eMedicine Specialties > General Surgery > Abdomen

Pyogenic Hepatic Abscesses

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

Introduction

Pyogenic hepatic abscesses are uncommon conditions that present diagnostic and therapeutic challenges to physicians. If left untreated, these lesions are invariably fatal.

Related eMedicine topics:
Amebiasis [Infectious Diseases]
Amebiasis [Pediatrics: General Medicine]
Amebic Hepatic Abscesses
Liver Abscess

History of the Procedure

Liver abscesses have been recognized since the age of Hippocrates. In 1883, Koch described the amoebae as a cause of liver abscess. In 1938, Ochsner and Debakey published the largest series of pyogenic and amebic liver abscesses in the literature.¹ Since the late 20th century, percutaneous drainage has become a useful therapeutic option.^2,3,4,5,6

Frequency

The incidence of pyogenic liver abscess has remained unchanged since just prior to the mid-20th century. In the United States, the incidence of pyogenic liver abscess is estimated to be 8-15 cases per 100,000 persons. This figure is considerably higher in countries where health care is not readily available. Studies indicate that the male-to-female ratio is approximately 2:1; the problem occurs most commonly in the fourth to sixth decade of life.⁷

Etiology

Biliary disease⁸

Biliary disease accounts for 21-30% of reported cases.^3,7,9 Extrahepatic biliary obstruction leading to ascending cholangitis and abscess formation is the most common cause^7,9 and is usually associated with choledocholithiasis, benign and malignant tumors,⁴ or postsurgical strictures. Biliary-enteric anastomoses (choledochoduodenostomy or choledochojejunostomy) have also been associated with a high incidence of liver abscesses.^2,9 Biliary complications (eg, stricture, bile leak) after liver transplantation are also recognized causes of pyogenic liver abscesses.

Infection via the portal system (portal pyemia)

The infectious process originates within the abdomen and reaches the liver by embolization or seeding of the portal vein. With the liberal use of antibiotics for intra-abdominal infections, portal pyemia is now a less frequent cause of pyogenic liver abscesses but still accounts for 20% of cases.⁷ Appendicitis and pylephlebitis are the predominant causes. However, any source of intra-abdominal abscess, such as acute diverticulitis, inflammatory bowel disease, and perforated hollow viscus, can lead to portal pyemia and hepatic abscesses.

Hematogenous (via the hepatic artery)

This infectious process results from seeding of bacteria into the liver in cases of systemic bacteremia from bacterial endocarditis, urinary sepsis, or following intravenous drug abuse.⁴

Blunt or penetrating trauma and liver necrosis from inadvertent vascular injury during laparoscopic cholecystectomy are recognized causes of liver abscess.⁷ In addition, transarterial embolization and cryoablation of liver masses are now recognized as new etiologies of pyogenic abscesses.¹⁰

Cryptogenic

No cause is found in approximately half of the cases. However, the incidence is increased in patients with diabetes or metastatic cancer. Patients with repeated cryptogenic liver abscesses should undergo biliary and gastrointestinal evaluation.⁷

Related eMedicine topics:
Cholangitis [Emergency Medicine]
Cholangitis [Gastroenterology]
Cholangitis, Recurrent Pyogenic

Pathophysiology

Pyogenic bacteria can gain access to the liver by direct extension from contiguous organs or through the portal vein or hepatic artery. Hepatic clearance of bacteria via the portal system appears to be a normal phenomenon in healthy individuals; however, organism proliferation, tissue invasion, and abscess formation can occur with biliary obstruction, poor perfusion, or microembolization.

Microbiology

The organisms isolated most often are included below. Most abscesses contain more than 1 organism and frequently are of biliary or enteric origin. Blood culture results are positive in 33-65% of cases,⁷ with positive results from abscess cultures reported in 73-100% of series.^7,9 Escherichia coli is the most common organism isolated in western series, while Klebsiella pneumoniae has recently emerged as a common isolate in patients with diabetes in Taiwan.^11,12,13

The most common microorganisms isolated from blood and abscess cultures are as follows^7,9 :

• E coli - 33%
• K pneumoniae - 18%
• Bacteroides species - 24%
• Streptococcal species - 37%
• Microaerophilic streptococci - 12%

Presentation

The clinical presentation of liver abscess is insidious; many patients have symptoms for weeks prior to presentation. Fever and right upper quadrant pain are the most common complaints. Pain is reported in as many as 80% of patients and may be associated with pleuritic chest pain or right shoulder pain. Symptoms are often misdiagnosed as acute cholecystitis. Fever occurs in 87-100% of patients and is usually associated with chills and malaise.⁹ Anorexia, weight loss, and mental confusion are also common symptoms. Physical examination findings are most notable for right upper quadrant tenderness. Hepatomegaly, liver mass, and jaundice are also common. Occasionally, patients may present with rales, pleural effusion, friction rub, or pulmonary consolidation. Rarely, patients are admitted with sepsis and peritonitis from intraperitoneal rupture of the abscess. The following table summarizes the signs and symptoms of pyogenic liver abscess.

Symptoms and Signs of Pyogenic Liver Abscess^9,14

Open table in new window

Indications

Presently, most liver abscesses are treated with antibiotics and catheter drainage under ultrasonographic or computed tomography (CT) scan guidance.

The 5 indications for surgical drainage are as follows:

• Abscess not amenable to percutaneous drainage secondary to location
• Coexistence of intra-abdominal disease that requires operative management
• Failure of antibiotic therapy
• Failure of percutaneous aspiration
• Failure of percutaneous drainage

Contraindications

Relative contraindications to surgery include the following:

• Multiple abscesses
• Polymicrobial infection
• Presence of associated malignancy or immunosuppressive disease
• Coexistence of other multiple and/or complicated medical problems or conditions

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