Pyogenic liver abscesses usually develop following peritonitis due to leakage of intraabdominal bowel contents. They may also result from arterial hematogenous seeding in the setting of systemic infection. The annual incidence of liver abcess has been estimated at /., cases per +(()((( populations and is higher among men than women.
Pyogenic liver abscesses usually develop following peritonitis due to leakage of intraabdominal bowel contents. They may also result from arterial hematogenous seeding in the setting of systemic infection. The annual incidence of liver abcess has been estimated at /., cases per +(()((( populations and is higher among men than women.
Pyogenic liver abscesses usually develop following peritonitis due to leakage of intraabdominal bowel contents. They may also result from arterial hematogenous seeding in the setting of systemic infection. The annual incidence of liver abcess has been estimated at /., cases per +(()((( populations and is higher among men than women.
INTRODUCTION Pyogenic liver abscesses usually develop
following peritonitis due to leakage of intraabdominal bowel contents
that subsequently spread to liver via the portal circulation or via direct spread from biliary infection. They may also result from arterial hematogenous seeding in the setting of systemic infection. The clinical approach to pyogenic liver abscess will be reviewed here. Amebic abscesses are discussed separately. (See !"traintestinal !ntamoeba histolytica amebiasis.# EPIDEMIOLOGY Prevalence $iver abscesses are the most common type of visceral abscess% in a report of &'( cases of intraabdominal abscesses) pyogenic liver abscesses accounted for '* percent of visceral abscesses and +, percent of intraabdominal abscesses -+.. The annual incidence of liver abscess has been estimated at /., cases per +(()((( populations and is higher among men than women (,., versus +., per +(()(((# -/0'.% substantially higher rates have been reported in Taiwan (+1.2 cases per +(()(((# -&.. Risk factors 3isk factors include diabetes) underlying hepatobiliary or pancreatic disease) and liver transplant -/),)2)1.. 4eographic and host factors may also play a role% for e"ample) a primary invasive liver abscess syndrome due to 5. pneumoniae has been described in !ast Asia. This is discussed separately. (See 6nvasive liver abscess syndrome caused by 5lebsiella pneumoniae.# Association with colorectal neolasia Several studies from Asia) where 5. pneumoniae is the primary cause of pyogenic liver abscesses) have suggested an association with underlying colorectal cancer -*0+,.. 6t is unclear whether these findings can be applied to other parts of the world. 6n a large retrospective analysis of claims data from the universal insurance program in Taiwan) the incidence of any subsequent gastrointestinal malignancy diagnosis among +')27( patients who had been diagnosed with pyogenic liver abscess was fourfold higher than that among &*)12( controls matched for age) se") and underlying diabetes mellitus (+(.* versus /.& cases per +((( person years# -+,.. 8olorectal carcinoma was the most common malignancy in both cohorts but was more frequent among liver abscess patients (1., versus +.2 cases per +((( person years#. 6n a separate retrospective study from Taiwan) in which +/&1 patients with pyogenic liver abscess were observed to have a high risk of subsequent liver or colorectal carcinoma) the greatest e"cess risk of a cancer diagnosis was in the first three months after the abscess diagnosis -7.. 6n most studies that evaluated for causative pathogens) liver abscesses caused by 5. pneumoniae appear to have a stronger association with colorectal cancer than those caused by other organisms -+(0 +/.) probably because most other organisms came from biliary tract diseases. The long0term follow0up prevalence of colorectal cancer among pyogenic liver abscess patients remained /., to ,./ percent -*)+/.. 9espite the limitations of these retrospective studies) the findings suggest the possibility of an occult colorectal neoplasia among patients diagnosed with pyogenic liver abscess) particularly due to 5. pneumoniae) in the absence of apparent underlying hepatobiliary disease. Pro!nosis The mortality rate in developed countries ranges from / to +/ percent -,)+'.. 