Pyogenic liver abscess overview
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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Yamuna Kondapally, M.B.B.S[2]
Overview
Pyogeinic liver abscess is caused by the local inflammatory reaction caused by bacteria in hepatic parenchyma leading to the development of intrahepatic pus collection.[1][2]They account for 80% of liver abscesses in developed world.[3]
Historical Perspective
Hippocrates described pyogenic liver abscess based on the type of fluid recovered from abscess. In 1938, Ocshner and colleagues reported that the major causal factors leading to hepatic abscess were appendicitis and amoebiasis.[4]
Classification
Pyogenic liver abscess may be classified according to international classification of diseases-10 (ICD-10) into K75.0.[5].
Pathophysiology
Development of pyogenic liver abscess is the result of infection through the following routes like portal vein (also from pylephlebitis of portal vein), hepatic arteries as metastatic abscesses, direct spread from nearby infection, trauma and retroperitoneal extension from appendix.[6][4][7][8]Ascending biliary infection is the most common source of pyogenic liver abscess.
Causes
Common causes of pyogenic liver abscess include hepatobiliary, portal, arterial, traumatic and cryptogenic causes.
Differential Diagnosis
Pyogenic liver abscess must be differentiated from other diseases with similar presentation such as amoebic liver abscess, fungal liver abscess, echinococcal (hydatid) cyst and malignancy (hepatocelluar carcinoma or metastasis).[9][10][11][12]
Risk Factors
Common risk factors in the development of pyogenic liver abscess are immunodeficiency, diabetes mellitus, pancreatic or hepatobiliary disease and liver transplant.[4][13][14][15]
Screening
According to the U.S. Preventive Service Task Force (USPSTF), there is insufficient evidence to recommend routine screening for pyogenic liver abscess.
Natural History, Complications and Prognosis
If left untreated, pyogenic liver abscess may progress to peritonitis or pleuritis secondary to rupture of the abscess into peritoneal or pleural cavities and sepsis.[16][17][18]Complications of pyogenic liver abscess include septicemia, intraabdominal abscess, hepatic failure, renal failure, recurrent liver abscess and free peritonitis.[19]The prognosis of liver abscess depends on underlying risk factors such as advanced age, malignancy, jaundice, multiple abscesses, heamoglobin <10g/dl and elevated blood urea nitrogen.[4]
Diagnosis
History and Symptoms
Symptoms of pyogenic liver abscess include abdominal pain, right lower chest pain, fever, chills, night sweats, nausea, vomiting, loss of appetite, right shoulder pain, weight loss, diarrhea, dyspnea and yellowish discoloration of skin (jaundice).[5][20]
Physical Examination
Common physical examination findings associated with pyogenic liver abscess include high grade fever, yellowish discoloration of skin (jaundice), icteric sclera, reduced breath sounds or crepitations at the base of lung, hepatomegaly with point tenderness, and abdominal guarding or rebound tenderness on palpation, dullness on percussion, and absent bowel sounds.[21]
Laboratory Findings
Laboratory tests consistent with diagnosis of pyogenic liver abscess include complete blood picture, ESR, C-reactive protein, liver function tests, pus culture, and blood culture.[7]
ECG
There are no ECG findings associated with pyogenic liver abscess.
Chest X Ray
Chest X ray findings include atelectasis, pulmonary infiltrates, pleural effusion, elevated right hemidiaphragm, and gas within the abscess or biliary tree or beneath the diaphragm.[5]
CT Scan
CT scan findings of pyogenic liver abscess include peripherally enhancing and centrally hypo attenuating lesions, solid or gas in the lesions (gas in the form of bubbles or air fluid levels), segmental, wedge-shaped or circumferential perfusion abnormalities, early enhancement may be seen on contrast enhanced CT scans, the double target sign and cluster sign.[22][23][24][25]
MRI
MRI findings of pyogenic liver abscess include hypointense and heterogenous centrally on T1, hyperintense signal on T2, enhancement of the capsule and multiple septations on T1+C, high signal within the abscess cavity on DWI, and low signal within the abscess on ACD.[26][5][27]
Ultrasound
The ultrasound findings include round or oval shape, hypoechoic appearance with fine and homogeneous echoes, gas bubbles within the abscess, and absence of central perfusion on color doppler.[28][29][30]
Other Imaging Studies
Other diagnostic studies include radionucleide scans which use technetium, indium, or gallium. They detect lesions <2 cm in size. These scans cannot distinguish between the cyst, tumor, or abscess and need confirmation with other diagnostic tests.[31]
Treatment
Medical Therapy
Treatment of pyogenic liver abscess include non-surgical treatment and open surgical drainage. Non-surgical treatment treatment includes conservative management with antibiotics alone and percutaneous drainage.[19]
Surgical Therapy
The maninstay of treatment of pyogenic liver abscess is percutaneous darinage of abscess. Other methods used are open surgical drainage and endoscopic retrograde cholangiopancreatography(ERCP).[32][33][2][34][8]
Primary Prevention
The risk of developing pyogenic liver abscess can be reduced by prompt treatment of abdominal and other infections.[5]
Secondary Prevention
Secondary prevention strategies following pyogenic liver abscess include long term monitoring which helps in preventing the complications and recurrence , monitoring the abscess cavity weekly for adequate drainage using CT or USG, persistent fever more than 2 weeks of therapy is an indication for more aggressive drainage, prolonged antibiotic therapy after discharge of patient is recommended and presence of underlying liver disease is the predisposing factor for the recurrence of pyogenic liver disease.[35]
References
- ↑ Lee KT, Wong SR, Sheen PC (2001). "Pyogenic liver abscess: an audit of 10 years' experience and analysis of risk factors". Dig Surg. 18 (6): 459–65, discussion 465-6. PMID 11799296.
