Recurrent Liver Abscess in a Patient with Large Juxtrapapillary Duodenal Diverticulum: A Case Report with Review of the Literature

Juxtra-papillary duodenal diverticulum (JPDD) has been described in association with cholangitis in the literature but has never been described in association with recurrent liver abscess. We present the first described case of recurrent extended spectrum beta lactamase producing (ESBL) liver abscess associated with a large JPDD. A 77 year old male with a past medical history of diabetes mellitus presented to our hospital with a 3 day history of fever, chills and vomiting. Initial blood cultures grew ESBL E. coli. An abdominal CT scan revealed a 2.2 cm hypodense lesion suggestive of a liver abscess in the right lobe of the liver. The abscess was drained and culture also grew ESBL E.coli. The patient was treated with IV Imipenem for 5 weeks. Two weeks after stopping the antibiotics the patient represented with fever. A repeat CT scan again showed a liver abscess in the same location and the blood cultures again grew ESBL E coli. The abscess was again drained under CT guidance and a drain was left in place. After 3 weeks and complete resolution of the abscess the drain was removed and an additional 4 weeks of IV Imipenem was administered. Ten weeks after completing a total of 7 weeks of antibiotic treatment, the patient presented again with fever and a repeat CT scan revealed a new larger abscess at the same location. On further review of the CT scans a large juxtra-papillary inflamed duodenal diverticulum was found abutting the CBD. An EGD confirmed the presence of a large diverticulum in the second part of duodenum. Further work-up with an abdominal ultrasound and an MRCP were negative for any biliary pathology. A colonoscopy was unremarkable except for mild left sided diverticulosis. Prior case reports and series describe an association of JPDD with acute cholangitis. However, this case is unique as recurrent ESBL liver abscess has never before been described in association with JPDD. Past studies also report a higher rate of colonization of JPDD with resistant E. coli. A pathophysiological explanation of the clinical scenario we described is that intermittent CBD obstruction caused by a distended JPDD can lead to reflux of colonized bacteria into the biliary tree resulting in recurrent liver abscess.Figure: CT scan of abdomen showing large duodenal diverticulum with air fluid level.Figure: CT scan image with the liver abscess and the duodenal diverticulum in proximity to the CBD.