6ndependent risk factors for mortality include need for open surgical drainage) the presence of malignancy) and the presence of anaerobic infection -+&)+2.. PAT"OGENE#I# A considerable proportion of pyogenic liver abscesses follow one or more episodes of portal vein pyemia) usually related to bowel leakage and peritonitis. Another important route is direct spread from biliary infection. :nderlying biliary tract disease such as gallstones or malignant obstruction is present in '( to 2( percent of cases -/)+')+1.. ;ccasionally) abscesses arise from surgical or penetrating wounds -+*.. $iver abscesses may also result from hematogenous seeding from the systemic circulation. A monomicrobial liver abscess due to a streptococcal or staphylococcal species should prompt evaluation for an additional source of infection. $iver abscesses most commonly involve the right lobe of the liver) probably because it is larger and has greater blood supply than the left and caudate lobes. $iver abscess may also be accompanied by pylephlebitis -+7.. (See Pylephlebitis.# MICRO$IOLOGY <any pathogens have been described% this variability reflects the different causes) types of medical intervention (such as biliary tree stenting) or immunosuppression due to cancer chemotherapy# and geographic differences. <ost pyogenic liver abscesses are polymicrobial% mi"ed enteric facultative and anaerobic species are the most common pathogens. Anaerobes are probably under0reported because they are difficult to culture and characteri=e in the laboratory. >or e"ample) in one series of /,, cases) mi"ed facultative and anaerobic species were implicated in one0third of patients) and bacteremia was documented in &2 percent of cases -/.. The highly variable microbiology ?ustifies pursuing a microbiological diagnosis in virtually every case. Potential pathogens include@ AThe Streptococcus milleri or S. anginosus group (including S. constellatus and S. intermedius# is an important cause of liver abscess. Bhen implicated) it should prompt a search for simultaneous metastatic infections at other locations. (See 6nfections due to the Streptococcus anginosus (Streptococcus milleri# group.# AS. aureus) S. pyogenes) and other 4ram positive cocci are recogni=ed pathogens in specific circumstances -/(.. >or e"ample) in a report of liver abscesses in patients who underwent transarterial emboli=ation for hepatocellular carcinoma) they accounted for 2( percent of pathogens. (See Consurgical therapies for locali=ed hepatocellular carcinoma@ Transarterial emboli=ation) radiotherapy) and radioemboli=ation) section on D8omplicationsD.# A8andida species have also been implicated in pyogenic liver abscess and accounted for // percent of liver abscesses in one series -/.. Eepatosplenic candidiasis can occur in patients who have received chemotherapy and presents with recovery of neutrophil counts following a neutropenic episode. (See 8hronic disseminated candidiasis (hepatosplenic candidiasis#.# A5lebsiella pneumoniae is an important emerging pathogen. This syndrome is discussed in detail separately (see 6nvasive liver a bscess syndrome caused by 5lebsiella pneumoniae #. ATuberculous liver abscesses are uncommon but should be considered when typical pyogenic organisms are not recovered from cultures -/+)//.. (See 8linical manifestations) diagnosis) and treatment of e"trapulmonary and miliary tuberculosis.# AFurkholderia pseudomallei (the agent of <elioidosis# should be considered in patients from endemic areas (Southeast Asia and Corthern Australia#. (See!pidemiology) pathogenesis) clinical manifestations) and diagnosis of melioidosis.# AAmebiasis should be considered as a cause of primary liver abscess) especially in patients who are from or have traveled to an endemic area within the past si" months. The clinical course and appearance may be difficult to distinguish from pyogenic liver abscess% this is discussed in detail separately. (See !"traintestinal !ntamoeba histolytica amebiasis.# CLINICAL MANI%E#TATION# The typical clinical manifestations of pyogenic liver abscess are fever and abdominal pain. ;ther common symptoms include nausea) vomiting) anore"ia) weight loss) and malaise. >ever occurs in appro"imately 7( percent of patients) and abdominal symptoms occur in &( to 1& percent of patients -/),)+')/,.. Abdominal symptoms and signs are usually locali=ed to the right upper quadrant and may include pain) guarding) rocking tenderness (pain caused by gently rocking the patientDs abdomen#) and even rebound tenderness. About one0half of patients with liver abscess have hepatomegaly) right upper quadrant tenderness) or ?aundice -/,.. The absence of right upper quadrant findings does not e"clude liver abscess. DIAGNO#I# The diagnosis of pyogenic liver abscess is made by history) clinical e"amination) and radiographic imaging followed by aspiration and culture of the abscess material. I&a!in! 8omputed tomography (8T# scan and ultrasound are the modalities of choice (image +# -+*.. 