Liver Abscess

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Background

Bacterial abscess of the liver is relatively rare. It has been described since the time of Hippocrates (400 BC), with the first published review by Bright appearing in 1936. In 1938, Ochsner's classic review heralded surgical drainage as the definitive therapy; however, despite the more aggressive approach to treatment, the mortality rate remained at 60-80%.[1] (See images below.)


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Computed tomography (CT) scan findings of liver abscess are shown. A large, septated abscess of the right hepatic lobe is revealed. Abscess was succes....


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Computed tomography (CT) scan findings of liver abscess are shown. A large anterior abscess involving the left hepatic lobe is revealed. Abscess was s....

The development of new radiologic techniques, the improvement in microbiologic identification, and the advancement of drainage techniques, as well as improved supportive care, have decreased mortality rates to 5-30%; yet, the prevalence of liver abscess has remained relatively unchanged. Untreated, this infection remains uniformly fatal.

The 3 major forms of liver abscess, classified by etiology, are as follows:

Pathophysiology

The liver receives blood from both systemic and portal circulations. Increased susceptibility to infections would be expected given the increased exposure to bacteria. However, Kupffer cells lining the hepatic sinusoids clear bacteria so efficiently that infection rarely occurs. Multiple processes have been associated with the development of hepatic abscesses; their relative frequencies are listed in the image below.


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Table 4: Underlying etiology of 1086 cases of liver abscess compiled from the literature.

Appendicitis was traditionally the major cause of liver abscess. As diagnosis and treatment of this condition has advanced, its frequency as a cause for liver abscess has decreased to 10%.

Biliary tract disease is now the most common source of pyogenic liver abscess (PLA). Obstruction of bile flow allows for bacterial proliferation. Biliary stone disease, obstructive malignancy affecting the biliary tree, stricture, and congenital diseases are common inciting conditions. With a biliary source, abscesses usually are multiple, unless they are associated with surgical interventions or indwelling biliary stents. In these instances, solitary lesions can be seen.

Infections in organs in the portal bed can result in a localized septic thrombophlebitis, which can lead to liver abscess. Septic emboli are released into the portal circulation, trapped by the hepatic sinusoids, and become the nidus for microabscess formation. These microabscesses initially are multiple but usually coalesce into a solitary lesion.

Microabscess formation can also be due to hematogenous dissemination of organisms in association with systemic bacteremia, such as endocarditis and pyelonephritis. Cases also are reported in children with underlying defects in immunity, such as chronic granulomatous disease and leukemia.

Approximately 4% of liver abscesses result from fistula formation between local intra-abdominal infections.

Despite advances in diagnostic imaging, cryptogenic causes account for a significant proportion of cases; surgical exploration has impacted this minimally. These lesions usually are solitary in nature.

Penetrating hepatic trauma can inoculate organisms directly into the liver parenchyma, resulting in pyogenic liver abscess. Nonpenetrating trauma can also be the precursor to pyogenic liver abscess by causing localized hepatic necrosis, intrahepatic hemorrhage, and bile leakage. The resulting tissue environment permits bacterial growth, which may lead to pyogenic liver abscess. These lesions are typically solitary.

Pyogenic liver abscess has been reported as a secondary infection of amebic abscess, hydatid cystic cavities, and metastatic and primary hepatic tumors. It is also a known complication of liver transplantation, hepatic artery embolization in the treatment of hepatocellular carcinoma, and the ingestion of foreign bodies, which penetrate the liver parenchyma. Trauma and secondarily infected liver pathology account for a small percentage of liver abscess cases.

The right hepatic lobe is affected more often than the left hepatic lobe by a factor of 2:1. Bilateral involvement is seen in 5% of cases. The predilection for the right hepatic lobe can be attributed to anatomic considerations. The right hepatic lobe receives blood from both the superior mesenteric and portal veins, whereas the left hepatic lobe receives inferior mesenteric and splenic drainage. It also contains a denser network of biliary canaliculi and, overall, accounts for more hepatic mass. Studies have suggested that a streaming effect in the portal circulation is causative.

Epidemiology

Frequency

United States

The incidence of pyogenic liver abscess has essentially remained unchanged by both hospital and autopsy data. Liver abscess was diagnosed in 0.7%, 0.45%, and 0.57% of autopsies during the periods of 1896-1933, 1934-1958, and 1959-1968, respectively. The frequency in hospitalized patients ranges from 8-16 cases per 100,000 persons. Studies suggest a small, but significant, increase in the frequency of liver abscess.

