S3626 Hepatic Abscess in Acute-on-Chronic Pancreatitis: A Rare and Challenging Complication

Introduction: Liver abscesses are an extremely rare complication in patients with acute-on-chronic pancreatitis. We present the case of a 68-year-old man with chronic pancreatitis who developed cholangitis and a liver abscess. Case Description/Methods: The patient, with a history of chronic pancreatitis due to pancreatic duct stones and multiple endoscopic retrograde cholangiopancreatography (ERCP)/endoscopic ultrasound (EUS) stent placements, presented with a 3-day history of fever, vomiting, and worsening abdominal pain. The pain was dull and non-radiating, with an intensity of 8/10. Abdominal examination revealed hyperactive bowel sounds and tenderness in the epigastrium and right upper quadrant, with a liver span of 14 cm. Laboratory results showed leukocytosis, lactic acidosis, and elevated liver and kidney enzymes. Imaging revealed loculated hypodense foci in liver segment 7, biliary dilatation, an obstructed common bile duct, and a pancreatic duct stent terminating at the ampulla. The patient was diagnosed with acute cholangitis and started on broad-spectrum antibiotics (meropenem), intravenous pressors, and fluids. An EUS/ERCP procedure successfully drained pus and sludge, replaced the pancreatic stent, and placed a covered metal stent. Despite initial improvement, the patient developed worsening abdominal pain, leukocytosis, lactic acidosis, increased pressor requirements, and acute kidney injury. A computed tomography-guided drainage of a right liver dome abscess was performed, yielding bilious fluid, and a JP drain was placed. Blood and fluid cultures grew Klebsiella and Streptococcus, and meropenem was switched to Zosyn and vancomycin. The patient’s condition improved the following day. Discussion: Liver abscesses can develop through portal circulation, biliary infections, or hematogenous spread. In this case, portal circulation involvement due to recurrent pancreatitis seemed most plausible. The morbidity and mortality rates for liver abscesses range from 2%-12%, depending on underlying conditions. Diagnosis involves radiographic imaging, followed by aspiration and culture of abscess material. Liver abscesses are typically polymicrobial or monomicrobial, with the microbial results guiding further infection evaluation. In conclusion, we present a rare case of pancreato-liver abscess in chronic pancreatitis, treated with antibiotics and percutaneous drainage, leading to satisfactory resolution.