Numerous liver abscesses after transjugular intrahepatic portosystemic shunt for decompensated liver cirrhosis: A case report

Abstract

BACKGROUND

Liver cirrhosis patients can develop various complications including bacteremia as the intestinal flora is heterologous. In those with low immunity, trauma, or following surgery, etc., the body is susceptible to concurrent systemic or local infections. Under these circumstances, even minimally invasive treatment methods such as interventional therapy like transjugular intrahepatic portosystemic shunt (TIPS) for liver cirrhosis patients can also result in complications such as infections.

CASE SUMMARY

A male patient with decompensated cirrhosis experienced multiple episodes of gastrointestinal bleeding and hypersplenism. He was admitted to hospital due to voluntary remedial TIPS. The patient developed a numerous intrahepatic liver abscess postoperatively. Following initial conservative treatment with intravenous antibiotics and parenteral nutrition, three months after TIPS, the liver abscess had disappeared on imaging examination. At the 6-month postoperative follow-up, outpatient re-examination showed that the patient had recovered and the liver abscess had resolved.

CONCLUSION

Attention should be paid to decreased blood cell counts, especially low leukocyte levels in patients with liver cirrhosis as the presence of intestinal microbiota dysregulation and portal pyemia can result in liver abscess and sepsis during invasive diagnostic and therapeutic procedures like TIPS. The addition of probiotics might reduce the risk in such patients.

Key Words: Liver cirrhosis; Portal hypertension; Transjugular hepatic portosystemic shunt; Numerous liver abscesses; Case report

Core Tip: Transjugular intrahepatic portosystemic shunt (TIPS) is currently used for the treatment of portal hypertension and its complications though numerous liver abscesses induced by such interventional minimally invasive treatment is uncommon. We report a case of numerous hepatic abscesses in a patient with decompensated cirrhosis postoperatively after TIPS. Following prolonged conservative treatment with intravenous antibiotics and supportive therapy, the liver abscesses disappeared, and the patient recovered completely.

INTRODUCTION

Patients with decompensated cirrhosis frequently have splenomegaly and hypersplenism, presenting with low white blood cell, red blood cell and platelet counts[1]. In particular, patients with a low white blood cell count are prone to develop concurrent abdominal infections, peritonitis, and other infections. Intestinal dysbiosis and inflammation in cirrhosis can also cause bacteremia leading to portal pyemia[2]. Even minimally invasive treatment methods for patients with liver cirrhosis can also be complicated by infectious lesions in various organs[3]. However, numerous liver abscesses induced by interventional minimally invasive treatment are uncommon.

Transjugular intrahepatic portosystemic shunt (TIPS) is currently used for the treatment of portal hypertension and its complications, such as variceal bleeding and refractory ascites, and achieves good clinical results[4]. Here, we report TIPS in a patient with decompensated cirrhosis, who developed numerous hepatic abscesses postoperatively. Following prolonged conservative treatment with intravenous antibiotics and supportive therapy, the liver abscesses disappeared, and the patient recovered fully.

CASE PRESENTATION

Chief complaints

A 47-year-old male patient who was admitted to our hospital for voluntary remedial TIPS for the management of decompensated liver cirrhosis. He presented without any gastrointestinal bleeding symptoms and was promptly assessed. A timely endoscopic examination was performed, and acid suppression was initiated.

History of present illness

Gastroscopy revealed esophageal-gastric varices, no visible bleeding but an ulcer scar was identified in the varicose veins at the base of the stomach. Abdominal computed tomography (CT) revealed liver cirrhosis and esophageal-gastric varices, splenomegaly, and a small amount of ascites.

History of past illness

Gastrointestinal bleeding in this patient was treated with medication, multiple endoscopic bands and sclerotherapy over the past three years.

Personal and family history

The patient has no relatives with similar illnesses or any family history of cirrhosis.

Physical examination

The patient presents with facial features of chronic liver disease and anemia. Examination of the heart and lungs were unremarkable, and the abdomen was flat and soft. The liver was not palpable and the spleen was palpable subcostally (three finger breadths). There was no edema in the lower limbs.

Laboratory examinations

Laboratory tests showed that he had low white blood cell, red blood cell and platelet counts (Table 1).

Table 1 Baseline characteristics of the patient.

