Asian Journal of Surgery (2017) 40, 66e69

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CASE REPORT

An unusual cause of acute abdomend

Gas-forming liver abscess due to
Salmonella enteritidis
Harry Hok Tee Yu, Simon Tsang, Tan To Cheung*

Department of Surgery, University of Hong Kong, Hong Kong, China

Received 23 January 2013; received in revised form 25 March 2013; accepted 9 July 2013
Available online 23 August 2013

KEYWORDS Summary Gas-forming pyogenic liver abscess (GFPLA) is considered to be a very severe form of
acute abdomen; PLA and carries a high mortality. Klebsiella pneumoniae is the most common pathogen respon-
free gas; sible for the disease, whereas cases where Salmonella is cited as the cause are very uncommon.
gas forming; We report the first case of a 53-year-old lady suffering from GFPLA due to Salmonella, who was
liver abscess; successfully treated with surgical drainage. To the best of our knowledge, this is the first case of
Salmonella GFPLA caused by Salmonella enteritidis to be reported in the English literature.
enteritidis Copyright 2013, Asian Surgical Association. Published by Elsevier Taiwan LLC. This is an open
access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-
nd/4.0/).

1. Introduction illness. However, the classical triad of abdominal pain,

fever, and chills may only account for a third of patients.1
Pyogenic liver abscess (PLA) is the most common form of Overall, 32.5% of GFPLA patients may present with shock,
liver abscess. Its incidence varies from 1.1 per 100,000 in- compared to 11.7% in the nongas-forming group.2
dividuals in Europe to 17.6 per 100,000 in Asia. A rising Because the mortality of patients suffering from GFPLA
prevalence rate in liver abscess is also reported.1 The can be as high as 27.7% as compared with the 14.4% mor-
incidence of gas-forming PLAs (GFPLAs) accounts for tality in the nongas-forming group,2 prompt recognition of
10e20% of all PLAs. the condition upon presentation is crucial. Any delay in
Common presentations of PLA include abdominal pain, treatment may result in hospital mortality.
fever, chills, nausea and vomiting, and a general feeling of

* Corresponding author. Department of Surgery, University of

2. Case report
Hong Kong, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong,
China. A 53-year-old woman, who works as a waitress in a
E-mail address: tantocheung@hotmail.com (T.T. Cheung). restaurant, was admitted through the emergency

http://dx.doi.org/10.1016/j.asjsur.2013.07.014
1015-9584/Copyright 2013, Asian Surgical Association. Published by Elsevier Taiwan LLC. This is an open access article under the CC BY-
NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
Unusual gas-forming pyogenic liver abscess 67