8T usually shows a fluid collection with surrounding edema. There may also be stranding and loculated subcollections. Pyogenic liver abscess cannot be reliably distinguished from amebic abscess by imaging studies -/+.. (See!"traintestinal !ntamoeba histolytica amebiasis) section on DAmebic liver abscessD.# Abscesses must be distinguished from tumors and cysts. Tumors have a solid radiographic appearance and may contain areas of calcification. Cecrosis and bleeding within a tumor may lead to a fluid0filled appearance% in such circumstances radiographic differentiation from abscess can be challenging. 8ysts appear as fluid collections without surrounding stranding or hyperemia. An elevated right hemidiaphragm) right basilar infiltrate) or right0 sided pleural effusion can be seen in /& to ,& percent of cases -/'.% these findings should prompt further investigation of the right upper quadrant with 8T or ultrasonography. <agnetic resonance imaging and tagged white blood cell scans are less useful for distinguishing abscess from other causes of liver mass. Micro'ial c(lt(res <aterial obtained from 8T or ultrasound0 guided aspiration should be sent to the laboratory for gram stain and culture (both aerobic and anaerobic#. Anaerobic culture should be specifically requested on the laboratory requisition. Flood cultures are essential% they are positive in up to &( percent of cases -/&.. 8ultures obtained from e"isting drains are C;T adequate for guiding antimicrobial therapy) since they are often contaminated with skin flora and other organisms. This was demonstrated in a study of 22 cases of liver abscess% cultures results obtained via radiographic guidance were compared with cultures obtained from a drain that had been in place for at least '* hours -//.. 8ultures from percutaneous specimens correlated with cultures from drainage catheters in only one0half of cases. Treatment based upon drainage culture results alone would have led to inappropriate therapy for the remaining patients. La'orator) fin*in!s $aboratory abnormalities may include elevated bilirubin andGor liver en=ymes. Serum alkaline phosphatase is elevated in 21 to 7( percent of cases and serum bilirubin and aspartate aminotransferase concentrations are elevated in about one0half of cases -/)+')/,.. ;ther laboratory abnormalities may include leukocytosis) hypoalbuminemia) and anemia (normochromic) normocytic#. TREATMENT Treatment of pyogenic liver abscess should include drainage and antibiotic therapy. Draina!e 9rainage techniques include 8T0guided or ultrasound0 guided percutaneous drainage (with or without catheter placement#) surgical drainage) or drainage by endoscopic retrograde cholangiopancreatography (!38P#. >or single abscesses with a diameter H& cm) either percutaneous catheter drainage or needle aspiration is acceptable -/20/7.. 9rainage catheters should remain in place until drainage is minimal (usually up to seven days#. 3epeat needle aspiration may be required in up to half of cases if a catheter is not left in situ -/2)/1.. >or percutaneous management of single abscesses with diameter I& cm) catheter drainage is preferred over needle aspiration. These principles were illustrated in a trial of 2( patients with pyogenic liver abscess treated with antibiotics and percutaneous drainage via catheter or needle aspiration -/7.. Among patients with an abscess diameter I& cm) treatment was successful in +(( percent of patients treated with catheter drainage compared with &( percent of patients with needle aspiration. Successful outcomes were observed for all patients with abscess H& cm) regardless of drainage modality. >or single abscesses with diameter I& cm) some favor surgical intervention over percutaneous drainage -,(),+.. The efficacy of this approach was suggested in a retrospective study of *( patients with abscess I& cm managed with percutaneous or surgical drainage% there was no difference in mortality) morbidity) duration of fever or complication rates. Eowever) the rate of treatment failure was lower with surgical drainage (1 versus /* percent#. Surgical drainage is also appropriate in the following circumstances@ A<ultiple abscesses A$oculated abscesses AAbscesses with viscous contents obstructing the drainage catheter A:nderlying disease requiring primary surgical management A6nadequate response to percutaneous drainage within seven days <ultiple or loculated abscesses may be successfully managed by percutaneous drainage% this was illustrated in a retrospective study of patients with pyogenic liver abscess -,/.. Successful percutaneous drainage was achieved in the setting of multiple abscesses (// of /' patients# and multiloculated abscesses (&+ of &' patients# -,/.. !ndoscopic retrograde cholangiopancreatography (!38P# can be useful for drainage of liver abscesses in patients with previous biliary procedures whose infection communicates with the biliary tree -+1),,.. Anti'iotics Co randomi=ed controlled trials have evaluated empiric antibiotic regimens for treatment of pyogenic liver abscess. Treatment recommendations are based upon the probable source of infection and should be guided by local bacterial resistance patterns) if known. (See D<icrobiologyD above.