- ↑ 2.0 2.1 Yu SC, Ho SS, Lau WY, Yeung DT, Yuen EH, Lee PS; et al. (2004). "Treatment of pyogenic liver abscess: prospective randomized comparison of catheter drainage and needle aspiration". Hepatology. 39 (4): 932–8. doi:10.1002/hep.20133. PMID 15057896.
- ↑ Krige JE, Beckingham IJ (2001). "ABC of diseases of liver, pancreas, and biliary system". BMJ. 322 (7285): 537–40. PMC 1119738. PMID 11230072.
- ↑ 4.0 4.1 4.2 4.3 Huang CJ, Pitt HA, Lipsett PA, Osterman FA, Lillemoe KD, Cameron JL; et al. (1996). "Pyogenic hepatic abscess. Changing trends over 42 years". Ann Surg. 223 (5): 600–7, discussion 607-9. PMC 1235191. PMID 8651751.
- ↑ 5.0 5.1 5.2 5.3 5.4 http://www.icd10data.com/ICD10CM/Codes/K00-K95/K70-K77/K75-/K75.0 Accessed on February 22, 2017
- ↑ Munro JC (1905). "VII. Lymphatic and Hepatic Infections Secondary to Appendicitis". Ann Surg. 42 (5): 692–734. PMC 1425980. PMID 17861705.
- ↑ 7.0 7.1 Rahimian J, Wilson T, Oram V, Holzman RS (2004). "Pyogenic liver abscess: recent trends in etiology and mortality". Clin Infect Dis. 39 (11): 1654–9. doi:10.1086/425616. PMID 15578367.
- ↑ 8.0 8.1 Lam YH, Wong SK, Lee DW, Lau JY, Chan AC, Yiu RY; et al. (1999). "ERCP and pyogenic liver abscess". Gastrointest Endosc. 50 (3): 340–4. doi:10.1053/ge.1999.v50.98065. PMID 10462653.
- ↑ Lodhi S, Sarwari AR, Muzammil M, Salam A, Smego RA (2004). "Features distinguishing amoebic from pyogenic liver abscess: a review of 577 adult cases". Trop Med Int Health. 9 (6): 718–23. doi:10.1111/j.1365-3156.2004.01246.x. PMID 15189463.
- ↑ Barbour GL, Juniper K (1972). "A clinical comparison of amebic and pyogenic abscess of the liver in sixty-six patients". Am J Med. 53 (3): 323–34. PMID 5054724.
- ↑ Barnes PF, De Cock KM, Reynolds TN, Ralls PW (1987). "A comparison of amebic and pyogenic abscess of the liver". Medicine (Baltimore). 66 (6): 472–83. PMID 3316923.
- ↑ Conter RL, Pitt HA, Tompkins RK, Longmire WP (1986). "Differentiation of pyogenic from amebic hepatic abscesses". Surg Gynecol Obstet. 162 (2): 114–20. PMID 3945889.
- ↑ Mohsen AH, Green ST, Read RC, McKendrick MW (2002). "Liver abscess in adults: ten years experience in a UK centre". QJM. 95 (12): 797–802. PMID 12454322.
- ↑ Chan KS, Chen CM, Cheng KC, Hou CC, Lin HJ, Yu WL (2005). "Pyogenic liver abscess: a retrospective analysis of 107 patients during a 3-year period". Jpn J Infect Dis. 58 (6): 366–8. PMID 16377869.
- ↑ Thomsen RW, Jepsen P, Sørensen HT (2007). "Diabetes mellitus and pyogenic liver abscess: risk and prognosis". Clin Infect Dis. 44 (9): 1194–201. doi:10.1086/513201. PMID 17407038.
- ↑ Branum GD, Tyson GS, Branum MA, Meyers WC (1990). "Hepatic abscess. Changes in etiology, diagnosis, and management". Ann Surg. 212 (6): 655–62. PMC 1358249. PMID 2256756.
- ↑ Farges O, Leese T, Bismuth H (1988). "Pyogenic liver abscess: an improvement in prognosis". Br J Surg. 75 (9): 862–5. PMID 3052693.
