Hepatic abscess

Background

Bile duct and pancreas anatomy. 1. Bile ducts: 2. Intrahepatic bile ducts; 3. Left and right hepatic ducts; 4. Common hepatic duct; 5. Cystic duct; 6. Common bile duct; 7. Sphincter of Oddi; 8. Major duodenal papilla; 9. Gallbladder; 10-11. Right and left lobes of liver; 12. Spleen; 13. Esophagus; 14. Stomach; 15. Pancreas: 16. Accessory pancreatic duct; 17. Pancreatic duct; 18. Small intestine; 19. Duodenum; 20. Jejunum; 21-22: Right and left kidneys.
Inferior view of the liver with surface showing lobes and impressions.
Liver vascular anatomy.
  • Uncommon overall - usually occurs in right liver lobe
    • More abscesses → more severe disease
  • History of camping is common
    • Endemic of Midwest


Types

  • Pyogenic (80%)
    • Most common cause
    • Associated with biliary tract obstruction (most common), cholangitis, diverticulitis, pancreatic abscess, appendicitis and inflammatory bowel disease.
    • Possible arterial hematogenous seeding: sepsis, direct trauma or instrumentation
    • Usually polymicrobial
  • Amebic (10%)
    • E. histolytica most common
    • Usually not septic and sick, rarely needs drainage
  • Fungal (<10%), candidal
  • Hydatid cyst (echinococcosis)
    • Associated with sheep farmers


Clinical Features

  • RUQ pain
  • High fever
  • Nausea, vomiting, anorexia
  • Clay-colored stool
  • Dark urine
  • Jaundice - seen with pyogenic, as opposed to amebic[1]
  • Often with right pleural effusions


Differential Diagnosis

Hepatic abscess

RUQ Pain


Evaluation

Liver abscess on axial CT image: a hypodense lesion in the liver with peripherally enhancement.
A large pyogenic liver abscess.

Work-up

  • CBC - Elevated white blood count (70-80%)
  • BMP
  • LFTs - Elevated alkaline phosphatase levels (90%)
  • Coags
  • Blood cultures
  • Amebic and echinococcal serologies
  • Ultrasound (80-100% sensitivity)
  • CT abd/pelvis (Imaging study of choice)
    • Triphasic CT scan to define the proximity of the abscess to the major branches of the portal and hepatic veins


Evaluation

  • Diagnosis usually made on imaging studies


Management

  • IV antibiotics[2]
    • Two or more antibiotics
      • Gram Negs: third or fourth generation cephalosporin (ceftriaxone) or aminoglycoside
      • Gram Pos: penicillin for streptococcal species (ampicillin)
        • For penicillin allergic, use fluoroquinolones
      • Anaerobes: metronidazole or clindamycin
  • Diagnostic aspiration and drainage of the abscess followed by placement of drainage catheter
    • Sonographic guidance for small or superficial abscesses
    • CT guidance for deep or multiple abscesses
  • Surgical drainage
    • Abscesses > 5cm
    • Abscesses not amenable to percutaneous drainage due to location
    • Failure of percutaneous aspiration and drainage
    • Coexistence of inra-abdominal disease that requires surgical management


Disposition

  • Admit for IV antibiotics and surgical drainage


See Also

  • Right upper quadrant abdominal pain
  • Amebiasis


References

  1. ↑ Oyama LC. Disorders of the Liver and Biliary Tract, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2013, (Ch) 90: p 1186-1205.
  2. ↑ Guss DA, Oyama LA: Disorders of the Liver and Biliary Tract, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 7. St. Louis, Mosby, Inc., 2010, (Ch) 88: p 1153-1171.
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