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Liver Abscess: Differential Diagnoses & Workup

Author: Ruben Peralta, MD, FACS, Professor of Surgery, Anesthesia and Emergency Medicine, Senior Medical Advisor, Board of Directors, Program Chief of Trauma, Emergency and Critical Care, Consulting Staff, Professor Juan Bosch Trauma Hospital, Dominican Republic
Coauthor(s): Michelle V Lisgaris, MD, Assistant Professor of Medicine, Case Western Reserve University; Associate Medical Director, Infection Control, Department of Internal Medicine, Division of Infectious Diseases, University Hospitals of Cleveland; Robert A Salata, MD, Chief and Clinical Program Director of Division of Infectious Diseases, Vice Chair for International Affairs, Professor, Department of Medicine, Case Western Reserve University School of Medicine; Sarah C Langenfeld, MD, Assistant Professor of Psychiatry, Department of Psychiatry, University of Massachusetts Medical School; Attending Psychiatrist, Community HealthLink
Contributor Information and Disclosures

Updated: Sep 15, 2009

Differential Diagnoses

Biliary Disease
Hydatid Cysts
Cholecystitis
Pneumonia, Bacterial
Empyema, Pleuropulmonary
Gastritis, Acute
Hepatocellular Carcinoma

Other Problems to Be Considered

Hepatitis, nonviral
Metastatic disease of the liver

Workup

Laboratory Studies

  • CBC count with differential
    • Anemia of chronic disease
    • Neutrophilic leukocytosis
  • Liver function studies
    • Hypoalbuminemia and elevation of alkaline phosphatase (most common abnormalities)
    • Elevations of transaminase and bilirubin levels (variable)
  • Blood cultures are positive in roughly 50% of cases.
  • Culture of abscess fluid should be the goal in establishing microbiologic diagnosis.
  • Enzyme immunoassay should be performed to detect E histolytica in patients either from endemic areas or who have traveled to endemic areas.

Imaging Studies

  • The advancement in radiologic techniques has been credited with the improvement in mortality rates. Comparisons in the diagnostic utility of the various radiologic techniques are described in the image below. (See also Image 3.)
Table 3: Comparison of the radiologic procedures ...

Table 3: Comparison of the radiologic procedures used in the diagnosis of liver abscess.

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Table 3: Comparison of the radiologic procedures ...

Table 3: Comparison of the radiologic procedures used in the diagnosis of liver abscess.

  • Computed tomography (CT) scan evaluation with contrast and ultrasonography remain the radiologic modalities of choice as screening procedures and also can be used as techniques for guiding percutaneous aspiration and drainage.
  • With advancements in multidetector CT scan technology, image quality has improved dramatically, allowing for improved detection.
  • CT scan (sensitivity 95-100%; see image below and Images 5-6.)
    • Lesions on CT evaluation are well-demarcated areas hypodense to the surrounding hepatic parenchyma. Peripheral enhancement is seen when IV contrast is administered.
    • Gas can be seen in as many as 20% of lesions.
    • CT scan is superior in its ability to detect lesions less than 1 cm.
    • This technique also enables the evaluation for an underlying concurrent pathology throughout the abdomen and pelvis. Indium-labeled WBC scans are somewhat more sensitive in this regard.
Computed tomography (CT) scan findings of liver a...

Computed tomography (CT) scan findings of liver abscess are shown. A large, septated abscess of the right hepatic lobe is revealed. Abscess was successfully treated with percutaneous drainage and antimicrobial therapy.

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Computed tomography (CT) scan findings of liver a...

Computed tomography (CT) scan findings of liver abscess are shown. A large, septated abscess of the right hepatic lobe is revealed. Abscess was successfully treated with percutaneous drainage and antimicrobial therapy.


Computed tomography (CT) scan findings of liver a...

Computed tomography (CT) scan findings of liver abscess are shown. A large anterior abscess involving the left hepatic lobe is revealed. Abscess was successfully treated with percutaneous drainage and antimicrobial therapy.

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Computed tomography (CT) scan findings of liver a...

