Sections View Full Chapter Figures Tables Videos Annotate Full Chapter Figures Tables Videos Supplementary Content + Download Section PDF Listen ++ For further information, see CMDT Part 16-18: Pyogenic Hepatic Abscess + Key Features Download Section PDF Listen +++ +++ 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 or gastrointestinal tract (eg, a fish or chicken bone) 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 Liver abscess caused by virulent strains of K pneumoniae May be associated with thrombophlebitis of the portal or hepatic veins and hematogenously spread septic ocular or CNS complications May be gas-forming, associated with diabetes mellitus, and result in a high mortality rate 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 Download Section PDF Listen +++ +++ Symptoms and Signs ++ The presentation is often insidious Fever is almost always present and may antedate other symptoms or signs Pain, localized to the right upper quadrant or epigastric area, may be a prominent complaint 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 Amoebic liver abscess Appendicitis Right lower lobe pneumonia Pancreatitis Echinococcosis (hydatid disease) Liver mass, eg, hepatocellular carcinoma + Diagnosis Download Section PDF Listen +++ +++ 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 Download Section PDF Listen +++ +++ Medications ++ Use antimicrobial agents (a third-generation cephalosporin [eg, ceftriaxone 2 g intravenously every 24 hours] and metronidazole [500 mg every 6 hours intravenously]) that are effective against coliform organisms and anaerobes Hepatic candidiasis often responds to intravenous amphotericin B (total dose of 2–9 g) +++ Surgery ++ If the abscess is at least 5 cm in diameter or the response to antibiotic therapy is not rapid, intermittent needle aspiration, percutaneous or endoscopic ultrasound-guided catheter drainage or stent placement, or if necessary, surgical (eg, laparoscopic) drainage should be done Fungal abscesses require drainage + Outcome Download Section PDF Listen +++ +++ Prognosis ++ The mortality rate is still substantial (≥ 5%) and is highest in underlying biliary malignancy or severe multiorgan dysfunction Other risk factors for mortality include Older age Cirrhosis Chronic kidney disease Cancer Fungal abscesses are associated with mortality rates of up to 50% +++ When to Admit ++ All patients + References Download Section PDF Listen +++ + +Kubovy J et al. Pyogenic liver abscess: incidence, causality, management and clinical outcomes in a New Zealand cohort. N Z Med J. 2019 Mar 29;132(1492):30–5. [PubMed: 30921309] + +Liao KF et al. Statin use correlates with reduced risk of pyogenic liver abscess: a population-based case-control study. Basic Clin Pharmacol Toxicol. 2017 Aug;121(2):144–49. [PubMed: 28273396] + +Peng YC et al. Risk of pyogenic liver abscess and endoscopic sphincterotomy: a population-based cohort study. BMJ Open. 2018 Mar 3;8(3):e018818. [PubMed: 29502088] + +Shi SH et al. Pyogenic liver abscess of biliary origin: the existing problems and their strategies. Semin Liver Dis. 2018 Aug;38(3):270–83. [PubMed: 30041279] + +Thng CB et al. Gas-forming pyogenic liver abscess: a world review. Ann Hepatobiliary Pancreat Surg. 2018 Feb;22(1):11–8. [PubMed: 29536051] + +Yoon JH et al. Prognosis of liver abscess with no identified organism. BMC Infect Dis. 2019 May 31;19(1):488. [PubMed: 31151426]