Mortality/Morbidity

Untreated, pyogenic liver abscess remains uniformly fatal. With timely administration of antibiotics and drainage procedures, mortality currently occurs in 5-30% of cases. The most common causes of death include sepsis, multiorgan failure, and hepatic failure.[3]

Sex

While abscesses once showed a predilection for males in earlier decades, no sexual predilection currently exists. Males have a poorer prognosis from hepatic abscess than females.

Age

History

Physical

Causes

Polymicrobial involvement is common, with Escherichia coli and Klebsiella pneumoniae being the 2 most frequently isolated pathogens. Reports suggest that K pneumoniae is an increasingly prominent cause.[4] The image below lists the common etiologic agents.


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Table 2: Microbiologic results from 312 cases of liver abscess compiled from the literature.

Laboratory Studies

Imaging Studies

Procedures

Medical Care

Surgical Care

Surgical drainage was the standard of care until the introduction of percutaneous drainage techniques in the mid 1970s. With the refinement of image-guided techniques, percutaneous drainage and aspiration have become the standard of care.

Consultations

Medication Summary

Until cultures are available, the choice of antimicrobial agents should be directed toward the most commonly involved pathogens. Regimens using beta-lactam/beta-lactamase inhibitor combinations, carbapenems, or second-generation cephalosporins with anaerobic coverage are excellent empiric choices for the coverage of enteric bacilli and anaerobes. Metronidazole or clindamycin should be added for the coverage of Bacteroides fragilis if other employed antibiotics offer no anaerobic coverage.

Amebic abscess should be treated with metronidazole, which will be curative in 90% of cases. Metronidazole should be initiated before serologic test results are available. Patients who do not respond to metronidazole should receive chloroquine alone or in combination with emetine or dehydroemetine.

Systemic antifungal agents should be initiated if fungal abscess is suspected and after the abscess has been drained percutaneously or surgically. Initial therapy for fungal abscess is currently amphotericin B. Lipid formulations may offer some benefit in that the complexing of drug to lipid moieties allows for concentration in hepatocytes. Further investigation is required for definitive proof. Cases of successful fluconazole treatment after amphotericin failure have been reported; however, its use as an initial agent is still being studied.

Ultimately, the organisms isolated and antibiotic sensitivities should guide the final choice of antimicrobials.

Duration of treatment has always been debated. Short courses (2 wk) of therapy after percutaneous drainage have been successful in a small series of patients; however, most series have reported recurrence of abscess even after more prolonged courses. Currently 4-6 weeks of therapy is recommended for solitary lesions that have been adequately drained. Multiple abscesses are more problematic and can require up to 12 weeks of therapy. Both the clinical and radiographic progress of the patient should guide the length of therapy.

Meropenem (Merrem)

Clinical Context:  Bactericidal broad-spectrum carbapenem antibiotic that inhibits cell-wall synthesis. Effective against most gram-positive and gram-negative bacteria.

Has slightly increased activity against gram negatives and slightly decreased activity against staphylococci and streptococci species compared to imipenem.

Imipenem and cilastatin (Primaxin)

Clinical Context:  For treatment of multiple organism infections in which other agents do not have wide-spectrum coverage or are contraindicated due to potential for toxicity.

Cefuroxime (Ceftin)

Clinical Context:  Second-generation cephalosporin maintains gram-positive activity that first-generation cephalosporins have; adds activity against Proteus mirabilis, Haemophilus influenzae, Escherichia coli, Klebsiella pneumoniae, and Moraxella catarrhalis. Condition of patient, severity of infection, and susceptibility of microorganism determine proper dose and route of administration.

Cefotetan (Cefotan)

Clinical Context:  Second-generation cephalosporin indicated for infections caused by susceptible gram-positive cocci and gram-negative rods.

Dosage and route of administration depends on condition of patient, severity of infection, and susceptibility of causative organism.

Cefoxitin (Mefoxin)

Clinical Context:  Second-generation cephalosporin indicated for gram-positive cocci and gram-negative rod infections. Infections caused by cephalosporin-resistant or penicillin-resistant gram-negative bacteria may respond to cefoxitin.

Cefaclor (Ceclor)

Clinical Context:  Second-generation cephalosporin indicated for infections caused by susceptible gram-positive cocci and gram-negative rods.

Determine proper dosage and route based on condition of patient, severity of infection, and susceptibility of causative organism.

Clindamycin (Cleocin)

Clinical Context:  Lincosamide for treatment of serious skin and soft tissue staphylococcal infections. Also effective against aerobic and anaerobic streptococci (except enterococci). Inhibits bacterial growth, possibly by blocking dissociation of peptidyl t-RNA from ribosomes causing RNA-dependent protein synthesis to arrest.

