Liver abscess overview

Abscess Main Page
Liver abscess Main Page
Overview
Causes
Classification Pyogenic liver abscess Amoebic liver abscess
Differential Diagnosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Yamuna Kondapally, M.B.B.S[2]

Overview

A liver abscess is a pus-filled mass inside or attached to the liver. Common causes are an abdominal infection such as appendicitis or diverticulitis. With treatment, the death rate is 10-30%.. Biliary tract disease is the most common cause but no cause identified in the majority of patients. There are nonspecific clinical findings hence a high degree of suspicion required for diagnosis. There are most often single, rather than multiple foci. Hyperbilirubinemia and elevated alkaline phosphatase in the majority of patients, but low specificity. E. coli is the most prevalent organism, followed by Klebsiella, Streptococcus, and Bacteroides species. Rare cause is bowel perforation following foreign body ingestion. Therapy for solitary liver abscess from causes other than bowel perforation is intravenous antibiotics and percutaneous US- or CT-guided drainage. Therapy for liver abscess caused by bowel perforation or foreign body is open surgical drainage. Amoebic liver abscess occurs in 94% of cases of amebiasis. Liver abscess is a relatively infrequent (1.7% according to Cho, D. et. al.), although possible, complication of percutaneous radiofrequency ablation of hepatic tumors.

Classification

Liver abscess may be classified into 3 types based on etiology into pyogenic, amoebic, and fungal liver abscess.

Liver abscess

Amoebic liver abscess

Pyogenic liver abscess

Fungal abscess

Entamoeba histolytica

Bacteria

Candida species

Gram-positive aerobes

Gram-negative enterics

Anaerobic organisms

Acid fast bacilli

Streptococcus sp Staphylococcus aureus / Staphylococcus epidermidis Actinomyces sp Enterococcus sp Streptococcus milleri

Escherichia coli Salmonella typhi Yersinia enterocolitica K.pneumonia Pseudomonas sp Proteus sp Eikenella corrodens Others

Bacteroids sp Fusobacterium Anaerobic/ Microaerophilic streptococci Other anaerobes

Mycobacterium tuberculosis

Differential Diagnosis

The differential Diagnosis of liver abscess include:

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 ✔✔✔		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	✔	✔	✔/✘	✔	✔	✔	✔	✔	✔	✔			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)	Hepatitis B and C Aflatoxins Alcohol Heamochromatosis Alpha 1 antitrypsin deficiency Non alcoholic fatty liver disease		✔ (uncommon)			✔	✔								Other symptoms: Splenomegaly Variceal bleeding Ascites Spider nevi Asterixis
Hepatocellular adenoma
Cholangiocarcinoma
Hemangioma
Focal nodular hyperplasia
Nodular regenerative hyperplasia
Simple hepatic cyst
Biliary cystadenoma or cystadenocarcinoma
Polycystic liver disease