Abstract
Percutaneous catheter drainage is one way of treating large liver abscesses that are partially liquefied or have thick pus. Apart from discomfort, severe pain, inflammation or frank cellulitis at the insertion site, and sometimes catheter dislodgement, failure to retrieve a catheter is unusual. This may occur either due to fibrous tissue securing the catheter or when inspissated secretions prevent the catheter tip from straightening. N-acetyl cysteine is a mucolytic and exerts action in many parts of the body such as the mouth, throat and lungs. We report successful removal of a catheter stuck in the liver using this substance.
Introduction
Surgical drainage of a liver abscess is associated with remarkably high (10%–47%) rates of morbidity and mortality; 1 thus percutaneous drainage with radiological control is now greatly preferred.
Case report
A 45-year-old man, without co-morbidity, presented with a liver abscess involving segment VI, which was managed with parenteral antibiotics and insertion of an ultrasound guided percutaneous 12-Fr Malecot catheter using the Seldinger technique. The Malecot type of catheter was selected because of its multiple drain holes, designed better to drain partially liquefied, thick purulent contents (Figure 1). Over two days, 100 mL of pus was thus drained. E. coli was isolated on culture. The patient was discharged on oral cotrimoxazole with his catheter in situ and at the three-week follow-up (he was living in the remote, hilly area of Uttarakhand), there was no further drainage, but it was impossible to extract the catheter by traction or after saline flushing. Manipulation with a guide wire also failed to dislodge it. However, after instillation of 10 mL 10% N-acetyl cysteine solution into the catheter and occluding it for 6 h, the Malecot catheter could be retrieved by minimal traction, thereby avoiding a surgical intervention (Figure 2). No complications ensued.
Ultrasound scan showing abscess cavity in liver with Malecot catheter in situ. Retrieved Malecot catheter with flower tip in its entirety.
Discussion
A liver drain or catheter should never be forcibly removed as severe hepatic injury may ensue, or fragments of the drain or catheter may be retained, producing foreign body irritation or infection. 2 A Malecot catheter provides large bore drainage compared with a pigtail catheter of similar size, but may more easily become stuck owing to its shape. Various methods of extraction include flushing with warm saline or other liquid substances, such as heparin or hydrogen peroxide, or probing with a stiff guide wire under fluoroscopic guidance. More invasive techniques include: endoscopic intervention by way of different access to the cavity drained and extraction under direct vision; or the ultimate recourse to laparoscopic or open surgical intervention. 3 N-acetyl cysteine contains free sulfhydryl groups that can cleave disulfide bridges, thus breaking down large proteins into smaller moieties. 4 Its use has been shown to be effective in reducing the viscosity of drain secretions. 5 There appear to be no side effects to its use.
Footnotes
Declaration of conflicting interests
The author(s) declare no potential conflict of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
ORCID iDs
Deepak Rajput https://orcid.org/0000-0001-9630-2932 Navin Kumar https://orcid.org/0000-0002-3397-1386 Amit Gupta 