Contents

Search

hepatic abscess

Etiology: 1) hematogenous spread of extra-hepatic infection 2) spread from portal system (portal pyemia) 3) seeding from infectious peritonitis 4) appendicitis 5) cholangitis 6) colorectal cancer 7) organisms a) Escherichia coli b) anaerobes - Bacteroides [5] - Clostridium perfringens (rare) [5] c) Klebsiella pneumoniae in Japan (Asia) - often associated with a subsequent diagnosis of colorectal cancer [4] d) Pseudomonas aeruginosa [5] e) Entamoeba histolytica (more common in HIV1 patients) 8) risk factors - *diabetes mellitus - *hepatobiliary disease - *pancreatic diseases - Klebsiella pneumoniae infection due to host factors - *glucocorticoid therapy - *alcoholism - *chronic disease - malignancy Pathology: - direct spread to the liver from biliary infection - transmission of bacteria via the portal vein from abdominal infections (diverticulitis etc) Clinical manifestations: - fever - dull, right upper quadrant pain - anorexia - malaise Laboratory: 1) complete blood count (CBC) 2) liver function tests 3) serology for Entamoeba histolytica 4) HIV1 testing may be prudent 5) culture a) blood culture b) culture of drainage fluid Special laboratory: - fine needle aspiration - hepatic abscesses < 5 cm are not amenable to percutaneous drainage [1] Radiology: - abominal US - abdominal CT - abdominal US less sensitive than abdominal CT for pypgenic abscess but equally sensitive for amebic abscess [1] Complications: - pyogenic hepatic abscess is associated with - sepsis & septic shock if left untreated - increased risk of gastrointestinal cancers [3] - colon cancer (RR=5.5) - small intestinal cancer (RR=12.7) - biliary carcinoma (RR=9.6) - pancreatic cancer (RR-2.5) Differential diagnosis: - Echinococcus granulosus - CT would show well demarcated cyst wall with septate daughter cysts Management: 1) pyogenic hepatic abscesses require drainage 2) broad spectrum IV antibiotics that cover Streptococcus, enteric gram-negative bacilli, & anaerobes should be initiated prior to needle aspiration [1] - ciprofloxacin + metronidazole also covers Entamoeba histolytica - ceftriaxone + metronidazole 3) consider percutaneous drainage for abscesses > 5 cm 4) antibiotics for amebic abscess [1] - ceftriaxone (gram negatives) + metronidazole (Entamoeba histolytica) [1] 5) surgical resection rarely needed

General

abscess liver disease hepatobiliary infection

References

  1. Medical Knowledge Self Assessment Program (MKSAP) 15, 16, 18, 19. American College of Physicians, Philadelphia 2009, 2012, 2018, 2021.
  2. Nickloes TA et al eMedicine: Pyogenic Heaptic Abscesses http://emedicine.medscape.com/article/193182-overview
  3. Lai H-C et al. Increased incidence of gastrointestinal cancers among patients with pyogenic liver abscess: A population-based cohort study. Gastroenterology 2014 Jan; 146:129 PMID: 24095786
  4. Gharib SD et al Case 21-2015 - A 37-Year-Old American Man Living in Vietnam, with Fever and Bacteremia. N Engl J Med 2015; 373:174-183. July 9, 2015 PMID: 26154791 http://www.nejm.org/doi/full/10.1056/NEJMcpc1411439
  5. Rothaus C Overcoming the Barrier. NEJM REsident 360. Dec 5, 2018 https://resident360.nejm.org/content_items/overcoming-the-barrier/
  6. Serraino C, Elia C, Bracco C et al Characteristics and management of pyogenic liver abscess: A European experience. Medicine (Baltimore). 2018 May;97(19):e0628 PMID: 29742700 PMCID: PMC5959441 Free PMC article