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Key Features

Essentials of Diagnosis

  • Fever, right upper quadrant pain, jaundice

  • Often in setting of biliary disease but up to 40% are cryptogenic in origin

  • Detected by imaging studies

General Considerations

  • The liver can be invaded by bacteria via

    • The portal vein (pylephlebitis)

    • The bile duct (acute "suppurative" [formerly ascending] cholangitis)

    • The hepatic artery, secondary to bacteremia

    • Direct extension from an infectious process

    • Traumatic implantation of bacteria through the abdominal wall

  • Acute cholangitis resulting from biliary obstruction due to a stone, stricture, or neoplasm is the most common identifiable cause of hepatic abscess in the United States

  • Statin use may reduce the risk of pyogenic liver abscess

  • In 10% of cases, liver abscess is secondary to appendicitis or diverticulitis

  • Up to 40% of abscesses have no demonstrable cause and are classified as cryptogenic; a dental source is identified in some such cases

  • The most frequently encountered organisms

    • Escherichia coli

    • Klebsiella pneumoniae

    • Proteus vulgaris

    • Enterobacter aerogenes

    • Multiple anaerobic species

  • Staphylococcus aureus is usually the causative organism in chronic granulomatous disease

  • Hepatic candidiasis, tuberculosis, and actinomycosis are seen in immunocompromised patients and those with hematologic malignancies

  • Rarely, hepatocellular carcinoma can present as a pyogenic abscess because of tumor necrosis, biliary obstruction, and superimposed bacterial infection

  • The possibility of an amebic liver abscess must always be considered

Clinical Findings

Symptoms and Signs

  • The presentation is often insidious

  • Fever is almost always present and may antedate other symptoms or signs

  • Pain may be a prominent complaint and is localized to the right upper quadrant or epigastric area

  • Jaundice, tenderness in the right upper abdomen, and either steady or spiking fever are the primary physical findings

  • Risk of acute kidney injury is increased

Differential Diagnosis

  • Cholecystitis

  • Cholangitis

  • Acute hepatitis

  • Amebic liver abscess

  • Appendicitis

  • Right lower lobe pneumonia

  • Pancreatitis

  • Echinococcosis (hydatid disease)

  • Liver mass, eg, hepatocellular carcinoma

Diagnosis

Laboratory Tests

  • Leukocytosis with a shift to the left

  • Liver biochemical tests are nonspecifically abnormal

  • Blood cultures are positive in 50–100% of cases

Imaging Studies

  • Chest radiographs usually reveal elevation of the diaphragm if the abscess is on the right side

  • Ultrasonography, CT, or MRI may reveal the presence of intrahepatic lesions

  • On MRI, characteristic findings include high signal intensity on T2-weighted images and rim enhancement

  • Hepatic candidiasis

    • Usually seen in the setting of systemic candidiasis

    • Characteristic appearance on CT scan is that of multiple "bulls-eyes"

    • However, imaging studies may be negative in neutropenic patients

Treatment

Medications

  • Use antimicrobial agents (a third-generation cephalosporin [eg, cefoperazone 1–2 g every 12 hours intravenously] and metronidazole [500 mg every 6 hours intravenously]) that are effective against coliform organisms and anaerobes

  • Hepatic candidiasis often responds to intravenous ...

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