A 72-year-old woman presented with a 6-month history of intermittent right upper quadrant abdominal and right flank pain unrelated to food intake. She denied fever, chills, night sweats, or weight loss. She had a laparoscopic cholecystectomy performed 10 years prior for symptomatic gallstones. Physical examination revealed erythema and mild tenderness on the right lateral aspect of the upper abdomen. Laboratory tests were unremarkable. A computed tomography (CT) of the abdomen showed a complex 21 x 5.8 x 8.8-cm subhepatic fluid collection with internal septations, which fistulized through the abdominal wall, forming a 5.6 x 2-cm subcutaneous fluid collection in the right flank (Figures 1 and 2). A hepatobiliary iminodiacetic acid (HIDA) scan and a magnetic resonance cholangiopancreatography (MRCP) were normal and showed no evidence of a bile leak. Ultrasound-guided drainage of the abscess produced 60 mL of thick, greenish, non-purulent fluid. Examination of the aspirate showed proteinaceous material with few inflammatory cells and many degenerated structures, suspicious for echinococcal cyst, but too poorly preserved for definitive diagnosis. Empiric intravenous ceftriaxone was started after aspiration of the fluid. Bacterial, fungal, and mycobacterial cultures of the abscess were negative, and ceftriaxone was stopped after a week. Testing for Mycobacterium tuberculosis and Entamoeba were negative. The patient was started on albendazole for suspected echinococcosis.
A PAIR procedure (puncture, aspiration, injection, and re-aspiration) with instillation of hypertonic saline was then performed, and 180 mL of thick greenish-white fluid was aspirated. The patient completed 6 weeks of albendazole; however, her symptoms persisted. A repeat CT scan failed to show a decrease in the size of the abscess. During exploratory laparotomy, 500 mL of greenish, non-purulent fluid was drained. Additionally, 28 gallstones were evacuated from the cavity. Fluid cultures were again negative for bacterial, fungal, and mycobacterial organisms. The patient's symptoms resolved following the surgery. Repeat CT scan performed 1 month after the surgery showed complete resolution of the abscess and normal liver parenchyma (Figure 3).