Computed tomography (CT) scan findings of liver abscess are shown. A large anterior abscess involving the left hepatic lobe is revealed. Abscess was successfully treated with percutaneous drainage and antimicrobial therapy.

  • Ultrasonography (sensitivity 80-90%)
    • Ultrasonographic evaluation reveals hypoechoic masses with irregularly shaped borders. Internal septations or cavity debris may be detected.
    • Ultrasonography allows for close evaluation of the biliary tree and simultaneous aspiration of the cavity.
    • The major benefits of this technique are its portability and diagnostic utility in patients who are too critical to undergo prolonged radiologic evaluation or to be moved out of monitored setting.
    • Operator dependence affects its overall sensitivity.
  • Gallium and technetium radionuclide scanning (sensitivity 50-90%)
    • The initial studies are used in diagnosis.
    • These techniques use the fact that the radiopharmaceuticals share the same uptake, transport, and excretion pathways as bilirubin and, thus, are effective agents in evaluating liver disease.
    • Sensitivity varies with the radiopharmaceutical utilized, technetium (80%), gallium (50-80%), and indium (90%).
    • Limitations include a delay in diagnosis and the need for confirmatory procedures; thus, they offer no benefit over other imaging modalities.
  • Chest radiographic findings of basilar atelectasis, right hemidiaphragm elevation, and right pleural effusion are present in approximately 50% of cases; before advancements in radiologic technique, these served as diagnostic clues. Pneumonias or pleural diseases often are initially considered because of the radiographic findings.

Procedures

  • Percutaneous needle aspiration
    • Under CT scan or ultrasound guidance, needle aspiration of cavity material can be performed.
    • Needle aspiration enables rapid recovery of material for microbiologic and pathologic evaluation.
    • Needle aspiration can be performed with the initial diagnostic procedure.
  • Percutaneous catheter drainage
    • Percutaneous drainage has become the standard of care and should be the first intervention considered for small cysts.
    • For cysts greater than 5 cm, ruptured cysts, and multiloculated cysts, surgical drainage is generally recommended over percutaneous intervention.
    • Advantages include reduced costs, recovery time, and postprocedure recovery rate; it eliminates the need for general anesthesia.  This also allows for gradual, controlled drainage.
    • A catheter is placed under ultrasound or CT guidance using the Seldinger or trocar techniques.
    • The catheter is flushed daily until output is less than 10 cc/d or cavity collapse is documented by serial CT scanning.
    • Multiple abscesses have been drained successfully by this method.
    • Failure to respond to catheter drainage is the main reported complication and is also an indication for surgical intervention.
    • Other complications reported (rarely) are bleeding at the catheter site, perforation of hollow viscus, and peritonitis from intraperitoneal spillage of cavity fluid.
    • Contraindications include coagulopathy; a difficult access path to the cavity; peritonitis; and/or a complicated, multiloculated, thick-walled abscess with viscous pus.

More on Liver Abscess

Overview: Liver Abscess
Differential Diagnoses & Workup: Liver Abscess
Treatment & Medication: Liver Abscess
Follow-up: Liver Abscess
Multimedia: Liver Abscess
References
Further Reading
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Further Reading

Related eMedicine topics:
Amebiasis [Infectious Diseases]
Amebiasis [Pediatrics: General Medicine]
Amebic Hepatic Abscesses
Fungal Infections in Preterm Infants
Hepatic Cysts
Pyogenic Hepatic Abscesses

Clinical guidelines:
ACR Appropriateness Criteria® liver lesion characterization. American College of Radiology - Medical Specialty Society. 1998 (revised 2006). 7 pages. NGC:005115

Clinical trials:
Moxifloxacin Versus Ceftriaxone in the Treatment of Primary Pyogenic Liver Abscess

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Keywords

liver abscess, hepatic abscess, pyogenic liver abscess, amebic liver abscess, amoebic liver abscess, bacterial liver abscess, bacterial abscess of the liver, bacterial hepatic abscess, endophthalmitis, Enterobacteriaceae, microaerophilic streptococci, anaerobic streptococci, liver abscess, liver abscess, fungal liver abscess

