A24) RUQ abdominal pain and fever

Review the Learning Outcomes, Hx, PE and Labs, and begin the module with your Provisional Diagnosis. Keep hitting "Next" to move through the module.

Learning Outcomes

  1. Articulate your relationship with the consulting diagnostic radiologists in the evaluation of a patient with right upper quadrant pain.
  2. Review the DDx considerations in a patient with right upper quadrant pain.
  3. Identify the spectrum of imaging findings in appropriate modalities for evaluating a patient with right upper quadrant pain.

History

Physical Exam

Labs

Provisional Diagnosis

Select the Dx you believe is most appropriate
This immunocompromised patient’s presentation of right upper quadrant pain and tenderness, fever, and leukocytosis in the setting of a previous liver transplant is concerning for a liver abscess.
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Potential Acuity

What is your assessment of the likely acuity for this patient?

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The patient meets sepsis criteria and therefore requires urgent workup and management.

First Imaging Study

What is the first imaging study you will order?

An ultrasound is an appropriate initial step to evaluate the liver parenchyma without ionizing radiation.
View ACR Appropriateness Criteria
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Pertinent Imaging Observations

Click on the links below to view images from the study, and assess these key findings as best you can.

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Second Imaging Study

What is the next imaging study you will order?

CT with IV contrast is a useful tool for the assessment of hepatic pathology such as liver abscess (including the ones <5 mm) and metastatic disease.
View ACR Appropriateness Criteria
Well done. You were correct

Pertinent Imaging Observations

Click on the links below to view images from the study, and assess these key findings as best you can.

View Report

Watch our video

View the full study if you'd like to like a look yourself

Third Imaging Study

What is the next imaging study you will order?

The diagnosis is made with the ultrasound and CT.

What is your Diagnosis now that you have seen the imaging results?

The patient’s clinical presentation is consistent with a liver abscess.

Current Acuity

Initially, you selected and we suggested acuity.

Has your concern for this patient changed?

This patient requires urgent management for their sepsis secondary to their hepatic abscess.

Assessment and Plan

Please provide your assessment and plan for this patient

The patient is a 55-year-old male with a prior liver transplant presenting with a sepsis secondary to a hepatic abscess. Blood cultures should be collected. The patient should be started on IV fluids, empiric, broad spectrum, antibiotics. Interventional radiology should also be consulted to evaluate for image-guided drainage.

Lessons Learned:
- Patients with a liver abscesses may present with nonspecific symptoms of fever, malaise, nausea, and RUQ pain.
- Ultrasound is a good initial imaging modality for patients presenting with right upper quadrant pain due to its lack of ionizing radiation and ability to distinguish solid and cystic masses. Findings would reveal a hypoechoic, heterogeneous intrahepatic lesion without internal blood flow within the abscess cavity.
- CT with IV contrast can be performed to confirm the diagnosis following an ultrasound. A liver abscess would have a heterogenous hypodense area of fluid density with an enhancing border. In some cases, abscesses may contain gas.
- The cluster sign is a feature of pyogenic hepatic abscesses and occurs when multiple low attenuation liver lesions are localized in an area to form a solitary abscess cavity.
- Treatment involves broad-spectrum antibiotics and drainage if symptoms do not subside. Urgent management is needed to prevent infection and sepsis.

Socioeconomic Factors:
- A prospective study was conducted to determine that 81.82% of patients in their cohort diagnosed with liver abscesses were of lower socioeconomic status. Poor living conditions, crowded homes, contaminated water, and poor hygiene are likely to contribute to this disparity.
- Along with low socioeconomic status, alcoholism is another major risk factor that may increase the incidence of liver abscess.

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