EUS-guided transgastric drainage of a hepatic abscess with a luminoposing metal stent. Better through the stomach than the liver. Darius Jahan Co-author Rishi Pawa We have no disclosures. A 71-year-old male presented to the emergency department with abdominal pain and recent onset altered mental status. They had a fever of 39.7 degrees Celsius and a white blood cell count of 30,000. They were started on broad-spectrum antibiotics and underwent a CT of the abdomen and pelvis. The CT demonstrated a 9.7 x 4.2 x 6.0 cm hepatic abscess. Due to the location, they were not a candidate for percutaneous transhepatic drainage by interventional radiology. We demonstrate an endoscopic ultrasound-guided transgastric drainage of a hepatic abscess using a 15 mm luminoposing metal stent. External compression of the stomach was appreciated on upper endoscopy. Linear Array EUS demonstrated an anechoic unilocular collection measuring up to 90 mm in its largest diameter, with hypochoic layering at the base. It was located within the caudate lobe of the liver and within 10 mm of the lesser curvature of the stomach. Fine needle aspiration was performed with a 19-gauge needle. The aspirate was consistent with Frank Puss and was sent for analysis with Gramstein Culture and Cytology. Transgastric drainage of the abscess was then performed with a 15 mm luminoposing metal stent. There was immediate and spontaneous drainage of pus across the lumen-opposing metal stent, appreciated here in both forward and retroflexed views. To further optimize drainage and to facilitate passage into the collection, wire and fluoroscopically guided balloon dilation was then performed of the lumen-opposing metal stent up to 15 mm. Direct inspection of the cavity revealed a large compartment with a substantial amount of pus remaining. Therefore, extensive and active irrigation and suction were performed until the cavity was ultimately clean. Lastly, a 10 French by 4 cm double pigtail was placed within the lumen-opposing metal stent to anchor the stent and minimize trauma to the opposite wall of the cavity. Over the next few days, the patient's clinical status improved, mental status returned to baseline, and they were discharged from the hospital. Follow-up imaging at 4 weeks illustrated complete resolution of the collection. Therefore, the double pigtail stent and lumen-opposing metal stent were ultimately removed. Subsequent imaging 6 months later did not demonstrate any recurrence of the abscess. The standard of care for liver abscesses is radiologically guided percutaneous drainage, but this patient's abscess in the caudate lobe was inaccessible by the percutaneous approach. The alternative would have traditionally been surgical drainage, which is a high rate of morbidity and mortality. Thus, EUS guided drainage was a minimally invasive approach that obviated the need for surgical intervention. EUS guided drainage with a lumen-opposing metal stent is a safe and effective method of managing liver abscesses that are not accessible for percutaneous drainage.

hepatic abscess

caudate lobe

endoscopic ultrasound-guided transgastric drainage

luminoposing metal stent

liver abscess