Chronic appendicitis complicated by appendicular abscess, pylephlebitis and liver abscess

Patient presenting to the ER with leftLeft upper and lower quadrant pain for several weeks. Shortness of breath since the night before. The patient felt generally unwell. The lab parameter shows a septic constellation with elevated WBC, CRP and PTC. Patient has a knownKnown history of alcohol and cigarette abuse.

FINDINGS: TwoTwo-phase contrast CT shows occlusion of the left main portal vein and its tributaries and subsequent hyperperfusion of the left liver lobe in the arterial phase, most likely due to consecutive predominant arterial supply of the left liver parenchyma via the hepatic artery.

Evidence of a heterogeneous subcapsular hepatic lesion subcapsular in segment II, measuring 4,5 x 2,7 x 3 cm. The lesion demonstrates a hypodense centre and a double ring, the thin inner ring being hyperdense and the thicker outer ring hypodense, 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 aA fluid collection is seen 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 thickened. Evidence of para-aortal lymphadenopathy.

No other acute findings. Secondary findings include 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 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 a superimposed hepatic abscess in the affected left liver segment II. The abscess demonstrates a double target sign which is a characteristic image feature of a hepatic abscess.