Recurrent Perihepatic Abscesses Arising from a Gastric Remna
A 66-year-old woman with a history of morbid obesity status post-Roux-en-Y gastric bypass (RYGB) complicated by gastro gastric fistula requiring revision with partial gastrectomy of the remnant stomach with revision of gastrojejunostomy (GJ) presented to her primary care provider with worsening abdominal pain, fevers, chills, and anorexia for 2 weeks. She was instructed to present to the emergency department (ED) for further evaluation. Since her RYGB revision, she had several hospital admissions for recurrent polymicrobial perihepatic abscesses, beginning 5 months after her revision, requiring prolonged courses of IV antibiotics and abscess drainage, however, with no overt cause identified. On exam at the ED, vital signs were notable for a temperature of 101.1 F, blood pressure of 101/55, and a heart rate of 69 BPM after receiving IV fluids and morphine for pain control. Pertinent laboratory assessment revealed alkaline phosphatase (ALP) of 280U/L, alanine transaminase (ALT) of 83 U/L, aspartate aminotransferase (AST) of 208 U/L, and WBC of 11.5 × 109/L with 80% neutrophils. Abdominal computed tomography (CT) scan revealed an 11 cm extrahepatic abscess between the liver and diaphragm and adjacent right pleural effusion.

She was started on broad-spectrum antibiotics and had a CT-guided abscess drain placement, returning 150 mL of green/yellow purulent fluid with subsequent cultures grown Klebsiella pneumoniae and Citrobacter freundii. Following the intervention, she was monitored in the inpatient setting and her clinical picture began to improve. However, due to the recurrent nature of the patient's abscess, the differential for the cause of her presentation was expanded to include fistula, biliary leak, or retained surgical product. An upper endoscopy was performed to assess postsurgical anatomy which revealed Roux-en-Y gastrojejunostomy anatomy with gastrojejunal anastomosis with healthy mucosa and a normal jejunum. A hepatobiliary iminodiacetic acid (HIDA) scan was completed to assess for a biliary leak which revealed a grossly normal hepatobiliary scan with no abnormal tracer accumulation in the right upper quadrant. An early CT fistulogram was completed which identified the known perihepatic collection but did not demonstrate a new fistulous tract. A repeat CT fistulogram showed a fistulous communication to the biliopancreatic limb (Figure 2). However, due to the limitations of the CT fistulogram, suspicion remained for a fistula in a portion of the bypass not adequately visualized. Thus, the patient was discharged on antibiotic therapy with her drain in place and follow-up scheduled with hepatobiliary surgery. She underwent an exploratory laparotomy with findings of a fistulous tract between the gastric remnant staple line and abdominal wall. A portion of the gastric remnant was adherent to the left lobe of the liver. There were no signs of distal obstruction or malignancy that could have contributed to the formation of the fistulous tract. The staple line of the gastric remnant along with the fistula was resected and oversewn in 2 layers with a successful repair. Additionally, the right lobe of the liver was mobilized and no apparent abscess formation was noted. Her postoperative course was complicated by surgical site infection and was managed with local wound care. In the 10 months following her exploratory laparotomy, she has had no further recurrences of perihepatic abscesses.