PYOGENIC LIVER ABSCESSES
Section snippets
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.
References (45)
- et al.
Pyogenic liver abscess: Treatment with needle aspiration
Clin Radiol
(1997) - et al.
Pyogenic liver abscesses: Successful non-surgical therapy
Lancet
(1982) - et al.
Pyogenic liver abscess. Changing patterns and approach
Am J Surg
(1968) - et al.
Successful medical treatment of pyogenic liver abscess
Gastroenterology
(1979) - et al.
Pyogenic abscess of the liver
Am J Surg
(1938) Focal inflammatory disease of the liver
Radiology Clinics of North America
(1998)- et al.
Hepatic abscess: Changes in clinical, bacteriologic and therapeutic aspects
Am J Med
(1974) - et al.
Pyogenic hepatic abscesses: MRI findings on T1- and T2-weighted and serial gadolinium-enhanced gradient-echo images
J Magn Reson Imaging
(1999) - et al.
Pyogenic liver abscess: A review of 10 years' experience in management
Aust N Z J Surg
(1999) - et al.
Treatment of pyogenic hepatic abscesses. Surgical vs percutaneous drainage
Arch Surg
(1986)
Pyogenic liver abscess
World J Surg
Hepatic abscess. Changes in etiology, diagnosis and management
Ann Surg
The role of computerized tomographic scanning in the surgical management of pyogenic hepatic abscess
Surg Gynecol Obstet
Pyogenic liver abscess
Gut
Single and multiple pyogenic liver abscesses: Clinical course, etiology, and results of treatment
World J Surg
The comparison of clinical course and results of treatment between gas-forming and non-gas-forming pyogenic liver abscess
Arch Surg
Prognostic factors for pyogenic abscess of the liver
J Am Coll Surg
Pyogenic liver abscess. An audit of experience over the past decade
Arch Surg
Miliary liver abscesses and skin infection due to Yersinia enterocolitica in a patient with unsuspected hemochromatosis [letter; comment]
Clin Infect Dis
Percutaneous catheter drainage of abdominal abscesses: A five-year experience
N Engl J Med
Pyogenic liver abscesses: 13 years of experience in percutaneous needle aspiration with US guidance
Radiology
Continuing changing patterns of disease in pyogenic liver abscess: A study of 38 patients
Am J Gastroenterol
Cited by (160)
Beyond conventional physical examination in hepatology: POCUS
2023, Revista de Gastroenterologia de MexicoManagement Practices and Predictors of Outcome of Liver Abscess in Adults: A Series of 1630 Patients from a Liver Unit
2021, Journal of Clinical and Experimental HepatologyEndogenous endophthalmitis in Klebsiella pneumoniae pyogenic liver abscess: Systematic review and meta-analysis
2020, International Journal of Infectious DiseasesUltrasound and hepatic abscess: A successful alliance for the internist
2019, European Journal of Internal MedicineBenign hepatic incidentalomas
2019, Current Problems in SurgeryLiver Abscess
2019, Shackelford's Surgery of the Alimentary Tract: 2 Volume Set
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]