Chronic appendicitis complicated by appendicular abscess, pylephlebitis and liver abscess

FINDINGS: Two phase contrast CT shows occlusion of the left main portal vein and its tributaries. Evidence of a heterogenous hepatic lesion subcapsular in segment II, measuring 4,5 x 2,7 x 3 cm. The lesion demonstrates a hypodense center and a double ring, the thin inner ring being hyperdense and the thicker outer ring hypondense, compared to the adjacent liver parenchyma. Hyperperfusion of the left liver lobe in the arterial phase, most likely due to occluded left portal vein branch and consecutive predominant arterial supply of the left liver parenchyma via the hepatic artery.

The appendix appears mildly swollen with moderate surrounding fat stranding. There is evidence of a fluid collection medial to the tip of the appendix with a thick hyperdense wall and hypodense content alongside some gas bubbles. This formation measures 6,5 x 2 x 3 cm and abutts the urinary bladder. The right ventral bladder wall appears markedly thickend. Evidence of paraaortal lymphadenopathy.

No other acute findings. Secondary findings inculde a hepatic steatosis, small liver cysts, advanced arteriosclerosis, reperfusion of the umbilical vein and some bilateral dystelecatic changes of the dorso-basal lung parenchyma

CONCLUSION: Clinical history, examination, lab results and CT features are in keeping with a chronic appendicitis with appendicular abscess and a pyogenic spread of the intraabdominal infection via the portal venous drainage way. Consecutive pylephlebitis of the left portal vein with superimposed hepatic abscess in the affected left liver segment II. The abscess demonstrates a "doubledouble target" sign which is a characteristic image feature of a hepatic abscess.