- ↑ Pitt HA, Zuidema GD (1975). "Factors influencing mortality in the treatment of pyogenic hepatic abscess". Surg Gynecol Obstet. 140 (2): 228–34. PMID 1124472.
- ↑ 19.0 19.1 Malik AA, Bari SU, Rouf KA, Wani KA (2010). "Pyogenic liver abscess: Changing patterns in approach". World J Gastrointest Surg. 2 (12): 395–401. doi:10.4240/wjgs.v2.i12.395. PMC 3014521. PMID 21206721.
- ↑ Lo JZ, Leow JJ, Ng PL, Lee HQ, Mohd Noor NA, Low JK; et al. (2015). "Predictors of therapy failure in a series of 741 adult pyogenic liver abscesses". J Hepatobiliary Pancreat Sci. 22 (2): 156–65. doi:10.1002/jhbp.174. PMID 25339111.
- ↑ Chu KM, Fan ST, Lai EC, Lo CM, Wong J (1996). "Pyogenic liver abscess. An audit of experience over the past decade". Arch Surg. 131 (2): 148–52. PMID 8611070.
- ↑ Bächler P, Baladron MJ, Menias C, Beddings I, Loch R, Zalaquett E; et al. (2016). "Multimodality Imaging of Liver Infections: Differential Diagnosis and Potential Pitfalls". Radiographics. 36 (4): 1001–23. doi:10.1148/rg.2016150196. PMID 27232504.
- ↑ Lee TY, Wan YL, Tsai CC (1994). "Gas-containing liver abscess: radiological findings and clinical significance". Abdom Imaging. 19 (1): 47–52. PMID 8161903.
- ↑ Mathieu D, Vasile N, Fagniez PL, Segui S, Grably D, Lardé D (1985). "Dynamic CT features of hepatic abscesses". Radiology. 154 (3): 749–52. doi:10.1148/radiology.154.3.3969480. PMID 3969480.
- ↑ Jeffrey RB, Tolentino CS, Chang FC, Federle MP (1988). "CT of small pyogenic hepatic abscesses: the cluster sign". AJR Am J Roentgenol. 151 (3): 487–9. doi:10.2214/ajr.151.3.487. PMID 3261506.
- ↑ Méndez RJ, Schiebler ML, Outwater EK, Kressel HY (1994). "Hepatic abscesses: MR imaging findings". Radiology. 190 (2): 431–6. doi:10.1148/radiology.190.2.8284394. PMID 8284394.
- ↑ Chan JH, Tsui EY, Luk SH, Fung AS, Yuen MK, Szeto ML; et al. (2001). "Diffusion-weighted MR imaging of the liver: distinguishing hepatic abscess from cystic or necrotic tumor". Abdom Imaging. 26 (2): 161–5. PMID 11178693.
- ↑ Ralls PW, Barnes PF, Radin DR, Colletti P, Halls J (1987). "Sonographic features of amebic and pyogenic liver abscesses: a blinded comparison". AJR Am J Roentgenol. 149 (3): 499–501. doi:10.2214/ajr.149.3.499. PMID 3303877.
- ↑ https://radiopaedia.org/articles/hepatic-abscess-1 Accessed on February 26, 2017
- ↑ Hui JY, Yang MK, Cho DH, Li A, Loke TK, Chan JC; et al. (2007). "Pyogenic liver abscesses caused by Klebsiella pneumoniae: US appearance and aspiration findings". Radiology. 242 (3): 769–76. doi:10.1148/radiol.2423051344. PMID 17325065.
- ↑ Halvorsen RA, Foster WL, Wilkinson RH, Silverman PM, Thompson WM (1988). "Hepatic abscess: sensitivity of imaging tests and clinical findings". Gastrointest Radiol. 13 (2): 135–41. PMID 3282964.
- ↑ Rajak CL, Gupta S, Jain S, Chawla Y, Gulati M, Suri S (1998). "Percutaneous treatment of liver abscesses: needle aspiration versus catheter drainage". AJR Am J Roentgenol. 170 (4): 1035–9. doi:10.2214/ajr.170.4.9530055. PMID 9530055.
- ↑ Ch Yu S, Hg Lo R, Kan PS, Metreweli C (1997). "Pyogenic liver abscess: treatment with needle aspiration". Clin Radiol. 52 (12): 912–6. PMID 9413964.
- ↑ Zerem E, Hadzic A (2007). "Sonographically guided percutaneous catheter drainage versus needle aspiration in the management of pyogenic liver abscess". AJR Am J Roentgenol. 189 (3): W138–42. doi:10.2214/AJR.07.2173. PMID 17715080.
- ↑ Cheng HC, Chang WL, Chen WY, Kao AW, Chuang CH, Sheu BS (2008). "Long-term outcome of pyogenic liver abscess: factors related with abscess recurrence". J Clin Gastroenterol. 42 (10): 1110–5. doi:10.1097/MCG.0b013e318157e4c1. PMID 18458641.