Characteristics	Pre-TIPS	Three days post-TIPS
Viral hepatitis	B	B
Child–Pugh A/B/C	A	B
MELD score	6	15
Laboratory tests
Alanine transaminase (U/L)	22	1531
Aspartate transaminase (U/L)	39	1776
Alkaline phosphatase (U/L)	93	140
Total bilirubin (mol/L)	8.7	26.1
Albumin (g/L)	35.9	26.3
Prothrombin time (s)	14.0	21.5
White cell count (109/L)	1.70	3.50
Red cell count (1012/L)	4.01	2.78
Hemoglobin (g/L)	106	73
Platelet count (109/L)	58	54
Clinical presentation
Jaundice	No	No
Splenomegaly	Large	Large
Lower limb edema	No	No
Ascites	Moderate	No
Pleural fluid	No	No
Varices	Moderate	Moderate

TIPS: Transjugular intrahepatic portosystemic shunt; MELD: Model of end-stage liver disease score.

Imaging examinations

This patient underwent gastroscopy examination that revealed esophageal-gastric varices, no visible bleeding but there was an ulcer scar in the varicose veins at the base of the stomach. Abdominal magnetic resonance imaging and CT portal venous phase showed cirrhosis, splenomegaly, and left portal vein thrombosis in the liver. After 3 days of TIPS, abdominal CT showed multiple small abscesses in the liver. After 45 days, liver CT showed multiple small abscesses, with a significant reduction in number. After 60 days, abdominal CT arterial and venous phases showed that the intrahepatic abscesses had disappeared and the TIPS shunt was patent (Figure 1).

Figure 1 This patient with decompensated cirrhosis underwent transjugular intrahepatic portosystemic shunt placement, developed numerous hepatic abscesses postoperatively, and subsequently recovered. A and B: Gastroscopy revealed esophageal-gastric varices, no visible bleeding but there was an ulcer scar in the varicose veins at the base of the stomach; C-E: Abdominal magnetic resonance imaging and computed tomography (CT) portal venous phase showed cirrhosis, splenomegaly, and left portal vein thrombosis in the liver; F-H: Angiography during transjugular intrahepatic portosystemic shunt (TIPS) revealed thickening of the portal vein; varicose veins did not appear after coil embolization; and the contrast agent flowed smoothly into the cardiac cavity through the implanted stent-graft; I-K: After 3 days, abdominal CT showed multiple small abscesses in the liver; L and M: After 30 days, abdominal CT showed multiple small abscesses in the liver, but slightly reduced in number; N and O: After 45 days, liver CT showed multiple small abscesses, with a significant reduction in number; P and Q: After 60 days, abdominal CT arterial and venous phases showed that the intrahepatic abscesses had disappeared and the TIPS shunt was patent.

FINAL DIAGNOSIS

The patient was diagnosed with decompensation of cirrhosis and gastrointestinal bleeding.

TREATMENT

Following prompt administration of antibiotic medications, the patient was generally stable. Comprehensive evaluation of liver function showed Child-Pugh class B, and the Model for End-stage Liver Disease score was 9. According to current guidelines, the patient was treated with TIPS for managing portal hypertension. TIPS was performed under local anesthesia as previously described[5]. The RUPS-100 puncture system was introduced into the right hepatic vein, and successfully punctured to the left branch of the intrahepatic portal vein. All varicose veins were embolized with coils, and the intrahepatic puncture tract was dilated with a balloon. A covered stent (Viatorr; 8 ´ 60 ´ 20 mm) was implanted in the shunt tract. After stent implantation, follow-up portal angiography showed good intrahepatic portal venous perfusion, and the portal gradient was reduced to less than 12 mmHg. Two distinct gastroesophageal collateral vessels observed during TIPS were coiled (Cook Inc., Bloomington, IL, United States) Subsequently, direct angiography was performed to assess whether the portal system was completely patent.

After the TIPS procedure, intravenous heparin (4000 U/day; Sanofi Pharma Co., Ltd., France) was administered for 3 days. Oral warfarin was not administered due to low platelet count.

OUTCOME AND FOLLOW-UP

TIPS decreased the portosystemic gradient from 40 to 12 mmHg. There were no intraoperative bleeding procedure-associated complications. There were no symptoms of recurrent gastrointestinal bleeding after TIPS and the hemostasis rate was 100%.

Three days after TIPS, the patient presented with fever and cough, and laboratory tests showed that he had lower white blood cell and platelet counts than pre-TIPS. Chest and abdominal CT revealed no other infectious lesions, but ultrasound and abdominal CT showed multiple small abscesses in the liver.

