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==Differential Diagnosis==
==Differential Diagnosis==
Pyogenic liver abscess must be differentiated from:<ref name="pmid15189463">{{cite journal| author=Lodhi S, Sarwari AR, Muzammil M, Salam A, Smego RA| title=Features distinguishing amoebic from pyogenic liver abscess: a review of 577 adult cases. | journal=Trop Med Int Health | year= 2004 | volume= 9 | issue= 6 | pages= 718-23 | pmid=15189463 | doi=10.1111/j.1365-3156.2004.01246.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15189463  }} </ref><ref name="pmid5054724">{{cite journal| author=Barbour GL, Juniper K| title=A clinical comparison of amebic and pyogenic abscess of the liver in sixty-six patients. | journal=Am J Med | year= 1972 | volume= 53 | issue= 3 | pages= 323-34 | pmid=5054724 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=5054724  }} </ref><ref name="pmid3316923">{{cite journal| author=Barnes PF, De Cock KM, Reynolds TN, Ralls PW| title=A comparison of amebic and pyogenic abscess of the liver. | journal=Medicine (Baltimore) | year= 1987 | volume= 66 | issue= 6 | pages= 472-83 | pmid=3316923 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3316923  }} </ref><ref name="pmid3945889">{{cite journal| author=Conter RL, Pitt HA, Tompkins RK, Longmire WP| title=Differentiation of pyogenic from amebic hepatic abscesses. | journal=Surg Gynecol Obstet | year= 1986 | volume= 162 | issue= 2 | pages= 114-20 | pmid=3945889 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3945889  }} </ref><ref name="pmid9834333">{{cite journal| author=Lipsett PA, Huang CJ, Lillemoe KD, Cameron JL, Pitt HA| title=Fungal hepatic abscesses: Characterization and management. | journal=J Gastrointest Surg | year= 1997 | volume= 1 | issue= 1 | pages= 78-84 | pmid=9834333 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9834333  }} </ref><ref name="pmid3275982">{{cite journal| author=Pastakia B, Shawker TH, Thaler M, O'Leary T, Pizzo PA| title=Hepatosplenic candidiasis: wheels within wheels. | journal=Radiology | year= 1988 | volume= 166 | issue= 2 | pages= 417-21 | pmid=3275982 | doi=10.1148/radiology.166.2.3275982 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3275982  }} </ref><ref name="pmid11452064">{{cite journal| author=Mortelé KJ, Ros PR| title=Cystic focal liver lesions in the adult: differential CT and MR imaging features. | journal=Radiographics | year= 2001 | volume= 21 | issue= 4 | pages= 895-910 | pmid=11452064 | doi=10.1148/radiographics.21.4.g01jl16895 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11452064  }} </ref><ref name="pmid7668917">{{cite journal| author=Suwan Z| title=Sonographic findings in hydatid disease of the liver: comparison with other imaging methods. | journal=Ann Trop Med Parasitol | year= 1995 | volume= 89 | issue= 3 | pages= 261-9 | pmid=7668917 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7668917  }} </ref><ref name="pmid3047423">{{cite journal| author=Esfahani F, Rooholamini SA, Vessal K| title=Ultrasonography of hepatic hydatid cysts: new diagnostic signs. | journal=J Ultrasound Med | year= 1988 | volume= 7 | issue= 8 | pages= 443-50 | pmid=3047423 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3047423  }} </ref><ref name="pmid7225721">{{cite journal| author=Niron EA, Ozer H| title=Ultrasound appearances of liver hydatid disease. | journal=Br J Radiol | year= 1981 | volume= 54 | issue= 640 | pages= 335-8 | pmid=7225721 | doi=10.1259/0007-1285-54-640-335 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7225721  }} </ref>