# !mpiric broad0spectrum parenteral antibiotics should be administered pending abscess gram stain and culture results. Be suggest one of the regimens outlined in the table (table +#. 3egardless of the initial empiric regimen) the therapeutic regimen should be revisited once culture and susceptibility results are available. 3ecovery of more than one organism should suggest polymicrobial infection including anaerobes) even if no anaerobes are isolated in culture. 6n such circumstances) anaerobic coverage should be continued. D(ration of thera) There are no randomi=ed controlled trials evaluating the optimal duration of therapy. This is typically determined by the e"tent of infection and the patientDs clinical response to initial management. Patients with abscess(es# that are difficult to drain or slow to resolve on follow0up imaging usually require longer courses of therapy. :seful clinical indicators to follow are temperature) white blood cell count and serum 80reactive protein. >ollow0up imaging should only be performed in the setting of persistent clinical symptoms or if drainage is not proceeding as e"pected% radiological abnormalities resolve much more slowly than clinical and biochemical markers. Among +(/ pyogenic liver abscess patients in Cepal) the mean time to ultrasonographic resolution of abscesses J+( cm was +2 weeks% mean time to resolution for abscesses I+( cm was // weeks -,'.. 9rainage catheters should remain in place until drainage is minimal (usually up to seven days#. 6f percutaneous needle aspiration was performed without catheter placement) repeat aspiration may be required in up to one0half of cases -/2)/1.. Antibiotic therapy should be continued for four to si" weeks -,&.. Patients who have had a good response to initial drainage should be treated with two to four weeks of parenteral therapy) while patients with incomplete drainage should receive four to si" weeks of parenteral therapy. The remainder of the course can then be completed with oral therapy tailored to culture results -/*)/7.. 6f culture results are not available) reasonable empiric oral antibiotic choices include amo"icillin0clavulanate alone or a fluoroquinolone (ciproflo"acin or levoflo"acin# plus metronida=ole. #UMMARY AND RECOMMENDATION# AThe clinical manifestations of pyogenic liver abscess usually include fever and abdominal pain% other symptoms may include nausea) vomiting) anore"ia) weight loss and malaise. (See D8linical manifestationsD above.# AThe diagnosis of pyogenic liver abscess is confirmed by radiographic imaging (computed tomography or ultrasound# followed by aspiration and culture of the abscess material. (See D9iagnosisD above.# A<ost pyogenic liver abscesses are polymicrobial. Amebic abscess is best distinguished from pyogenic liver abscess by serology. (See D<icrobiologyD above.# ABe recommend draining liver abscesses (Gra*e +$#. >or drainage of abscesses H& cm in diameter) we suggest needle aspiration rather than percutaneous catheter drainage (Gra*e ,C#. 3epeat needle aspiration may be required. (See D9rainageD above.# A>or drainage of abscesses I& cm in diameter) we suggest percutaneous catheter drainage rather than needle aspiration (Gra*e ,$#. 9rainage catheters should remain in place until drainage ceases (usually up to seven days#. (See D9rainageD above.# ABe suggest surgical drainage (rather than percutaneous drainage# in the following circumstances (Gra*e ,C#. (See D9rainageD above.#@ K<ultiple abscesses (depending on number) position) and si=e# K$oculated abscesses KAbscesses with viscous contents obstructing drainage catheter K:nderlying disease requiring primary surgical management K6nadequate response to percutaneous drainage within seven days ABe recommend empiric parenteral antibiotic therapy pending culture and susceptibility results (Gra*e +C#. Suggested regimens are outlined in the table (table +#. (See DAntibioticsD above.# ABhen there is a clinical response to therapy) oral antibiotics may be substituted for parenteral therapy (with the guidance of susceptibility testing# to complete a four to si" week course of treatment. (See D9uration of therapyD above.# :se of :pTo9ate is sub?ect to the Subscription and $icense Agreement.