Due to the small size of these abscesses, transhepatic puncture biopsy was unsuitable, and incubation of bacteria in multiple blood cultures failed. Sulperazon (Cefoperazone + Sulbactam) was administered pre-TIPS, the patient then underwent conservative treatment with intravenous Tienam (Imipenem + Cilastatin sodium), parenteral nutrition, infusion of plasma, and infusion of coagulation factors periodically. After three days, fever and cough symptoms had disappeared, and did not recur. Thereafter, there was a consistent pattern of weakness, lassitude, and intermittent lower limb edema without ascites.

A CT of the upper abdomen one and a half months later revealed small, sparse foci of abscess in the liver. At 2 months postoperatively, outpatient re-examination of the abdominal CT showed that the liver abscesses had disappeared, and his general condition had improved. Transient minor hepatic encephalopathy occurred one month postoperatively, and the symptoms disappeared after oral administration of ornithine aspartate. At an outpatient follow-up visit, the patient’s overall condition was good.

DISCUSSION

We report a patient with decompensated cirrhosis and recurrent gastrointestinal bleeding who underwent TIPS placement and subsequently developed numerous liver abscesses. The patient was treated with antibiotic therapy, supportive care and subsequently recovered.

Comlpications of TIPS included TIPS procedure itself, the stent, portosystemic shunting, and so on[6]. These complications are rare and can include arrhythmias, hemoperitoneum, liver capsule rupture, stent migration, kinking, hemolytic anemia, hepatic ischemia, and infarction which compromise liver function and are also recognized[7].

However, cases of numerous hepatic abscesses after TIPS are rare. The patient in this study who had decompensated cirrhosis and recurrent gastrointestinal bleeding developed numerous hepatic abscesses after the TIPS procedure. Chest and abdominal CT revealed no other infectious lesions, but numerous small abscesses were identified in the liver. With nearly three months of antibiotic therapy and supportive care, the patient recovered, and this experience has provided some important lessons.

Cirrhosis is a well-known pro-inflammatory state, and it has been shown that in patients with cirrhosis, intestinal microflora imbalance (increased number of Enterobacter species, decreased number of Clostridium species) and displacement may promote the inflammatory reaction[8]. Thus, in this circumstance, the patient is prone to local or systemic infection. Interventional therapy such as minimally invasive treatment methods for patients with liver cirrhosis can also result in complications such as infectious lesions[9], and TIPS, which involves surgery, alters the hemodynamics of the liver and portal venous system and has been implicated in a catastrophic hepatic complication in our case.

This patient had cirrhosis, splenomegaly and hypersplenism with low preoperative blood cell levels, especially leukocytes before TIPS placement. After the TIPS procedure, the white blood cell count was lower, but we did not find any symptoms of rebleeding. We also reviewed the gastroscopy results and did not find any signs of rebleeding. This may have been due to factors such as sepsis which caused the decreased hemoglobin level. We only focused on the patient's postoperative recurrent gastrointestinal bleeding and reviewed the gastroscopy, but did not focus on the low level of white blood cells and hemoglobin, and whether this was due to infection.

The intestinal flora is dysregulated in cirrhosis, and often displaced[10]. TIPS, which aggravates dysregulation of the intestinal flora, particularly by the opening of the hepatic shunt, may also aggravate the displacement of harmful flora in the intestine[11]. In addition, reduced white blood cells in hypersplenism and lower immune function in cirrhosis could have led onto the development of extensive hepatic abscesses.

In this patient, a transhepatic biopsy of the intrahepatic lesion was not performed, and the causative agent was not identified following blood culture. Due to the small size of the intrahepatic abscesses and the concerns regarding the possibility of additional infection resulting from the needle biopsy, we decided to treat the patient with intravenous Tienam empirically with an improvement of his condition.

CONCLUSION

This case highlights the importance of considering serious infections including liver abscess in patients with cirrhosis following invasive treatments including TIPS. Preoperatively, attention should be paid to decreased blood cell counts, especially low leukocyte levels. In addition, the presence of intestinal microbiota dysregulation and displacement should be considered, and whether to add probiotics has become a topic of discussion for such patients.

ACKNOWLEDGEMENTS

The authors would like to thank the patients who participated in this study as well as their colleagues at our hospital for their contribution in the data collection process.