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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.#
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