O.O. Afuwape, I.N.C. Chibuzo, O.O Ayandipo and N.A. Nwafulume
Department of Surgery, University College Hospital, Ibadan, Nigeria.
Abstract
Hepatic abscess as a manifestation of sickle cell disease is rare. A 25 year old Nigerian male with sickle cell disease presented with right sided upper abdominal pain, fever, massive hepatomegaly, neutrophilic leucocytosis and mildly deranged liver enzymes. Sonographic findings were a large thin walled right hepatic lobe abscess; with an estimated volume of 2000ml. He had percutaneous laparoscopic trocar drainage of 2250mls of pus with insertion of a drain. The drain was removed after ten days and the patient was discharged home.
Keywords: Hepatic abscess, Trocar drainage, Sickle cell disease
Correspondence:
Dr. Afuwape O.O
Department of Surgery,
University College Hospital,
Ibadan
E-mail: dolafpe@yahoo.co.uk
Phone: 2348035381994
Introduction
Hepatic abscesses could be pyogenic, amoebic or less frequently, fungal.1 Hepatic abscesses are uncommon in the general population (0.029 to 1.47%),2 and are even less common in sickle cell disease.3 The use of less invasive surgical modalities in sickle cell patients improves outcome. We report a case of laparoscopic trocar drainage of a large hepatic abscess in a sickle cell disease patient.
CASE PROFILE
A 25-year old Nigerian Yoruba male with sickle cell disease presented with six weeks history of intermittent fever and right upper quadrant abdominal pain and swelling. The pain was referred to the right shoulder. There was a tinge of jaundice. He had no pruritus. There was no preceding abdominal trauma, dysentery, respiratory tract infection or recent blood transfusion. He had taken multiple courses of oral antibiotics.
On examination, he was acutely ill-looking, pale, febrile (38.6oC) and had a tinge of jaundice. He was tachycardic, with a pulse of 112 per minute. There was reduced air entry in the right lower lung zone of the chest. The abdomen was asymmetrically distended. He had tender hepatomegaly of 16 cm below the right costal margin in the mid-clavicular line and a liver span of 24 cm. The chest X-ray showed elevation of the right hemi-diaphragm with no consolidation or effusion detected. The abdominopelvic ultrasound scan showed hepatomegaly with a liver span of 22 cm and a huge thin walled hypo-echoic collection in the right lobe of the liver, with an approximate volume of 1419 ml (Fig 1).
His haematocrit was 18%. The white blood cell count was 12,550/ul with predominant neutrophilia (70.2%). The clotting profile was deranged with an international normalised ratio (INR) of 1. 56. The liver function test revealed elevated total serum bilirubin of 2.8 mg/ dl, conjugated bilirubin of 2.3mg/dl, elevated liver enzymes: alkaline phosphatase of 226 iu/l; aspartate amino transferase of 112iu/l: alanine transaminase of 44iu/l: - glutamyltransferase of 44 iu/l: hypoalbuminaemia
of 2.4g/dl with total protein of 9.4 g/dl. His serum was non-reactive for Hepatitis C virus, Hepatitis B surface antigen and Human Immunodeficiency Virus. He was transfused with four units of fresh frozen plasma. The INR normalised to 1.04. Parenteral broad spectrum antibiotics were administered empirically.