{| class="wikitable"
! rowspan="3" |Disease
! rowspan="3" |Causes
! colspan="11" |symptoms
! rowspan="3" |Lab Findings
! rowspan="3" |Imaging Findings
! rowspan="3" |Other Findings
|-
! rowspan="2" | Fever
! colspan="2" | Pain
! rowspan="2" | cough
! rowspan="2" | Hepatomegaly
! rowspan="2" | Jaundice
! rowspan="2" | Weight loss
! rowspan="2" | Anorexia
! rowspan="2" | Diarrhoea
or Dysentry
! rowspan="2" | Nausea and
vomiting
! rowspan="2" | Stool
|-
! Abdominal pain
(right upper quadrant pain)
! Pleuritic pain
|-
|[[Amoebic liver abscess]]
|[[Entamoeba histolytica]]
|✔✔✔
|✔✔✔
|✔/✘
|✔
|✔✔/✘
|✔
(late stages)
|✔
(late stages)
|✔
|✔
|✔
|
|[[Hypoalbuminemia]]
(✔)
|
* Ultrasound is the gold standard technique for diagnosing [[amoebic liver abscess]]
|
* Respond well to [[chemotherapy]] and rarely require drainage
* Marked male predominance
* More common in developing countries
* Sero-positive
* Right lobe is more frequently involved
|-
|[[Pyogenic liver abscess]]
|Bacteria
* Gram-positive aerobes
* Gram-negative enterics
* Anaerobic organisms
* Acid fast bacilli
|✔
|✔
|✔✔
|✔✔
|✔/✘
|✔✔✔
|✔
(acute loss)
|✔
|
|✔
|Pale/dark
|[[Hypoalbuminemia]]
(✔✔✔)
|Cluster sign
* CT scan shows cluster sign
* Aggregation of multiple low attenuation [[liver]] lesions in a localized area to form a solitary larger [[abscess]] cavity
|
* Abnormal pulmonary findings
* [[Diabetes mellitus]] increases the risk
* Medical-surgical approach is indicated
* More common in developed countries
* Culture positive and sero-negative
* Both lobes are commonly involved
|-
|Fungal liver abscess
|''[[Candida|Candida species]]''<br>[[Aspergillus|Aspergillus species]]
|✔
|✔
|✔/✘
|✔
|✔
|✔
|✔
|✔
|✔
|✔
|
|
|CT and Us findings with four patterns of presentation:
* Wheel-within-a-wheel pattern
* Bull’s-eye configuration pattern
* Uniformly hypoechoic nodule
* echogenic foci with variable degrees of posterior acoustic shadowing
|
* Less common
* Pure fungal abscess or associated with [[pyogenic abscess]]
* [[Candida]] and [[Aspergillus]] are commonly found in the culture of aspirated pus
* Associated with underlying malignancy or DM
|-
|[[hydatid cyst|Echinococcal (hydatid) cyst]]
|[[Echinococcus granulosus]]
|
|✔
|
|✔
|
|✔
(Obstructive jaundice)
|✔
|✔
|
|
|
|Histology: Hydatid cyst with three layers
a.The outer pericyst, which corresponds with compressed and fibrosed [[liver]] tissue
b.The endocyst, an inner germinal layer
c.The ectocyst, a thin, translucent interleaved membrane
|Ultrasound:
* Cystic to solid-appearing pseudotumors
* Water lily sign
* Calcifications seen peripherally
|
* Blood or liquid from the ruptured cyst may be coughed up
* [[Pruritis]]
|-
|Malignancy
(Hepatocellular carcinoma/Metastasis)
|
*[[Hepatitis B]] and [[hapatitis C|C]]
*[[Aflatoxins]]
*[[Alcohol]]
*[[Hemochromatosis]]
*[[Alpha 1 antitrypsin deficiency]]
*[[Non alcoholic fatty liver disease]]
|✔
|✔
(uncommon)
|
|
|✔
|✔
|✔✔
|
|
|✔✔
|Pale/Chalky
|
* High levels of [[alpha-fetoprotein|AFP]] in serum
* Abnormal liver function tests
|
* [[Liver biopsy]]
|Other symptoms:
* [[Splenomegaly]]
* [[Variceal bleeding]]
* [[Ascites]]
* [[Spider nevi]]
* [[Asterixis]]
|}

