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SAEM Clinical Images Series: A Dangerous Cause of Abdominal Pain

Posted by Ho Tai-Hung, MD on

A 65-year-old male presented with chest and abdominal pain for three weeks. He endorsed a poor appetite and a weight loss of 16 kilograms in the last month. He denied fever, vomiting, diarrhea, and tarry stools and described having his usual bowel movements.

Additional Images

Physical Exam

Vitals: BP 172/71; HR 127; T 35.9°C; O2 Sat 100%

General: In acute distress

Cardiovascular: Regular rate and rhythm; no murmur; bilateral upper extremity and lower extremity pulses palpable

Gastrointestinal: Soft; generalized tenderness, no abdominal masses, palpable subcutaneous emphysema

Laboratory Data

Complete blood count (CBC): WBC 31 x 10^3/mcl; Hgb 15 g/dl; Hct 49.1%; Plt 477 x 10^3/mcl

Basic metabolic panel (BMP): Na 130 mmol/L; K 5.6 mmol/L; Glucose 538 mg/dL

CRP: 42.6 mg/dL

Ketone body: 5.9 mmol/L

Venous blood gas (VBG): pH 6.967; pCO2 27.9 mmHg; pO2 45.8 mmHg; BE -24.7 mmol/L

Case Question: What is the diagnosis?

Rupture of gas-forming pyogenic liver abscess complicated by necrotizing fasciitis. The most common pathogen is Klebsiella pneumoniae, and diabetes mellitus is the most common risk factor.

Case Question: What is the treatment?

Treatment includes drainage, systemic antibiotic therapy, and emergent surgical intervention.

Case Discussion

Take-Home Points

  • Gas-forming pyogenic liver abscess is a rare but life-threatening disease. Consider it especially in the patient with abdominal pain with diabetes mellitus.
  • Treatment includes not only drainage and systemic antibiotic therapy, but also emergent surgical intervention if complicated by necrotizing fasciitis.

References

  • Chen CE, Shih YC. Monomicrobial Klebsiella pneumoniae Necrotizing Fasciitis With Liver Abscess: A Case Report and Literature Review. Ann Plast Surg. 2017 Mar;78(3 Suppl 2):S28-S31. doi: 10.1097/SAP.0000000000001001. PMID: 28177973.
  • Cheng NC, Yu YC, Tai HC, Hsueh PR, Chang SC, Lai SY, Yi WC, Fang CT. Recent trend of necrotizing fasciitis in Taiwan: focus on monomicrobial Klebsiella pneumoniae necrotizing fasciitis. Clin Infect Dis. 2012 Oct;55(7):930-9. doi: 10.1093/cid/cis565. Epub 2012 Jun 19. PMID: 22715175.

Copyright

Images and cases from the Society of Academic Emergency Medicine (SAEM) Clinical Images Exhibit at the 2023 SAEM Annual Meeting | Copyrighted by SAEM 2023 – all rights reserved. View other cases from this Clinical Image Series on ALiEM .

Author information

Ho Tai-Hung, MD

Resident Physician
Taipei Veterans General Hospital

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The post SAEM Clinical Images Series: A Dangerous Cause of Abdominal Pain appeared first on ALiEM.

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