although several complications of liver abscess have been reported , cases of hepatogastric fistula secondary to liver abscess are rare . there are no established guidelines for the diagnosis and management of this complication .
although surgical management is a definitive treatment , conservative management has also shown clinical improvement in several reports [ 2 - 4 ] .
we present a case of liver abscess complicated by hepatogastric fistula that was successfully managed with surgery .
an 88-year - old woman without relevant medical history visited the emergency room because of generalized weakness associated with fever and chills over the prior 3 days .
laboratory tests revealed a white blood cell ( wbc ) count of 11,380/l , with 87% neutrophils , and a platelet level of 25,000/l .
the patient s blood chemistry profile was as follows : fasting glucose , 103 mg / dl ; total protein , 5.7 g / dl ; albumin , 2.7 g / dl ; total bilirubin , 0.4 mg / dl ; aspartate aminotransferase , 134 u / l ; alanine aminotransferase , 137 u / l ; alkaline phosphatase , 203 u / l ; gamma - glutamyl transferase , 18 u / l ; and amylase , 68 u / l .
c - reactive protein level was 24.37 mg / dl ( normal range < 0.3 mg / dl ) and procalcitonin level was 7.17 ng / ml ( normal range < 0.05 ng / ml ) .
serologic tests for tumor markers were as follows : alpha - fetoprotein , 1.2 ng / ml ( normal range , 0 - 20 ) ; ca 19 - 9 , 46.8 u / ml ( 0 - 37 ) .
a computed tomography ( ct ) scan of the abdomen showed an approximately 5 cm sized lobulated hypodense lesion with internal septa and marginal enhancement in the left lateral section ( fig .
an early liver abscess was initially suspected ; however , the coexistence of cholangiocarcinoma could not be completely ruled out .
initially , ultrasonography - guided aspiration or drainage was not performed due to the lesion s immature characteristics .
an ultrasonography - guided biopsy was performed after 9 days of hospitalization due to the possibility of combined malignancy .
after treatment with intravenous antibiotics for 14 days , fever subsided , and wbc count decreased to 8,910/l .
2 ) 17 days after hospitalization showed low t1 and high t2 signal intensities and rim - like enhancement in the left lateral section .
the anterior wall of the stomach was in close proximity to the liver abscess , and communication between the gastric lumen and the liver was found ( white arrowhead ) . because magnetic resonance imaging showed a more mature appearance compared to the initial ct scan , ultrasonography - guided percutaneous drainage of the liver abscess was performed .
after injection of contrast media through a pigtail catheter , the fistulous tract between the liver and stomach was visualized ( fig .
resection of the involved portion of the stomach and the lateral section of the liver was performed .
liver abscesses may rupture into adjacent pleural , pericardial , and peritoneal cavities   however , fistulization into the gastrointestinal tract is rare [ 2 - 7 ] . to date , there have been only a handful of case reports of a rare complication following liver abscess ( table 1 ) . in previous reports , hepatogastric fistula presented with melena , bilious vomiting , drainage of food particles from the catheter , and/or a sudden decrease in the size of hepatic lesions . however , specific symptoms or signs were not present in our patient .
diagnosis of hepatogastric fistula is generally based on imaging and endoscopic findings . on ct , an abscess cavity with an internal air pocket in continuity with the gastric lumen
fistulous openings in the base of the ulcer may be seen on esophagogastroduodenoscopy . in our case ,
owing to the absence of specific manifestations , the diagnosis of hepatogastric fistula was made accidentally on magnetic resonance imaging and tubography during insertion of a drainage catheter in this patient . in our case ,
the drainage procedure was deferred due to the initial immature features of the abscess cavity , but resulted in spontaneous fistulization into the stomach .
this implies that proper drainage of pyogenic liver abscesses should be recommended to prevent spontaneous abscess rupture into adjacent structures .
early drainage of liver abscess to prevent such complication was also highlighted on previous reports .
definitive guidelines for the management of hepatogastric fistula have not to be identified ; in general , surgical treatment is recommended as a definitive therapy .
conservative management including antibiotics and proton pump inhibitors has also led to spontaneous closure of fistulas [ 2 - 4,6 ] .
we have managed patients surgically for the curative treatment of liver abscess and fistula . in summary ,
the possibility of hepatogastric fistula should be kept in mind in patients with liver abscess for which drainage is delayed , even when there are no specific symptoms .
 hepatogastric fistula following a pyogenic liver abscess is extremely rare , and only a handful of cases have been reported . 
 an 88-year - old female presented with generalized weakness , fever and chills . 
 an abdominal computed tomography scan revealed a 5cm - sized hypodense lesion with internal septa in the left lateral section of the liver . due to initial suspicion of early liver abscess , 
 she was treated with empirical intravenous antibiotics . 
 initially , aspiration or drainage of the liver abscess was not performed due to immature lesion characteristics . 
 an ultrasonography - guided percutaneous drainage of the liver abscess was performed 17 days after hospitalization due to a more mature lesion appearance on follow - up imaging . 
 on tubography , contrast media leakage through the fistulous tract was visualized . 
 surgical management was performed , and she was discharged 2 weeks after surgery . 
INTRODUCTION
CASE REPORT
DISCUSSION