Pyogenic liver abscess as a late complication after embolization of a hepatic adenoma

http://dx.doi. org/10.1590/0100-3984.2017. 0157 Luiz de Abreu Junior1,2,a, Gustavo Garcia Marques2,b, Ingredy Tavares da Silva2,c, Flávia Munhos Granja2,d, Marcelo Zindel Salem3 1. Grupo Fleury, São Paulo, SP, Brazil. 2. Universidade São Camilo, São Paulo, SP, Brazil. 3. Hospital São Luiz – Rede D’Or, São Paulo, SP, Brazil. Correspondence: Dr. Luiz de Abreu Junior. Grupo Fleury. Avenida General Valdomiro Lima, 508, Jabaquara. São Paulo, SP, Brazil, 04344-903. Email: labreudr@ gmail.com. a. https://orcid.org/0000-0001-7750-6948; b. https://orcid.org/0000-0002-7170-7818; c. https://orcid.org/0000-0003-1596-5190; d. https://orcid.org/0000-0002-2156-5480. Received 18 September 2017. Accepted after revision 19 October 2017. posed of milk), or trichobezoars (composed of hair). Phytobezoars account for 40% of all bezoars and are composed of materials of vegetable origin that human beings cannot digest (seeds, peels, roots, etc.); they develop through a multifactorial process. Individuals with a greater propensity to develop phytobezoars include not only vegetarians but also individuals who do not chew their food well, those with impaired gastric motility, and those with hypochlorhydria, as well as those who have undergone gastrectomy. A history of gastric surgery is a risk factor because it reduces the surface area of the stomach and acid secretions, causing inadequate digestion and allowing larger masses of agglomerated material to pass into the small intestine. Phytobezoars can also occur in patients who have had bariatric surgery. In addition to the aforementioned factors, nonabsorbable sutures can act as vegetable fiber hooks, resulting in a bolus that forms in the anastomosis. Phytobezoar formation evolves to intestinal obstruction in 60% of cases. CT has become the imaging examination of choice for the diagnosis of acute abdominal obstruction, because it is a rapid method that produces high-resolution images to confirm the obstructive scenario, often making it possible identify the etiological factor. On CT, intestinal obstruction is characterized by dilated proximal intestinal loops (with a caliber > 2.5 cm), distal loops that are collapsed or are proportionally smaller than the proximal loops, and intraluminal air-fluid levels. The diagnosis of a phytobezoar should be considered in cases of intestinal obstruction when there is an obstructive intraluminal focal mass that is of low density and contains images suggestive of air bubbles. Modifying the amplitude and centering of the imaging window can facilitate the identification of aspects characteristic of a bezoar, which has been described as looking like “a lump of bread”. The differential diagnoses of a phytobezoar include foreign bodies, abscesses, and a worm bezoar. When the mass is seen in a colonic loop, a diagnosis of fecaloma should also be considered. Jackfruit is common in the northern and northeastern regions of Brazil. Its potential to form phytobezoars is due to its large concentration of fibers and other components such as calcium, phosphorous, and iron. When assessing intestinal obstructions in patients who have undergone bariatric surgery, radiologists should be aware of the possibility of a bezoar as the cause. Preoperative clinical suspicion optimizes the surgical results.