PYOGENIC LIVER ABSCESSES

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Bacterial or pyogenic liver abscess does not represent a specific liver disease, but rather a final common pathway of many pathologic processes. In the preantibiotic era, liver abscesses were typically the sequelae of unchecked appendicitis. In such cases, prompt surgical drainage offered the only hope for cure. Many advances, including the development of antibiotics, recognition of the role of anaerobic bacteria, the advent of noninvasive imaging, and the use of nonsurgical drainage have improved this once bleak outlook. By improving treatment of underlying diseases that once led to abscess formation, these advances also have transformed the epidemiology and presentation of pyogenic liver abscess. The classic triad of fever, right upper quadrant pain or fullness, and jaundice resulting from advanced pylephlebitis seldom is seen now. Despite these changes, pyogenic liver abscess remains an important clinical entity for which prompt recognition and treatment are essential for a favorable outcome.

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EPIDEMIOLOGY

In published reports, the incidence of pyogenic liver abscess ranges from 8 to 20 cases per 100,000 hospital admissions (Table 1). It is unclear whether the slight increasing trend is due to changes in the true incidence, improved detection, or admission practices. A recent population-based study found 11 cases per million persons per year.17 With the availability of effective antimicrobials, pyogenic liver abscess shifted abruptly to a disease of middle-aged persons, and the average patient

PATHOGENESIS

Liver abscess formation occurs whenever the initial inflammatory response fails to clear an infectious insult from the liver. Abscesses are classified by presumed route of hepatic invasion: (1) biliary tree, (2) portal vein, (3) hepatic artery, (4) direct extension from contiguous focus of infection, and (5) penetrating trauma (Table 2).

Suppurative cholangitis is now the major identifiable cause of pyogenic liver abscess. In such cases, multiple abscesses are generally present. Biliary

MICROBIOLOGY

With the diverse pathologic processes discussed above, sweeping generalizations about the microbiology of pyogenic liver abscess are difficult. This picture is further complicated because abscess material rarely is obtained prior to the administration of antibiotics. Even in the preantibiotic era, the rates of sterile cultures were high, and probably reflected inadequate culture techniques. Despite these difficulties, progress has been made in the understanding of the microbiology of pyogenic

CLINICAL PRESENTATION

Only one in ten patients presents with the classic triad of fever, jaundice, and right upper quadrant tenderness. Fever and constitutional symptoms including malaise, fatigue, anorexia, and weight loss are common (Table 5). When present, localizing symptoms such as vomiting or abdominal pain are not specific. The duration of symptoms prior to presentation varied widely in most case series, and there was seldom agreement on an average duration. Butler and McCarthy7 attempted to address this

DIAGNOSIS

Clues to the diagnosis of pyogenic liver abscess on examination include hepatomegaly and right upper quadrant tenderness, seen in about one half of patients. Jaundice most commonly is seen in patients with underlying biliary disease or those who are gravely ill. Leukocytosis is present in most patients and can be high. Although liver function tests are abnormal in most patients, these elevations are seldom marked; moreover, normal results do not exclude the diagnosis. Alkaline phosphatase

THERAPY

Untreated pyogenic liver abscesses are almost uniformly fatal.31 Traditionally, treatment consists of antibiotic administration and drainage of purulent collections. Although this remains the standard approach to the patient with hepatic abscess, some investigators have advocated the use of antibiotics alone in selected patients.

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    Address reprint requests to Lawrence C. Madoff, MD, Channing Laboratory and Division of Infectious Disease, Brigham and Women's Hospital, 181 Longwood Avenue, Boston, MA 02115, [email protected]

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