eMedicine Specialties > General Surgery > Abdomen

Pyogenic Hepatic Abscesses: Workup

Author: Todd A Nickloes, DO, Assistant Professor of Surgery, Division of Trauma/Critical Care, University of Tennessee Medical Center
Coauthor(s): Brian Reed, MD, Staff Physician, Department of Surgery, University of Tennessee Medical Center; LaMar O Mack, MD, Staff Physician, Department of Surgery, University of Tennessee Medical Center; Mohamed Akoad, MD, Liver Transplant Surgeon, Division of Hepatobiliary and Liver Transplantation, Department of Surgery, Veterans Administration Pittsburgh Healthcare System; Richard W Golub, MD, FACS, Consulting Surgeon, Sarasota Memorial Hospital and Doctors Hospital; Consulting Surgeon, Intercoastal Medical Group
Contributor Information and Disclosures

Updated: Jan 23, 2009

Workup

Laboratory Studies

  • Complete blood cell count
    • Anemia is observed in 50-80% of patients.7,9
    • Leukocytosis of more than 10,000/mm3 is observed in 75-96% of patients.7,9
    • Bands of more than 10% are observed in 40% of patients.
  • Erythrocyte sedimentation rate (ESR) is commonly elevated.
  • Liver function tests
    • An elevated alkaline phosphatase level3 is observed in 95-100% of patients.7,9
    • An elevated serum aspartate aminotransferase level, an elevated serum alanine aminotransferase level, or elevated levels of both are observed in 48-60% of patients.
    • An elevated bilirubin level8 is observed in 28-73% of patients.7,9
    • A decreased albumin level (<3 g/dL) and increased globulin value (>3 g/dL) are frequently observed.
  • Prothrombin time8 : This is elevated in 71-87% of patients.

Imaging Studies

  • Chest and abdominal radiographs are nonspecific, but they are frequently obtained at the initial evaluation.
  • Chest radiography
    • Findings are abnormal in approximately half the patients.
    • Nonspecific findings may include an elevated right hemidiaphragm, subdiaphragmatic air-fluid level, pneumonitis, consolidation, and pleural effusion
  • Abdominal radiograph: If gas-forming organisms are present, the abdominal x-ray film might show evidence of intrahepatic air, portal venous gas, air-fluid levels, or air in the biliary tree.
  • Radionucleotide sulfur colloid scan - The role of the radionucleotide scan has been completely replaced by CT scan and ultrasonography.
    • Findings can help reliably detect masses larger than 2 cm.
    • The sensitivity of the findings ranges from 50-80%; however, they lack specificity.
  • Ultrasonography5,9,15,16
    • Real-time ultrasonography findings are 80-100% sensitive.17,18
    • A round or oval hypoechoic mass is consistent with pyogenic abscess.
  • CT scanning5,9,15,16
    • CT scanning has become the imaging study of choice for detecting liver lesions.17,18
    • Pyogenic liver abscesses are not enhanced on images after intravenous contrast administration.
    • Triphasic CT scanning with arterial and portal venous phases helps to define the proximity of the abscess to the major branches of the portal and hepatic veins
    • Findings have sensitivity similar to that of ultrasonography, but they lack specificity.

Computed tomography scan of liver abscess reveali...

Computed tomography scan of liver abscess revealing a large, septated abscess of the right hepatic lobe. Abscess was successfully treated with percutaneous drainage and antimicrobial therapy. Image courtesy of Michelle V. Lisgaris, MD.

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Computed tomography scan of liver abscess reveali...

Computed tomography scan of liver abscess revealing a large, septated abscess of the right hepatic lobe. Abscess was successfully treated with percutaneous drainage and antimicrobial therapy. Image courtesy of Michelle V. Lisgaris, MD.


Diagnostic Procedures

  • Diagnostic aspiration is performed under ultrasonographic or CT guidance9,15 and is usually followed by drainage catheter placement. The aspirate is sent for culture and cytology.

More on Pyogenic Hepatic Abscesses

Overview: Pyogenic Hepatic Abscesses
Workup: Pyogenic Hepatic Abscesses
Treatment: Pyogenic Hepatic Abscesses
Follow-up: Pyogenic Hepatic Abscesses
Multimedia: Pyogenic Hepatic Abscesses
References
Further Reading
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References

  1. Ochsner A, DeBakey M, Murray S. Pyogenic abscess of the liver. Am J Surg. 1938;40:292.

  2. Gerzof SG, Johnson WC, Robbins AH, et al. Intrahepatic pyogenic abscesses: treatment by percutaneous drainage. Am J Surg. Apr 1985;149(4):487-94. [Medline].

