A 40-year-old gentleman came in outpatient department with complaints of pus discharge for three days from the right subcostal area. Amount of pus was minimal but enough to soil his cloth. As per history and records provided by the patient, he was a follow-up case of pyogenic liver abscess and was discharged about one and half month back from our hospital after successful treatment. On Examination, patient’s vital parameter was normal and there was sub centimetric sinus like opening with granulation tissue at the right subcostal area near anterior axillary line (Figure-1a, 1b). As per history and documentary evidence this was probably the site from where percutaneous catheter drainage was done. Patient was admitted for further evaluation. His detailed previous record in the hospital suggests that he came in emergency department of our hospital more than one and half month back for chief complaints of pain in right upper abdomen and fever with chills and rigor for 7days.The patient was known chronic alcoholic for last fifteen years. On clinical examination his temperature was 101° F, pulse rate 110/min, blood pressure was 126/74 mmHg, respiratory rate was 28/min. Mild icterus was present. On systemic examination he had tenderness in right hypochondrium with guarding. Liver was enlarged and palpable till 7cm below costal margin. At that time of admission his total leucocyte counts were raised i.e., 27,000/mm³, haemoglobin was 8.5 g/dL. Liver function tests showed raised serum bilirubin 3.7 mg/dL, raised alkaline phosphatase 436 IU/L, mildly raised liver enzymes (ALT 234 IU/L and AST 212 IU/L). On admission, he was diagnosed with Type2 Diabetes Mellitus and glycaemic control was achieved with insulin. Rest of the laboratory parameters were within normal limit.

Ultrasound abdomen revealed enlarged liver span (19 cm) with a round mix-echoic lesion of 11.9x11.3 cm in the right lobe of the liver (780 mL volume) suggestive of liver abscess. Under USG guidance percutaneous catheter drainage of liver abscess was done which drained about 500 ml of thick yellow colour pus. The pus culture report isolated the E. coli and antibiotics regime including metronidazole was started accordingly. The catheter was removed following six days of the treatment when it stopped draining the pus and ultrasound abdomen showed collapsed abscess cavity. At the time of discharge patient was advised a course of antibiotics for further ten days. His recovery during follow-up was uneventful.

On his current admission, the ultrasound abdomen was suggestive of healed abscess cavity in segments 4 an 8 with tubular tract up to skin surface (Figure 2). We obtained MR-Fistulogram which revealed a T2 hyperintense lesion with thick enhancing wall in segment 4 of the liver measuring about 16x10x14 mm with a tract arising from its anterior wall and extending up to skin surface in right hypochondrium. The length of the tract was about 55 mm and 5-6 mm in thickness (Figure 3).

His pus culture isolated mix organism mainly E. coli and streptococcus spp. He was managed conservatively by irrigation lavage of fistula track with normal saline thrice daily along with chosen parenteral antibiotic (Ceftriaxone 1 gm. twice daily). The patient had pus discharge for about seven days which then gradually resolved. No other symptoms or signs were present during this period. The fistulous tract healed spontaneously in 2 weeks (Figure-1c, 1d).