EUS–guided abscess drainage in an elderly patient with an abscess in the right liver lobe (with video)

Percutaneous drainage is used as first-line drainage for liver abscesses. However, elderly patients sometimes experience delirium, increasing the risk of tubes being pulled out. Recently, EUS–guided abscess drainage (EUS-AD) is considered an alternative method.[1,2] The right liver lobe is distant from the gastrointestinal wall, making EUS-AD of an abscess in the right lobe challenging.[3] An 89-year-old woman with a high fever, hypotension, and hypoxemia was referred to our hospital. Computed tomography (CT) revealed multiple abscesses in her right liver lobe [Figure 1A]. Antibiotic therapy, oxygen, and a vasopressor were administered. The patient's blood pressure and respiration gradually improved; however, an enlarged abscess in the right liver lobe was observed [Figure 1B]. The patient suffered from delirium, and therefore tubes risked being pulled out. An EUS-AD was attempted [Video 1] despite the gastrointestinal wall being distant to the right liver lobe. The liver abscess was visualized with convex EUS and punctured with a 19-gauge needle from the duodenal wall. Blood vessels were avoided by using color Doppler ultrasonography. After detecting pus, a 0.025-inch guidewire (VisiGlide 2; Olympus, Tokyo, Japan) was placed within the abscess [Figure 2]. The fistula was dilated using MTW catheter, and then a 0.035-inch guidewire (RevoWave SeekMaster hard; Piolax Medical Devices, Yokohama, Japan) was replaced. A 7F × 7-cm double-pigtail stent (Advanix J; Boston Scientific, Tokyo, Japan) was deployed into the abscess [Figure 3]. CT 2 weeks later revealed a residual right liver lobe abscess [Figure 4]. As endoscopic reintervention (E-RI), a fully covered self-expandable metallic stent (8 mm × 8 cm, HANAROSTENT Benefit; Boston Scientific) was placed into the abscess after removing the double-pigtail stent [Figure 5]. One week after E-RI, the liver abscess had completely resolved, and the stent was removed under fluoroscopic guidance.Figure 1: Computed tomography revealed multiple abscesses in the right lobe of the liver (A). The abscess in the right liver lobe was enlarged (B).Figure 2: The liver abscess was punctured with a 19-gauge needle from the duodenal wall that followed a 0.025-inch guidewire that was placed within the abscess.Figure 3: A 7F × 7-cm double-pigtail stent was deployed into the abscess.Figure 4: A residual abscess in the right liver lobe.Figure 5: A fully covered self-expandable metallic stent was placed into the liver abscess.In this case, we described EUS-AD in an elderly patient with an abscess in the right liver lobe that was successfully performed. EUS-AD with internal drainage, which has no risk of self-extraction of tubes compared with external drainage, may be one of the treatment options for elderly patients. Videos are only available at the official website of the journal (http://www.eusjournal.com).