  3. Kandel G, Marcon NE. Pyogenic liver abscess: new concepts of an old disease. Am J Gastroenterol. Jan 1984;79(1):65-71. [Medline].

  4. Rintoul R, O'Riordain MG, Laurenson IF, et al. Changing management of pyogenic liver abscess. Br J Surg. Sep 1996;83(9):1215-8. [Medline].

  5. Seeto RK, Rockey DC. Pyogenic liver abscess. Changes in etiology, management, and outcome. Medicine (Baltimore). Mar 1996;75(2):99-113. [Medline].

  6. Stain SC, Yellin AE, Donovan AJ, et al. Pyogenic liver abscess. Modern treatment. Arch Surg. Aug 1991;126(8):991-6. [Medline].

  7. Branum GD, Tyson GS, Branum MA, et al. Hepatic abscess. Changes in etiology, diagnosis, and management. Ann Surg. Dec 1990;212(6):655-62. [Medline]. [Full Text].

  8. Chu KM, Fan ST, Lai EC, et al. Pyogenic liver abscess. An audit of experience over the past decade. Arch Surg. Feb 1996;131(2):148-52. [Medline].

  9. Gyorffy EJ, Frey CF, Silva J Jr, et al. Pyogenic liver abscess. Diagnostic and therapeutic strategies. Ann Surg. Dec 1987;206(6):699-705. [Medline]. [Full Text].

  10. Rockey D. Hepatobiliary infections. Curr Opin Gastroenterol. May 1999;15(3):229-33. [Medline].

  11. Tsai FC, Huang YT, Chang LY, et al. Pyogenic liver abscess as endemic disease, Taiwan. Emerg Infect Dis. Oct 2008;14(10):1592-600. [Medline]. [Full Text].

  12. Pastagia M, Arumugam V. Klebsiella pneumoniae liver abscesses in a public hospital in Queens, New York. Travel Med Infect Dis. Jul 2008;6(4):228-33. [Medline].

  13. Cheng HC, Chang WL, Chen WY, et al. Long-term outcome of pyogenic liver abscess: factors related with abscess recurrence. J Clin Gastroenterol. Nov-Dec 2008;42(10):1110-5. [Medline].

  14. Giorgio A, de Stefano G, Di Sarno A, et al. Percutaneous needle aspiration of multiple pyogenic abscesses of the liver: 13-year single-center experience. AJR Am J Roentgenol. Dec 2006;187(6):1585-90. [Medline].

  15. Hashimoto L, Hermann R, Grundfest-Broniatowski S. Pyogenic hepatic abscess: results of current management. Am Surg. May 1995;61(5):407-11. [Medline].

  16. Benedetti NJ, Desser TS, Jeffrey RB. Imaging of hepatic infections. Ultrasound Q. Dec 2008;24(4):267-78. [Medline].

  17. Rubinson HA, Isikoff MB, Hill MC. Diagnostic imaging of hepatic abscesses: a retrospective analysis. AJR Am J Roentgenol. Oct 1980;135(4):735-45. [Medline].

  18. Ferrucci JT Jr, vanSonnenberg E. Intra-abdominal abscess. Radiological diagnosis and treatment. JAMA. Dec 11 1981;246(23):2728-33. [Medline].

  19. Hope WW, Vrochides DV, Newcomb WL, et al. Optimal treatment of hepatic abscess. Am Surg. Feb 2008;74(2):178-82. [Medline].

  20. Chung YF, Tan YM, Lui HF, et al. Management of pyogenic liver abscesses - percutaneous or open drainage?. Singapore Med J. Dec 2007;48(12):1158-65; quiz 1165. [Medline].

  21. Men S, Akhan O, Koroglu M. Percutaneous drainage of abdominal abcess. Eur J Radiol. Sep 2002;43(3):204-18. [Medline].

  22. Yanaga K, Kitano S, Hashizume M, et al. Laparoscopic drainage of pyogenic liver abscess. Br J Surg. Jul 1994;81(7):1022. [Medline].

