Fig. 3). However, those results are similar to the distribution of colon cancer reported in Japan, the number of patients is too few small to reveal characteristic trends. Destruction of the mucosal barrier of colon and bacterial translocation through them are thought to be the pathogenesis of hepatic abscesses in cases of colon cancer (9, 10). In the present cases, colon cancer was found in 7.3% of all the hepatic abscess patients. Our results are similar to the results of past studies, which reported that the percentage of patients complicated with colon cancer ranged from 5% to 11.5% (11, 12), thus it is not a rare etiology. It is important to examine the lower intestinal tract in hepatic abscess cases that do not have hepatobiliary or pancreatic diseases. Further, in those cases with colon cancer, the existence of metastasis from an extra-hepatic tumor must be ruled out (13), though we could not detect liver metastasis in the present 3 cases with colon cancer. Hepatic abscesses are often caused by malignancy and colon cancer is not a rare complication. Therefore, after performing a PTAD, a general examination including a colonoscopy is a required routine examination. A greater accumulation of liver abscess cases associated with colon cancer is needed to more fully elucidate these issues. References 1. Pitt HA, Zuidema GD. Factors influencing mortality in the treatment of pyogenic hepatic abscess. Surg Gynecol Obstet 140: , McDonald MI, Corey GR, Gallis HA, Durack DT. Single and multiple pyogenic liver abscess. Medicine 63: , Huang CJ, Pitt HA, Lipsett PA, et al. Pyogenic hepatic abscess. Changing trends over 42 years. Ann Surg 223: , Petri A, Höhn J, H di Z, Wolf rd A, Balogh A. Pyogenic liver abscess 20 years experience comparison of results of treatment in two periods. Langenbecks Arch Surg 387: 27-31, Mathieu D, Vasile N, Fagniez PL, Segui S, Grably D, Lardé D. Dynamic CT features of hepatic abscesses. Radiology 154: , Subramanyam BR, Balthazar EJ, Raghavendra BN, Horii SC, Hilton S, Naidich DP. Ultrasound analysis of solid-appearing abscesses. Radiology 146: , Barakate MS, Stephen MS, Waugh RC, et al. Pyogenic liver abscess: a review of 10 years experience in management. Aust NZJ Surg 69: , Teruya T, Miyasato H, Yogi M. A case of descending colon cancer accompanied by liver abscess. J Jpn Soc Coloproctol 58: 89-94, 2005 (in Japanese). 9. Lonardo A, Grisendi A, Pulvirenti M, et al. Right colon adenocarcinoma presenting as Bacteroides fragilis liver abscess. J Clin Gastroenterol 14: , Teitz S, Guidetti-Sharon A, Manor H, Halevy A. Pyogenic liver abscess: warnig indicator of silent colonic cancer. Report of a case and review of literature. Dis Colon Rectum 38: , Cohen JL, Martin FM, Rossi RL, Schoetz DJ Jr. Liver abscess. The need for complete gastrointestinal evaluation. Arch Surg 124: , Yeh TS, Jan YY, Jeng LB, et al. Pyogenic liver abscesses in patients with malignant disease. A report of 52 cases treated at a single institution. Arch Surg 133: , Trump DL, Fahnestock R, Cloutier CT, Dickman MD. Anaerobic liver abscess and intrahepatic metastases: a case report and review of the literature. Cancer 41: , The Japanese Society of Internal Medicine