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Chief
complaint
Recurrent RUQ pain 6 months after treatment of liver
abscess
Present
illness
This 48 y/o male had been well before except old pulmonary
TB and GB stones s/p cholecystectomy 30 years ago. He smoked
2/3 PPD for 10 years and drank half bottle of 紹興 per-day for
20 years. In March 2002, gradual onset of intermittent RUQ
pain was noted. There was no fever, diarrhea or vomiting. Body
weight loss about 7 kg in the past 3 months was also noted.
Due to progressive worsening of pain and a newly developed
palpable mass over epigastric area, he visited a local
hospital. Abdominal echo revealed a 4cm hepatic tumor and he
was admitted to our hospital in April for further
evaluation.
After admission, low grade fever and
leukocytosis were noted. There was no significant finding on
physical examination. Abdominal CT revealed a heterogeneous
hepatic tumor with mild left IHD dilatation (figure 1
). Echo-guilded
aspiration showed greenish thick pus. Liver abscess was
diagnosed and antibiotics with Cefmetazole and Metronidazole
were given empirically. Pus culture grew Fusobacterium
nucleatum. Serum IHA and pus cytology were negative. His
symptoms improved and antibiotics was shifted to oral
Cefuroxime 2 weeks later. He was then discharged.
However, recurrent RUQ pain developed
in Sep 2002. He visited our clinic and oral Cefuroxime was
given again for suspicion of recurrent liver abscess.
Follow-up abdominal CT revealed a hypodense cystic hepatic
tumor with progressive dilated left IHD as compared with
previous CT films (figure 2
). He was then admitted again in Nov 2002 for further
study.
Physical
examination
Consciousness: clear
Vital sign: T/P/R: 36.9C/82/16 BP:
142/88 mmHg
Eye: conjunctiva: not pale, sclera: not
yellowish; pupil: isocoric
Neck: supple, no JVE or
LAP
Chest: symmetric expansion, clear breath sound, no
spider angioma
Abdomen: flat and soft, normoactive bowel
sound,
No tenderness or rebound pain, Shifting dullness
(-),
Liver, spleen: impalpable
Extremity: no pitting
edema, no rash
Course and
treatment
After admission, hemogram and blood
chemical values were within normal limit. Elevated CEA (10.9
ng/ml) and CA19-9 (135.4 ng/ml) were noted. Abdominal MRI and
MRCP revealed a cystic hepatic tumor at left lateral segment
with remarkable left IHD dilatation (figure 3
). He received left lateral
segmentectomy on Nov 18, 2002 and pathology revealed biliary
(mucinous) cystadenocarcinoma without lymph node involvement.
Post-OP course was smooth and he was discharged. F/U CEA and
CA19-9 at OPD declined to normal limit.
Lab data
|
CBC/DC |
WBC
K/uL |
Hb
g/dL |
PLT
K/uL |
MCV
fL |
Seg
% |
Eos
% |
Lym
% |
|
|
2002-4-3 |
11380 |
12.6 |
545 |
91.2 |
66.1 |
4.3 |
21.1 |
1st
admission |
| 2002-11-8 |
6610 |
13.5 |
315 |
86.5 |
69.6 |
1.2 |
21.9 |
2nd
admission |
|
BCS+e- |
A/G
g/dL |
T-Bil
mg/dL |
AST
U/L |
ALT
U/L |
ALP
U/L |
rGT
U/L |
BUN
mg/dL |
Cre
mg/dL |
|
2002-4-3 |
3.9/3.3 |
0.4 |
28 |
19 |
265 |
102 |
12.8 |
0.8 |
|
2002-11-8 |
4.4/3.3 |
0.5 |
29 |
19 |
152 |
24 |
18.6 |
0.9 |
| Tumor markers |
AFP
ng/dL |
CEA
ng/mL |
CA19-9
U/mL |
| 2002-4-3 |
<20 |
|
|
| 2002-11-9 |
|
10.9 |
135.4 |
病案分析
本病例為一原發性肝腫瘤以肝膿瘍為起始表現的例子。病患一開始雖有些許肝膿瘍的臨床表現，肝穿刺細菌培養顯示出厭氧細菌，再加上膿瘍細胞檢查沒有不正常細胞組成。但由於屢次斷層掃描與核磁共振檢查都顯示出不正常的膽道擴張現象與持續存在的肝囊狀腫瘤，再加上血清腫瘤標記尤其顯示CA19-9升高，biliary
cystadenocarcinoma mimic liver abscess的可能性需加以考慮。
文獻顯示許多肝腫瘤有時會以肝膿瘍為起始表現，不管是原發性腫瘤(如肝癌，膽管癌，淋巴癌等)或是轉移性肝腫瘤(如大腸癌,胰臟癌等)都在文獻上有所報告。而根據某醫院的系列病例報告中，約有2%的肝癌及8.5%的膽管癌以膿瘍表現。而Biliary
cystadenocarcinoma mimic abscess文獻中也有提及。一般認為長的快速的腫瘤或是有biliary
system involvement的腫瘤就易發生肝膿瘍，另外腫瘤經栓塞或局部治療後也可能形成膿瘍。
分辨true
tumor和abscess最重要的是要注意病患是否有不尋常的症狀或是影像學表現(例如本病人有不尋常的體重減輕和進行性膽道擴張)
，細胞抽吸檢查及血清腫瘤標記可以提供很大的幫忙，另外持續影像學追蹤可疑病兆直到消失甚至必要時病理切片檢查都是必須注意。近幾年因為MRI的進步，有些研究開始利用diffusion-weighted
imaging (DWI) 和apparent diffusion coefficient
(ADC)來做鑑別診斷，似乎有不錯的sensitivity和specificity。而若確定是原發性肝腫瘤，若可能行手術切除，則會有較良好的預後。切除後的血清腫瘤標記及定時的影像檢查可用來追蹤是否復發。
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Case Discussion
繼續教育考題