SUMMARYA 69-year-old cachexic man presented with tachycardia and hypotension on a background of 7 days of vomiting and constipation. He was not obviously in pain. He had a raised white cell count of 24.8×10 9 /l, and a lactate of 2.2 mmol/l. A chest x-ray had the appearance of free air under the diaphragm and he was suspected of having a bowel obstruction with perforation. An abdominal CT scan showed instead a large fluid and gas-filled hepatic abscess, and a second smaller simple cyst. The abscess was percutaneously drained, and the purulent fluid drained grew Streptococcus milleri. The patient was discharged home 2 weeks later. BACKGROUND