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Video 1  Large heterogenous abscess in the caudate lobe and segment 4 with peritoneal rupture. A 19G EUS needle was introduced into the abscess through the transgastric route, followed by coiling of 0.035-inch guidewire in the abscess cavity. Serial dilatation was performed using a 6F cystotome followed by a 7F and 10F Sohendra dilator. Active aspiration was done with a 10F Sohendra dilator. An 8F double pigtail stent was then deployed for transmural drainage.

A 30-year-old man presented with high-grade fever and abdominal pain for 2 weeks. Laboratory testing revealed a total leukocyte count of 33,400/mm 3 with 90 % neutrophils, serum creatinine 1.46 mg/dL, and serum albumin 2.2 g/dL. Ultrasound showed a large, heterogenous subcapsular abscess in segment 4B and the caudate lobe (volume 259 mL) ( Fig. 1 ) with moderate ascites without any septae. Ascitic fluid aspiration showed frank pus. A diagnosis of ruptured liver abscess with peritonitis was considered.

 Ultrasound showing heterogenous subcapsular abscess in segment 4b and the caudate lobe, inaccessible to PCD.

The abscess was high risk for PCD as opined by an interventional radiologist because it was in the caudate lobe and segment 4B with intervening vessels in the path of access. The patient was given the option of surgery or EUS-guided transluminal drainage of the liver abscess, followed by PCD for intraperitoneal collection. The patient consented to EUS-guided drainage with surgery as a backup.

EUS-guided drainage was done with active aspiration of 160-mL, thick, anchovy-sauce pus suggestive of amoebic etiology. This was followed by placement of an 8F transmural stent ( Video 1 and Fig. 2 and Fig. 3 ).

 Active aspiration of anchovy sauce with 10F Sohendra dilator.

 Fluoroscopic image showing deployment of double pigtail stent.

Interventional radiology-guided drains were then placed in the right and left paracolic gutter. Contents showed pus with a bilirubin of 16.64 mg/dL. After drainage, the abscess cavity refilled from a volume of 90 mL to 138 mL within 48 hours. In addition, there was a high-volume bilious output from both paracolic gutter drains. The possibility of stent dysfunction and biliary communication of abscess was considered.

Repeat EUS-guided drainage with active aspiration of the contents and placement of an 8F NCD was done alongside the previously placed stent ( Fig. 4 ).

 Fluoroscopic image showing 8F pigtail stent and 8F NCD placed through high lesser curve.

Following repeat drainage, the abscess cavity collapsed. However, NCD continued to drain a high volume of bile.

ERCP nasobiliary drain (NBD) placement was done bridging the biliary communication with the abscess cavity ( Fig. 5 ).

 Fluoroscopic image of ERCP showing guidewire bridging the biliary communication with stent and NCD in situ.

The patient received intravenous (IV) antibiotics for 2 weeks. NCD and paracolic gutter drains dried up on day 14. Because the NCD dye study showed no leakage, NCD was internalized into the stomach. Thereafter, the NBD was removed and the patient was discharged. The stent and NCD were removed after 3 months.

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