department for fever and epigastric pain radiating to the

back. Apart from osteoarthritis of the knees, which was
relieved by simple analgesia, she has enjoyed good health
in the past.
An examination on admission revealed epigastric
tenderness, dyspnea, and decreased breath sound on the
right. Her white blood cell count was 23  109/L on
admission, and the serum bilirubin level was 45 mmol/L.
Other laboratory results were as follows: serum alkaline
phosphatase level, 132 U/L; serum aspartate aminotrans-
ferase level, 328 U/L; serum alanine aminotransferase,
376 U/L; international normalized ratio, 1.8; serum glucose
level, 1.7 mmol/L.
Radiography of the chest was performed (Fig. 1). The
chest X-ray showed mild haziness over the right lower zone
of the lung. In addition, there was a lucency occupying the
right subphrenic area. In view of the patients clinical
condition and abnormal chest X-ray result, an urgent
computed tomography (CT) scan of the abdomen with
contrast was performed that showed a 16.5-cm gas-forming
liver abscess involving segments 6e8 (Fig. 2).
CT-guided drainage of the liver abscess was performed,
Figure 2 Contrast computed tomography: faintly rim-
but only a minimal amount of pus was obtained. The pa-
enhancing gas-forming abscess in the right lobe of the liver.
tient continued to run a high fever with hypotension. A
decision was made to perform laparotomy and open enteritidis. The bacteria were sensitive to piperacillin. A
drainage of the liver abscess. During the laparotomy, a histology section of the abscess did not yield any evidence
large amount of turbid fluid was noted in the peritoneal of malignancy. The abdominal drains were removed 3
cavity. The liver was grossly edematous and the large ab- weeks after the operation. The patient was given 3 weeks
scess was seen at the dome of the liver with pus and gas of intravenous piperacillin and 3 weeks of oral amoxicillin/
discharge. Open drainage was then performed. Operative cavulanate, and was discharged home 49 days after the
cholangiogram showed contrast leakage into the abscess procedure. The T tube was removed 6 weeks after the
cavity, indicating the communication of the bile duct to the operation. A reassessment contrast CT scan showed reso-
abscess. The common bile duct was explored, and a T-tube lution of the liver abscess at 3 months after the operation
was placed to facilitate biliary drainage in a controlled (Fig. 4).
manner (Fig. 3). Abdominal drains were placed in the ab-
scess cavity and the subhepatic area. The patient was
supported in the intensive care unit after the operation. 3. Discussion
Both abscess tissue and pus only yielded Salmonella
GFPLA is a rare condition that carries a high mortality. The
usual cause of PLA is mainly due to portal seeding from
appendicitis and diverticulitis. With the improvement of
antibiotics, biliary tract diseases have become the most
common identifiable cause, although most of them are
cryptogenic in origin.3 Patients with compromised immu-
nology may be more often affected. Diabetes mellitus is not
regarded as a cause of PLA; however, a high prevalence of
the disease is noted among patients suffering from PLA in
Asia. Reports suggested that about 43% of patients suffering
from PLA are known to have diabetes.1,4 An even higher
proportion of diabetic patients are noted in gas-forming
entities associated with higher mortality rates.1,2,4
In the management of this patient, a prompt decision to
operate was made. Apart from drainage of the liver ab-
scess, cholecystectomy was performed as cholecystitis was
the usual source for liver abscess formation. Operative
cholangiogram was performed in the same operation to
identify the presence of a possible biliary stone or sludge
that could have led to liver abscess formation. Because the
liver abscess contained a large portion of solid debris, open
drainage and debridement of the abscess had been per-
Figure 1 Erect chest X-ray on admission: lucency below the formed. The displaced intrahepatic duct was unavoidably
right diaphragm. broken down together with the abscess. Because the
68 H.H. Tee Yu et al.

