PYOGENIC LIVER

ABSCESS
Last literature review for version 16.1: Jan. 31, 008
This topic last updated: Feb. 6, 2008

Presented by: Yu-Yin Huang

EPIDEMIOLOGY

most common type of visceral abscess

Incidence : higher in men
Risk factors : DM, underlying hepatobiliary or
pancreatic malignancy, and liver transplant.
Geographic factors may also play a role.
mortality rate : 2 ~ 12% (mortality appears to
be related to underlying comorbidities rather
than to the abscess itself.)

MICROBIOLOGY

Klebsiella pneumoniae liver abscess is an

important emerging infection.
Streptococcus milleri group (S. anginosis, S.
constellatus and S. intermedius) is an
important cause of liver abscess.
Other gram-positive organisms (including S.
aureus and S. pyogenes) can be important
causes of liver abscesses.

MICROBIOLOGY

Amebiasis : should be considered in patients

who are from or have traveled to an endemic
area within the past six months
Candida species : Hepatosplenic candidiasis
usually occurs in patients who have received
chemotherapy and presents with recovery a
neutropenic episode.
Tuberculous liver abscess is uncommon but
should be considered in patients when other
organisms are not recovered.

CLINICAL
MANIFESTATIONS

Fever (90%) and abdominal pain (50-75%)

Abdominal symptoms and signs are usually
localized to the RUQ and may include pain,
guarding, and even rebound tenderness.
About one-half of patients with liver abscess have
hepatomegaly, RUQ tenderness, or jaundice

Nausea, vomiting, anorexia, weight loss and

malaise

DIAGNOSIS - Imaging

CT and ultrasound are the modalities of

choice for demonstrating the distinguishing
features of liver abscess.
An abscess appears radiographically as a
fluid collection with surrounding edema and
inflammation that may contain loculated
subcollections.
Abscesses must be distinguished from tumors
and cysts.

DIAGNOSIS - Imaging
Tumors

solid radiographic appearance

calcification
necrosis and bleeding within a tumor may
lead to a fluid-filled appearance
Cysts

appear as fluid collections without

surrounding inflammation.

DIAGNOSIS - Microbial
cultures

Material obtained from CT or ultrasoundguided aspiration should be sent for gram

stain and culture.
Blood cultures should always be performed
when liver abscess is suspected; they are
positive in up to 50 percent of cases.

DIAGNOSIS - Laboratory
findings

elevated bilirubin or liver enzymes; serum

ALP is elevated in 67 to 90 percent of cases
and serum bilirubin and AST concentrations
are elevated in about one-half of cases

leukocytosis, hypoalbuminemia and anemia

TREATMENT - Drainage

For single abscesses with diameter 5 cm :

percutaneous catheter drainage or needle aspiration
is acceptable.
For single abscesses with diameter >5 cm :
percutaneous management : catheter drainage is
preferred over needle aspiration.
some favor surgical intervention over
percutaneous drainage, the rate of treatment
failure was lower with surgical drainage

TREATMENT - Drainage

Surgical drainage is also appropriate in the

following circumstances
Multiple abscesses
Loculated abscesses
Abscesses with viscous contents
obstructing the drainage catheter
Inadequate response to percutaneous
drainage within seven days

TREATMENT - Antibiotics

Empiric broad-spectrum antibiotics should be

administered pending abscess gram stain
and culture results.
A third generation cephalosporin such as
ceftriaxone PLUS metronidazole.(Flumarin)
fluoroquinolone (eg, ciprofloxacin PLUS
metronidazole
Monotherapy with a carbapenem

Duration of therapy

follow imaging, WBC count and serum CRP

Drainage catheters should remain in place
until drainage is minimal (usually up to seven
days).
Patients who have had a good response to
initial drainage should be treated with 2~4
weeks of therapy, while patients with no or
incomplete drainage should receive 4~6
weeks of therapy.

How to choose antibiotics ?

Flumarin
Cleocin + Cefazolin + SABS
Cefazolin + Gentamycin + SABS
fluoroquinolone
carbapenem