(357) Pneumoperitoneum in the Setting of Hepatic Abscess Without Known Predisposing Pathology

Introduction: Moderate pneumoperitoneum formation in the absence of an existing hepatic pathology is almost unheard of in current literature. We describe the unique presentation and surgical management of a patient with moderate pneumoperitoneum from a hepatic source without any known predisposing pathology.

Description: A 63-year-old man without significant known medical history presented with a two-week history of right upper quadrant pain and jaundice. A computed tomography (CT) abdomen/pelvis revealed moderate pneumoperitoneum in the perihepatic region with air containing lesions in hepatic segment 6 and mesenteric venous gas. There were also several hepatic and liver cysts concerning polycystic kidney and liver disease. Based on the CT findings, an exploratory laparotomy was performed, though no bowel ischemia or perforations were identified. Cultures from the liver abscess were collected which grew Escherichia coli (E. Coli) and Clostridium perfringens (C. Perfringens). The patient was prescribed metronidazole and vancomycin for treatment. The patient subsequently underwent cholecystectomy with irrigation and debridement of the liver abscess. Post-operatively, the patient had an unremarkable recovery. He was discharged with a drain and no additional complications. The patient is currently undergoing work-up for polycystic kidney and liver disease.

Discussion: In patients without significant known predisposing pathology or evidence of bowel perforation, pneumoperitoneum is rarely reported. In this patient, numerous hepatic and liver cysts were identified on CT and intraoperative ultrasound. Polycystic liver disease can lead to the development of multiple hepatic cysts. Hepatic cysts can become infected due to bacterial translocation from the intestines. In rare cases, hepatic cysts can rupture and form liver abscesses, subsequently resulting in pneumoperitoneum formation. Thus, we propose that untreated polycystic kidney and liver disease should be considered as a potential risk factor for the development of pneumoperitoneum due to bacterial stasis in these cysts, leading to abscesses with gas-producing organisms such as E. Coli and C. perfringens. Abscess drainage and culture-guided antibiotic therapy should be the mainstay treatment, though other causes of pneumoperitoneum must be excluded.