Hepatic abscess: Diagnosis and management.

Microbial contamination of the liver parenchyma leading to hepatic abscess (HA) can occur via the bile ducts or vessels (arterial or portal) or directly, by contiguity. Infection is usually bacterial, sometimes parasitic, or very rarely fungal. In the Western world, bacterial (pyogenic) HA is most prevalent; the mortality is high approaching 15%, due mostly to patient debilitation and persistence of the underlying cause. In South-East Asia and Africa, amebic infection is the most frequent cause. The etiologies of HA are multiple including lithiasic biliary disease (cholecystitis, cholangitis), intra-abdominal collections (appendicitis, sigmoid diverticulitis, Crohn's disease), and bile duct ischemia secondary to pancreatoduodenectomy, liver transplantation, interventional techniques (radio-frequency ablation, intra-arterial chemo-embolization), and/or liver trauma. More rarely, HA occurs in the wake of septicemia either on healthy or preexisting liver diseases (biliary cysts, hydatid cyst, cystic or necrotic metastases). The incidence of HA secondary to Klebsiella pneumoniae is increasing and can give rise to other distant septic metastases. The diagnosis of HA depends mainly on imaging (sonography and/or CT scan), with confirmation by needle aspiration for bacteriology studies. The therapeutic strategy consists of bactericidal antibiotics, adapted to the germs, sometimes in combination with percutaneous or surgical drainage, and control of the primary source. The presence of bile in the aspirate or drainage fluid attests to communication with the biliary tree and calls for biliary MRI looking for obstruction. When faced with HA, the attending physician should seek advice from a multi-specialty team including an interventional radiologist, a hepatobiliary surgeon and an infectious disease specialist. This should help to determine the origin and mechanisms responsible for the abscess, and to then propose the best appropriate treatment. The presence of chronic enteric biliary contamination (i.e., sphincterotomy, bilio-enterostomy) should be determined before performing radio-frequency ablation and/or chemo-embolization; substantial stenosis of the celiac trunk should be detected before performing pancreatoduodenectomy to help avoid iatrogenic HA.

Massive rectal bleeding distant from a blunt car trauma.

Mesenteric trauma is one of the possible injuries caused by the use of seat belts in case of motor vehicle crash. We report here a rare case of rectal bleeding by rupture of a mesosigmoid haematoma. An emergent laparotomy revealed a mesosigmoid haematoma with a centimetric rectal perforation. The wearing of safety belts added some specific blunt abdominal trauma, which directly depends on lap-and-sash belts. Mesenteric injuries are found out up to 5% of blunt abdominal traumas. "Seat belt mark" leads the surgical team to strongly suspect an intra-abdominal trauma. When "seat belt mark" sign is found, in patients with mild to severe blunt car injuries, CT-scan has to be realised to eliminate intra-abdominal complications, including mesenteric and mesosigmoid ones. In case of proved mesenteric haematoma associated to intestinal bleeding, a surgical treatment must be considered as first choice. Conservative approach remains possible in stable patients but surgical exploration remains necessary in unstable patients with active bleeding.