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Contributor Information and Disclosures

Author

Ruben Peralta, MD, FACS, Professor of Surgery, Anesthesia and Emergency Medicine, Senior Medical Advisor, Board of Directors, Program Chief of Trauma, Emergency and Critical Care, Consulting Staff, Professor Juan Bosch Trauma Hospital, Dominican Republic
Ruben Peralta, MD, FACS is a member of the following medical societies: American College of Surgeons, American Medical Association, Association for Academic Surgery, Eastern Association for the Surgery of Trauma, Massachusetts Medical Society, Society of Critical Care Medicine, and Society of Laparoendoscopic Surgeons
Disclosure: Nothing to disclose.

Coauthor(s)

Michelle V Lisgaris, MD, Assistant Professor of Medicine, Case Western Reserve University; Associate Medical Director, Infection Control, Department of Internal Medicine, Division of Infectious Diseases, University Hospitals of Cleveland
Michelle V Lisgaris, MD is a member of the following medical societies: American College of Physicians, American Medical Association, Infectious Diseases Society of America, and Society for Healthcare Epidemiology of America
Disclosure: Nothing to disclose.

Robert A Salata, MD, Chief and Clinical Program Director of Division of Infectious Diseases, Vice Chair for International Affairs, Professor, Department of Medicine, Case Western Reserve University School of Medicine
Robert A Salata, MD is a member of the following medical societies: American Association of Immunologists, American Federation for Medical Research, American Medical Association, Central Society for Clinical Research, Infectious Diseases Society of America, Ohio State Medical Association, and Society for Healthcare Epidemiology of America
Disclosure: Nothing to disclose.

Sarah C Langenfeld, MD, Assistant Professor of Psychiatry, Department of Psychiatry, University of Massachusetts Medical School; Attending Psychiatrist, Community HealthLink
Sarah C Langenfeld, MD is a member of the following medical societies: American Medical Association, American Psychiatric Association, and Massachusetts Medical Society
Disclosure: Nothing to disclose.

Medical Editor

Marco G Patti, MD, Professor of Surgery, Director, Center for Esophageal Diseases, University of Chicago Pritzker School of Medicine
Marco G Patti, MD is a member of the following medical societies: American Association for the Advancement of Science, American College of Surgeons, American Gastroenterological Association, American Medical Association, American Surgical Association, Association for Academic Surgery, Pan-Pacific Surgical Association, Society for Surgery of the Alimentary Tract, Society of American Gastrointestinal and Endoscopic Surgeons, Southwestern Surgical Congress, and Western Surgical Association
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: eMedicine Salary Employment

Managing Editor

Joseph F John Jr, MD, FACP, FIDSA, FSHEA, Clinical Professor of Medicine, Molecular Genetics and Microbiology, Medical University of South Carolina; Associate Chief of Staff for Education, Ralph H Johnson Veterans Affairs Medical Center
Disclosure: BioMerieux Honoraria Review panel membership; Cubist Honoraria Review panel membership; Pfizer Honoraria Speaking and teaching; Merck Stock dividends stock holdings

CME Editor

Paolo Zamboni, MD, Professor of Surgery, Chief of Day Surgery Unit, Chair of Vascular Diseases Center, University of Ferrara, Italy
Paolo Zamboni, MD is a member of the following medical societies: American Venous Forum and New York Academy of Sciences
Disclosure: Nothing to disclose.

Chief Editor

John Geibel, MD, DSc, MA, Vice Chairman, Professor, Department of Surgery, Section of Gastrointestinal Medicine and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director of Surgical Research, Department of Surgery, Yale-New Haven Hospital
John Geibel, MD, DSc, MA is a member of the following medical societies: American Gastroenterological Association, American Physiological Society, American Society of Nephrology, Association for Academic Surgery, International Society of Nephrology, New York Academy of Sciences, and Society for Surgery of the Alimentary Tract
Disclosure: AMGEN Royalty Other

 
 
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