Liver abscess


Pyogenic liver abscess incidence 8-20 cases per 100,000 hospital admissions.

Incidence of pyogenic liver abscess slowly increasing.

Pyogenic type of abscesses most common in north America compared to amebic abscesses which are most common hepatic abscess lesions worldwide.

Pyogenic liver abscesses are solitary in half the cases and involve the right lobe three fourths of the time and 20% in the right lobe and 5% in the caudate lobe.

Pyogenic infections associated a result of portal vein drainage abscesses may occur as a result of diverticular disease, pancreatitis, inflammatory bowel disease, peptic ulcer disease, malignancy or peritonitis.

Non penetrating trauma to the liver may also lead to liver abscess by causing liver necrosis, hemorrhage and bile leakage which can lead to bacterial proliferation and abscess formation.

May be a secondary infection with amebic abscess, primary or secondary liver tumors, hepatic transplantation, hepatic artery embolization therapy and radioablation therapy.

The right hepatic lobe is involved more often than the left hepatic lobe 2:1.

Hepatic abscesses may be bilateral in 5% of cases.

Localized septic thrombophlebitis related to infections in the portal bed can lead to liver abscess by septic emboli in the portal circulation with trapping in the liver sinusoids.

Microabscesses may develop in the liver from hematogenous dissemination of organisms from a systemic bacteremia, such as endocarditis or pyelonephritis.

May develop from immune abnormalities in chronic granulomatous disease and leukemia.

Cryptogenic causes account for significant number of cases.

Bacterial abscess relatively rare process.

Mortality rates with modern drainage techniques have decreased to 5-30%.

Prevalence of bacterial liver abscess has remained the same.

Without treatment the process of bacterial abscess is fatal.

Polymicrobial in 80% of cases.

Amebic abscesses due to Entamoeba histolytica account for 10% of cases.

Fungal abscesses account for 10% of cases.

Appendicitis cause of hepatic abscess in 10% of cases.

Biliary tract disease is the most common cause for bacterial abscess, as obstruction of bile flow allows bacterial proliferation.

Abscesses from biliary disease usually associated with multiple lesions.

Pyogenic infection associated with systemic bacterial seeding from endocarditis sepsis or oral bacteria.

Pyogenic infection may occur as a contiguous infection from cholecystitis, subphrenic abscess, perinephric abscess or trauma related infection.

Pyogenic liver abscess patients usually in middle age, about 50-60 years of age.

Pyogenic abscess patients usually resent with fever (80%), and abdominal pain in 70% of cases.

Pyogenic liver abscess patients may have nausea, vomiting, weight loss and about 50% have hepatomegaly with right upper quadrant tenderness, or jaundice.

Pyogenic abscess associated with leucocytosis, anemia, elevated erythrocyte sedimentation rate and occasionally mild elevation of liver function tests.

Pyogenic abscess associated with increased alkaline phosphatase levels in two thirds of patients, and it is out of proportion to other liver function tests.

Blood cultures are positive in about 50% of cases and the early empiric use of antibiotics can often lead to sterile abscess fluid and negative blood cultures.

Most lesions are polymicrobial with the most common organisms E. Coli, Klebsiella pneumoniae, Proteus species, and Streptococcus species.

Complications include: sepsis, empyema, or peritonitis from rupture into the pleural or peritoneal spaces, and retroperitoneal extension.

Treatment should include drainage, either percutaneous or surgical.

Antibiotic therapy as a sole treatment modality is not routinely advocated, though it has been successful in a few reported cases.

Antibiotic therapy as a sole treatment may be the only alternative in patients too ill to undergo invasive procedures or in those with multiple abscesses not amenable to percutaneous or surgical drainage.

In these instances, patients are likely to require many months of antimicrobial therapy.

Antimicrobial treatment is a common adjunct to percutaneous or surgical drainage.

Percutaneous drainage and aspiration have become the standard of care.

Indications for the surgical treatment of pyogenic liver abscess are for the treatment of underlying intra-abdominal processes, existence of a known abdominal surgically approachable abnormality, failure of previous drainage attempts; and the presence of a complicated, multiloculated, thick-walled abscess with viscous pus.

A laparoscopic approach is also commonly used.

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