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Liver Abscess Treatment & Management

  • Author: Ruben Peralta, MD, FACS; Chief Editor: John Geibel, MD, DSc, MSc, MA  more...
Updated: Jun 20, 2016

Medical Care

An untreated hepatic abscess is nearly uniformly fatal as a result of complications that 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. It 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 with serial imaging and close monitoring for associated complications.

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


Surgical Care

Surgical drainage was the standard of care until the introduction of percutaneous drainage techniques in the mid-1970s. With the refinement of image-guided techniques, percutaneous drainage and aspiration have become the standard of care.

Current indications for the surgical treatment of pyogenic liver abscess are for the treatment of underlying intra-abdominal processes, including signs of peritonitis; existence of a known abdominal surgical pathology (eg, diverticular abscess); failure of previous drainage attempts; and the presence of a complicated, multiloculated, thick-walled abscess with viscous pus.

Shock with multisystem organ failure is a contraindication for surgery.

Open surgery can be performed by either of the following two approaches:

  • A transperitoneal approach allows for abscess drainage and abdominal exploration to identify previously undetected abscesses and the location of an etiologic source
  • For high posterior lesions, a posterior transpleural approach can be used; although this affords easier access to the abscess, the identification of multiple lesions or a concurrent intra-abdominal pathology is lost

A laparoscopic approach is also commonly used in select cases. This minimally invasive approach affords the opportunity to explore the entire abdomen and to significantly reduce patient morbidity. A growing literature is defining the optimal population for this mode of intervention.

A retrospective chart review compared surgery versus percutaneous drainage for liver abscesses greater than 5 cm. Morbidity was comparable for the two procedures, but those treated with surgery had fewer secondary procedures and fewer treatment failures.

Postoperative complications are not uncommon and include recurrent pyogenic liver abscess, intra-abdominal abscess, hepatic or renal failure, and wound infection.



Obtain an interventional radiology consultation as soon as the diagnosis is considered to allow rapid collection of cavity fluid and the potential for early therapeutic drainage of abscess.

Immediately seek a consultation with a general surgeon if the source of the abscess is a known underlying abdominal pathology or in cases with peritonitis. In cases undergoing percutaneous drainage, seek the involvement of a general surgeon if drainage of the abscess cavity is unsuccessful.

Gastroenterology involvement may be useful after successful drainage to evaluate for underlying gastrointestinal disease using colonoscopy or endoscopic retrograde cholangiopancreatography (ERCP).

Infectious disease consultation should be considered in complicated cases and when the involved pathogens are unusual or difficult to treat, such as in fungal abscesses.


Long-Term Monitoring

Aggressively seek an underlying source of the abdominal pathology.

Perform weekly serial computed tomography (CT) or ultrasound examinations to document adequate drainage of the abscess cavity. Continue radiologic evaluation to document progress of therapy after discharge.

Drain care may be required. Maintain drains until the output is less than 10 mL/day.

Monitor fever curves. Persistent fever after 2 weeks of therapy may indicate the need for more aggressive drainage.

For patients with an underlying malignancy, definitive treatment, such as surgical removal of the mass, should be pursued if at all possible.

Patients will require prolonged parenteral antimicrobial therapy that may continue after discharge. Monitoring of medication levels, renal function, and blood counts may be needed. Enteral nutrition is the preferred route unless it is clinically contraindicated.

Contributor Information and Disclosures

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 Association of Blood Banks, American College of Surgeons, American Medical Association, Association for Academic Surgery, Massachusetts Medical Society, Society of Critical Care Medicine, Society of Laparoendoscopic Surgeons, Eastern Association for the Surgery of Trauma, American College of Healthcare Executives

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 and Translational Research, Infectious Diseases Society of America, Ohio State Medical Association, Society for Healthcare Epidemiology of America

Disclosure: Nothing to disclose.

Michelle V Lisgaris, MD Assistant Professor of Medicine, Case Western Reserve University School of Medicine

Michelle V Lisgaris, MD is a member of the following medical societies: American College of Physicians, American Medical Association, Infectious Diseases Society of America, Society for Healthcare Epidemiology of America

Disclosure: Nothing to disclose.

Specialty Editor Board

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

Joseph F John, Jr, MD, FACP, FIDSA, FSHEA Clinical Professor of Medicine, Molecular Genetics and Microbiology, Medical University of South Carolina College of Medicine; Associate Chief of Staff for Education, Ralph H Johnson Veterans Affairs Medical Center

Joseph F John, Jr, MD, FACP, FIDSA, FSHEA is a member of the following medical societies: Charleston County Medical Association, Infectious Diseases Society of America, South Carolina Infectious Diseases Society

Disclosure: Nothing to disclose.

Chief Editor

John Geibel, MD, DSc, MSc, MA Vice Chair and Professor, Department of Surgery, Section of Gastrointestinal Medicine, and Department of Cellular and Molecular Physiology, Yale University School of Medicine; Director, Surgical Research, Department of Surgery, Yale-New Haven Hospital; American Gastroenterological Association Fellow

John Geibel, MD, DSc, MSc, 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, Society for Surgery of the Alimentary Tract

Disclosure: Received royalty from AMGEN for consulting; Received ownership interest from Ardelyx for consulting.

Additional Contributors

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 Surgical Association, American College of Surgeons, American Gastroenterological Association, American Medical 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, Western Surgical Association

Disclosure: Nothing to disclose.

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Table 1: Presenting symptoms and signs in 715 patients diagnosed with liver abscess.
Table 2: Microbiologic results from 312 cases of liver abscess compiled from the literature.
Table 3: Comparison of the radiologic procedures used in the diagnosis of liver abscess.
Table 4: Underlying etiology of 1086 cases of liver abscess compiled from the literature.
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 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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