  23. Siu WT, Chan WC, Hou SM, et al. Laparoscopic management of ruptured pyogenic liver abscess. Surg Laparosc Endosc. Oct 1997;7(5):426-8. [Medline].

  24. Bowers ED, Robison DJ, Doberneck RC. Pyogenic liver abscess. World J Surg. Jan-Feb 1990;14(1):128-32. [Medline].

  25. Chou FF, Sheen-Chen SM, Chen YS, et al. Prognostic factors for pyogenic abscess of the liver. J Am Coll Surg. Dec 1994;179(6):727-32. [Medline].

  26. Wang W, Lee WJ, Wei PL, et al. Laparoscopic drainage of pyogenic liver abscesses. Surg Today. 2004;34(4):323-5. [Medline].

  27. Robles PJ, Lara JG, Lancaster B. Drainage of hepatic amebic abscess successfully treated by laparoscopy. J Laparoendosc Surg. Dec 1994;4(6):451-4. [Medline].

  28. Barakate MS, Stephen MS, Waugh RC, et al. Pyogenic liver abscess: a review of 10 years' experience in management. Aust N Z J Surg. Mar 1999;69(3):205-9. [Medline].

  29. Carrafiello G, Lagana D, Dizonno M, et al. Emergency percutaneous treatment in iatrogenic hepatic arterial injuries. Emerg Radiol. Jul 2008;15(4):249-54. [Medline].

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Further Reading

Related eMedicine topics:
Amebiasis [Infectious Diseases]
Amebiasis [Pediatrics: General Medicine]
Amebic Hepatic Abscesses
Bile Duct Strictures
Cholangitis [Emergency Medicine]
Cholangitis [Gastroenterology]
Cholangitis, Recurrent Pyogenic
Liver Abscess

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Keywords

pyogenic hepatic abscess, abscess, metronidazole, clindamycin, abscess drainage, abscess liver, liver abscess, drain abscess, biliary disease, biliary obstruction, cholangitis, choledocholithiasis, malignant tumors, benign tumors, post-surgical strictures, postsurgical strictures, biliary-enteric anastomoses, choledochoduodenostomy, portal pyemia, appendicitis, pylephlebitis, diverticulitis, inflammatory bowel disease, proctitis, systemic septicemia, pyogenic bacteria

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Contributor Information and Disclosures

Author

Todd A Nickloes, DO, Assistant Professor of Surgery, Division of Trauma/Critical Care, University of Tennessee Medical Center
Todd A Nickloes, DO is a member of the following medical societies: American College of Osteopathic Surgeons, American Medical Association, American Osteopathic Association, Association for Academic Surgery, Eastern Association for the Surgery of Trauma, Society of Critical Care Medicine, Society of Laparoendoscopic Surgeons, Southeastern Surgical Congress, and Southern Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

Brian Reed, MD, Staff Physician, Department of Surgery, University of Tennessee Medical Center
Brian Reed, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Surgeons, and American Medical Association
Disclosure: Nothing to disclose.

LaMar O Mack, MD, Staff Physician, Department of Surgery, University of Tennessee Medical Center
LaMar O Mack, MD is a member of the following medical societies: American Urological Association, National Medical Association, and Student National Medical Association
Disclosure: Nothing to disclose.

Mohamed Akoad, MD, Liver Transplant Surgeon, Division of Hepatobiliary and Liver Transplantation, Department of Surgery, Veterans Administration Pittsburgh Healthcare System
Disclosure: Nothing to disclose.

Richard W Golub, MD, FACS, Consulting Surgeon, Sarasota Memorial Hospital and Doctors Hospital; Consulting Surgeon, Intercoastal Medical Group
Richard W Golub, MD, FACS is a member of the following medical societies: American College of Gastroenterology, American College of Surgeons, American Society for Gastrointestinal Endoscopy, American Society of Colon and Rectal Surgeons, Association for Academic Surgery, Association for Surgical Education, Crohns and Colitis Foundation of America, Society for Surgery of the Alimentary Tract, and Society of American Gastrointestinal and Endoscopic Surgeons
Disclosure: Nothing to disclose.

Medical Editor

Alex Jacocks, MD, Program Director, Professor, Department of Surgery, University of Oklahoma School of Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

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

Managing Editor

David L Morris, MD, PhD, Professor, Department of Surgery, St George Hospital, University of New South Wales, Australia
Disclosure: RFA Medical None Director; MRC Biotec None Director

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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