Metronidazole (Flagyl)

Clinical Context:  Imidazole ring-based antibiotic active against various anaerobic bacteria and protozoa. Used in combination with other antimicrobial agents (except for Clostridium difficile enterocolitis).

Class Summary

Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens in the context of the clinical setting.

Amphotericin B (AmBisome)

Clinical Context:  Produced by a strain of Streptomyces nodosus; can be fungistatic or fungicidal. Binds to sterols, such as ergosterol, in the fungal-cell membrane, causing intracellular components to leak with subsequent fungal-cell death.

Fluconazole (Diflucan)

Clinical Context:  Synthetic oral antifungal (broad-spectrum bistriazole) that selectively inhibits fungal cytochrome P-450 and sterol C-14 alpha-demethylation.

Class Summary

Their mechanism of action may involve an alteration of RNA and DNA metabolism or an intracellular accumulation of peroxide that is toxic to the fungal cell.

Further Inpatient Care

Further Outpatient Care

Complications

Prognosis

Author

Ruben Peralta, MD, FACS, Professor of Surgery, Anesthesia and Emergency Medicine, Senior Medical Advisor, Board of Directors, Program Chief of Trauma, Emergency and Critical Care, Consulting Staff, Professor Juan Bosch Trauma Hospital, Dominican Republic

Disclosure: Nothing to disclose.

Coauthor(s)

Michelle V Lisgaris, MD, Assistant Professor of Medicine, Case Western Reserve University School of Medicine

Disclosure: Nothing to disclose.

Robert A Salata, MD, Chief and Clinical Program Director of Division of Infectious Diseases, Vice Chair for International Affairs, Professor, Department of Medicine, Case Western Reserve University School of Medicine

Disclosure: Nothing to disclose.

Specialty Editors

Marco G Patti, MD, Professor of Surgery, Director, Center for Esophageal Diseases, University of Chicago Pritzker School of Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Joseph F John Jr, MD, FACP, FIDSA, FSHEA, Clinical Professor of Medicine, Molecular Genetics and Microbiology, Medical University of South Carolina College of Medicine; Associate Chief of Staff for Education, Ralph H Johnson Veterans Affairs Medical Center

Disclosure: Nothing to disclose.

Paolo Zamboni, MD, Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy

Disclosure: Nothing to disclose.

Chief Editor

John Geibel, MD, DSc, MA, Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director, Surgical Research, Department of Surgery, Yale-New Haven Hospital

Disclosure: AMGEN Royalty Consulting; Ardelyx Ownership interest Board membership

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Computed tomography (CT) scan findings of liver abscess are shown. A large, septated abscess of the right hepatic lobe is revealed. Abscess was successfully treated with percutaneous drainage and antimicrobial therapy.

Computed tomography (CT) scan findings of liver abscess are shown. A large anterior abscess involving the left hepatic lobe is revealed. Abscess was successfully treated with percutaneous drainage and antimicrobial therapy.

Table 4: Underlying etiology of 1086 cases of liver abscess compiled from the literature.

Table 1: Presenting symptoms and signs in 715 patients diagnosed with liver abscess.

Table 2: Microbiologic results from 312 cases of liver abscess compiled from the literature.

Table 3: Comparison of the radiologic procedures used in the diagnosis of liver abscess.

Computed tomography (CT) scan findings of liver abscess are shown. A large, septated abscess of the right hepatic lobe is revealed. Abscess was successfully treated with percutaneous drainage and antimicrobial therapy.

Computed tomography (CT) scan findings of liver abscess are shown. A large anterior abscess involving the left hepatic lobe is revealed. Abscess was successfully treated with percutaneous drainage and antimicrobial therapy.

Table 1: Presenting symptoms and signs in 715 patients diagnosed with liver abscess.

Table 2: Microbiologic results from 312 cases of liver abscess compiled from the literature.

Table 3: Comparison of the radiologic procedures used in the diagnosis of liver abscess.

Table 4: Underlying etiology of 1086 cases of liver abscess compiled from the literature.

Computed tomography (CT) scan findings of liver abscess are shown. A large, septated abscess of the right hepatic lobe is revealed. Abscess was successfully treated with percutaneous drainage and antimicrobial therapy.

Computed tomography (CT) scan findings of liver abscess are shown. A large anterior abscess involving the left hepatic lobe is revealed. Abscess was successfully treated with percutaneous drainage and antimicrobial therapy.