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A 24-year-old man presented with a high-grade fever and abdominal pain of 7 days duration. Abdominal ultrasound showed multiple liver abscesses. Segment 4B abscess (volume 70 mL) had ruptured and was inaccessible to PCD as it was deep seated with intervening vasculature. The ruptured contents were localized in the perihepatic region. Laboratory examination revealed a hemoglobin (Hgb) of 7.8 g/dL, total leukocyte count 41,800/mm 3 with 97 % neutrophils, serum creatinine 3.47 mg/dL, serum bilirubin 4.92 mg/dL with direct serum bilirubin 4.38 mg/dL and serum alkaline phosphatase 425 IU.

A diagnosis of multiple liver abscesses with contained rupture of segment 4B abscess, sepsis, and early organ dysfunction was considered. The patient was started on IV antibiotics. Because the patient had sepsis, all abscesses required drainage. A hybrid approach of EUS-guided transgastric drainage with 10F NCD placement in the ruptured segment 4 abscess ( Fig. 6 ) and percutaneous aspiration (PCA) of radiologically accessible abscesses was done. Transmural drainage was done as contents of the ruptured segment 4 abscess were thick and there was the possibility of biliary communication.

 Fluoroscopic image showing NCD placed transantrally.

Initially, the NCD output was anchovy sauce, which became bilious and then stopped over the next few days. The patient received IV antibiotics for 2 weeks. NCD was internalized at 7 days and removed after 8 weeks.

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