A 72-year-old man comes to the emergency department due to a weeklong history of malaise, fever, dry cough, shortness of breath, and pain in the right upper abdomen. Two months ago, the patient was diagnosed with unresectable adenocarcinoma of the head of the pancreas. He refused chemotherapy, and a palliative biliary stent was placed. Temperature is 38.4 C (101.1 F), blood pressure is 110/64 mm Hg, pulse is 108/min, and respirations are 20/min. Physical examination reveals decreased breath sounds at the right lung base and guarding and tenderness in the right upper quadrant. Laboratory results are as follows: Chest x-ray reveals a pleural effusion on the right side. In addition to intravenous fluids and empiric antibiotics, which of the following is the best next step in management of this patient?

Question

A 72-year-old man comes to the emergency department due to a weeklong history of malaise, fever, dry cough, shortness of breath, and pain in the right upper abdomen.  Two months ago, the patient was diagnosed with unresectable adenocarcinoma of the head of the pancreas.  He refused chemotherapy, and a palliative biliary stent was placed.  Temperature is 38.4 C (101.1 F), blood pressure is 110/64 mm Hg, pulse is 108/min, and respirations are 20/min.  Physical examination reveals decreased breath sounds at the right lung base and guarding and tenderness in the right upper quadrant.  Laboratory results are as follows:  Chest x-ray reveals a pleural effusion on the right side.  In addition to intravenous fluids and empiric antibiotics, which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

This patient with unresectable pancreatic cancer who recently had palliative biliary stenting (eg, to relieve biliary obstruction due to the cancer) now has fever, leukocytosis, elevated liver enzymes, and right upper quadrant (RUQ) pain. This presentation is most concerning for a pyogenic liver abscess, which can result from direct spread from the biliary tract (eg, infected biliary stent) or hematogenous spread through the portal vein (eg, intraabdominal infection) or systemic circulation (eg, endocarditis). Pyogenic liver abscesses usually present with fever, RUQ pain, and hepatomegaly. Leukocytosis and elevated liver enzymes are common, typically with greater increases in alkaline phosphatase and bilirubin than in aminotransferases. When located in the hepatic dome, a liver abscess can cause diaphragmatic irritation and a sterile right-sided pleural effusion; occasionally the abscess may rupture, spread through the diaphragm, seed the pleural space, and create an empyema. Liver abscesses are diagnosed with abdominal imaging (eg, CT scan of the abdomen, ultrasound), which can be performed rapidly and noninvasively. Management includes blood cultures, intravenous antibiotics, and abscess drainage with culture of the aspirated material. (Choice A) Bronchoscopy is sometimes used to evaluate dry cough and shortness of breath because it can visualize the tracheobronchial tree lumen (eg, bronchial obstruction) and/or facilitate bronchoalveolar lavage (eg, atypical respiratory infection). However, this patient's chest x-ray shows a pleural effusion rather than a mass or infiltrates; therefore, after obtaining an abdominal CT scan (to diagnose the underlying hepatic etiology), thoracentesis with pleural fluid analysis is indicated rather than bronchoscopy. (Choice B) CT pulmonary angiography can help diagnose a pulmonary embolism, which may present with tachycardia, tachypnea, and fever; however, RUQ pain and abnormal liver function tests would be atypical. (Choice D) Endoscopic retrograde cholangiopancreatography may eventually be required in this patient (eg, to replace an infected biliary stent) but is not an ideal initial diagnostic tool for liver abscess because it is invasive and can cause complications (eg, pancreatitis). In contrast, an abdominal CT scan is a rapid, noninvasive way to confirm the diagnosis and guide therapy. (Choice E) A hepatobiliary radionuclide scan may be used (typically if ultrasound is equivocal) to diagnose acute cholecystitis, which can cause RUQ pain, leukocytosis, and fever; however, uncomplicated cholecystitis would not be expected to cause liver function test abnormalities (eg, elevated alkaline phosphatase) or a pleural effusion. Educational objective: Pyogenic liver abscesses typically present with fever, right upper quadrant pain, hepatomegaly, leukocytosis, and elevated liver enzymes; an associated right-sided pleural effusion may occur. Diagnosis requires abdominal imaging, and management includes blood cultures, antibiotics, and drainage. References: Pyogenic liver abscess. (http://www.ncbi.nlm.nih.gov/pubmed/31040988)

A 72-Year-Old Man Comes to the Emergency Department Due to a Weeklong