complete maturation of the T-tube track. (We had an un-

pleasant experience of leakage from the tract when the T
tube was removed prematurely.)
The usual organisms found in the liver abscess were
Gram-negative bacterium. Mezhir et al3 reported that
multiple microorganisms were usually cultured in Western
countries, and the most common species include Strepto-
coccus, Enterococcus, and Escherichia coli. By contrast,
studies in Asia showed that Klebsiella pneumoniae were the
most predominant bacteria (63e79%), followed by Escher-
ichia coli. Single microorganisms were responsible in the
majority of cases in Asia.1,2,5,6 In the case of GFPLAs, K.
pneumoniae is the most frequently cultured organism, ac-
counting for 87% of cases.2 Salmonella is a rare pathogen
for PLAs. Since 2000, only two reports of Salmonella-
related PLA have appeared in the English literature. Both
reports found that patients with immunocompromised sta-
tus were at risk for this condition.7,8 This study represents
the first report of a GFPLA due to Salmonella species
without an underlying pathology.
GFPLA is a condition where vigorous metabolism and
growth of bacteria are seen. Bacteria obtain their energy
Figure 3 Operative cholangiogram: contrast extravasation through fermentation of glucose, which leads to an accu-
via right anterior bile duct into the abscess. mulation of acids and introduction of an acidic environ-
ment. Salmonella, a gas-forming microorganism, will
produce formic hydrogen lyase, which converts formic acid
operative cholangiogram had successfully identified the to CO2 and H2. The accumulation of gas involves the
leakage, exploration of the common bile duct and T-tube increased production of gas, impaired transportation of
placement for external drainage was performed. The T- gas, and equilibrium between the gas in the local tissue and
tube placement aimed to ensure adequate drainage of the that in the abscess.9 Salmonella-related GFPLA is rare. Our
bile and enhanced the healing of the biliary system. case is the first report since Lee et al7 had reported a
Alternatively, Endoscopic retrograde cholangiopancreatog- spontaneous GFPLA by the bacteria within a hepatocellular
raphy (ERCP) could be performed after the operation if carcinoma. The gas-forming ability of Salmonella is also
persistent leakage of the bile is noted in the drainage tube. reported in other organs.10
Because the patient was in shock during the operation, the Empirical antibiotics are mandatory for the treatment of
surgeon decided to advocate a more definitive approach for PLA. Systemic antibiotics alone have been shown to be
biliary drainage. In our institute, T tubes are usually effective for small-sized abscesses (<3 cm) in well-selected
removed 6 weeks after the operation in order to allow a patients.11 Drainage of the abscess, either percutaneous or
operative, facilitates recovery in larger size abscesses. There
is no consensus on the mode of drainage with regard to the
characteristics of the abscess. Hope et al11 reported that 83%
of uniloculated abscesses larger than 3 cm can be drained
percutaneously, whereas only 33% of the complex multi-
locular abscess can be drained percutaneously. Tan et al6 also
suggested that surgical drainage for abscesses larger than
5 cm provides better clinical outcome in terms of reduced
need for reintervention and shorter hospital stays, with
comparable morbidity and mortality rates. However, others
reported conflicting results.3 In general, percutaneous
drainage is regarded as the priority choice in view of the
improvements in imaging and avoidance of general anes-
thesia. Surgical drainage is reserved for those who had been
unresponsive to medical treatment and for whom the
percutaneous option failed, and those who had ruptured
abscess with peritonitis, anatomical difficulty in performing
percutaneous drainage, or primary intra-abdominal pathol-
ogy.1,2,5 Nonetheless, if biliary communication is evident,
concomitant biliary drainage should be considered.
The prognosis of the PLA can be predicted by the
severity of the disease at presentation. A retrospective
Figure 4 Computed tomography scan after 3 months showed study had reviewed 298 patients suffering from PLA. A
regression of the liver abscess without gas content. multivariate analysis identified GFPLA, anaerobic infection,
Unusual gas-forming pyogenic liver abscess 69

Acute Physiology and Chronic Health Evaluation II (APACHE) 3. Mezhir JJ, Fong Y, Jacks LM, et al. Current management of
II score, and Simplified Acute Physiology II (SAP II) score as pyogenic liver abscess: surgery is now second-line treatment. J
independent variables and to be statistically significantly Am Coll Surg. 2010;210:975e983.
affecting the mortality rate of PLA. In patients affected by 4. Yang CC, Chen CY, Lin XZ, et al. Pyogenic liver abscess in
Taiwan: emphasis on gas-forming liver abscess in diabetes. Am
PLA, an APACHE II score of more than 14 or a SAP II score of
J Gastroenterol. 1993;88:1911e1915.
more than 27 resulted in a markedly increased risk of 5. Chen SC, Huang CC, Tsai SJ, et al. Severity of disease as main
mortality, whereas an APACHE II score lower than 6 or a SAP predictor for mortality in patients with pyogenic liver abscess.
II score below 22 indicated a zero mortality rate.5 Our pa- Am J Surg. 2009;198:164e172.
tient is classified as a high-risk patient because she has an 6. Tan YM, Chung AYF, Chow PKH, et al. An appraisal of surgical
APACHE II score of 6 and a SAP II score of 31. and percutaneous drainage for pyogenic liver abscesses larger
Immediate diagnosis of the condition, decisive surgical than 5 cm. Ann Surg. 2005;241:485e490.
management, and dedicated intensive care during the 7. Lee CC, Poon SK, Chen GH. Spontaneous gas-forming liver ab-
postoperative period are the key to surviving this critical scess caused by Salmonella within hepatocellular carcinoma: a
disease. case report and review of the literature. Dig Dis Sci. 2002;47:
586e589.
8. Chou YP, Changchien CS, Chiu KW, et al. Salmonellosis with
liver abscess mimicking hepatocellular carcinoma in a diabetic
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