Revision as of 18:59, 6 March 2017


Overview

Causes

Classification

Differential Diagnosis

Pyogenic liver abscess must be differentiated from:[1][2][3][4][5][6][7][8][9][10]

Disease Causes symptoms Lab Findings Imaging Findings Other Findings
Fever Pain cough Hepatomegaly Jaundice Weight loss Anorexia Diarrhoea

or Dysentry

Nausea and

vomiting

Stool
Abdominal pain

(right upper quadrant pain)

Pleuritic pain
Amoebic liver abscess Entamoeba histolytica ✔✔✔ ✔✔✔ ✔/✘ ✔ ✔✔/✘ ✔

(late stages)

✔

(late stages)

✔ ✔ ✔ Hypoalbuminemia

(✔)

  • Respond well to chemotherapy and rarely require drainage
  • Marked male predominance
  • More common in developing countries
  • Sero-positive
  • Right lobe is more frequently involved
Pyogenic liver abscess Bacteria
  • Gram-positive aerobes
  • Gram-negative enterics
  • Anaerobic organisms
  • Acid fast bacilli
 ✔ ✔ ✔✔ ✔✔ ✔/✘ ✔✔✔ ✔

(acute loss)

✔ ✔ Pale/dark Hypoalbuminemia

(✔✔✔)

Cluster sign
  • CT scan shows cluster sign
  • Aggregation of multiple low attenuation liver lesions in a localized area to form a solitary larger abscess cavity
  • Abnormal pulmonary findings
  • Diabetes mellitus increases the risk
  • Medical-surgical approach is indicated
  • More common in developed countries
  • Culture positive and sero-negative
  • Both lobes are commonly involved
Fungal liver abscess Candida species
Aspergillus species 		✔ ✔ ✔/✘ ✔ ✔ ✔ ✔ ✔ ✔ ✔ CT and Us findings with four patterns of presentation:
  • Wheel-within-a-wheel pattern
  • Bull’s-eye configuration pattern
  • Uniformly hypoechoic nodule
  • echogenic foci with variable degrees of posterior acoustic shadowing
  • Less common
  • Pure fungal abscess or associated with pyogenic abscess
  • Candida and Aspergillus are commonly found in the culture of aspirated pus
  • Associated with underlying malignancy or DM
Echinococcal (hydatid) cyst Echinococcus granulosus ✔ ✔ ✔

(Obstructive jaundice)

✔ ✔ Histology: Hydatid cyst with three layers

a.The outer pericyst, which corresponds with compressed and fibrosed liver tissue

b.The endocyst, an inner germinal layer

c.The ectocyst, a thin, translucent interleaved membrane

Ultrasound:
  • Cystic to solid-appearing pseudotumors
  • Water lily sign
  • Calcifications seen peripherally
  • Blood or liquid from the ruptured cyst may be coughed up
  • Pruritis
Malignancy

(Hepatocellular carcinoma/Metastasis)

✔ ✔

(uncommon)

✔ ✔ ✔✔ ✔✔ Pale/Chalky
  • High levels of AFP in serum
  • Abnormal liver function tests
 Other symptoms:
  1. ↑ 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.
  2. ↑ 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.
  3. ↑ 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.
  4. ↑ 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.
  5. ↑ Lipsett PA, Huang CJ, Lillemoe KD, Cameron JL, Pitt HA (1997). "Fungal hepatic abscesses: Characterization and management". J Gastrointest Surg. 1 (1): 78–84. PMID 9834333.
  6. ↑ Pastakia B, Shawker TH, Thaler M, O'Leary T, Pizzo PA (1988). "Hepatosplenic candidiasis: wheels within wheels". Radiology. 166 (2): 417–21. doi:10.1148/radiology.166.2.3275982. PMID 3275982.
  7. ↑ Mortelé KJ, Ros PR (2001). "Cystic focal liver lesions in the adult: differential CT and MR imaging features". Radiographics. 21 (4): 895–910. doi:10.1148/radiographics.21.4.g01jl16895. PMID 11452064.
  8. ↑ Suwan Z (1995). "Sonographic findings in hydatid disease of the liver: comparison with other imaging methods". Ann Trop Med Parasitol. 89 (3): 261–9. PMID 7668917.
  9. ↑ Esfahani F, Rooholamini SA, Vessal K (1988). "Ultrasonography of hepatic hydatid cysts: new diagnostic signs". J Ultrasound Med. 7 (8): 443–50. PMID 3047423.
  10. ↑ Niron EA, Ozer H (1981). "Ultrasound appearances of liver hydatid disease". Br J Radiol. 54 (640): 335–8. doi:10.1259/0007-1285-54-640-335. PMID 7225721.
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