eMedicine Specialties > General Surgery > Abdomen

Pyogenic Hepatic Abscesses: Treatment

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

Treatment

Medical Therapy

The most dramatic change in the treatment of pyogenic liver abscess has been the emergence of CT-guided drainage. Prior to this modality, open surgical drainage was the treatment most often employed, with mortality rates as high as 70%. If the abscess is multiloculated, multiple catheters might be needed to achieve adequate drainage.

The current accepted approach includes 3 steps, as follows:

  • Initiation of antibiotic therapy
  • Diagnostic aspiration and drainage of the abscess
  • Surgical drainage in selected patients6,19

Antibiotic therapy3,4,5,6,19

Diagnostic aspiration should be performed as soon as possible. The antimicrobial agent should provide adequate coverage against aerobic gram-negative bacilli, microaerophilic streptococci, and anaerobic organisms, including Bacteroides fragilis. Usually, a combination of 2 or more antibiotics is used. Metronidazole and clindamycin have wide anaerobic coverage and provide excellent penetration into the abscess cavity. A third-generation cephalosporin or an aminoglycoside provides excellent coverage against most gram-negative organisms. Fluoroquinolones are an acceptable alternative in patients who are allergic to penicillin. This modality has been shown to be effective in patients with unilocular abscesses that are less than 3 cm in size.20

Percutaneous drainage2,3,4,5,6,19

Diagnostic aspiration should be performed as soon as the diagnosis is made. It can be performed under ultrasonographic14,21 (if small or superficial) or CT guidance and is usually followed by placement of a drainage catheter. Multiple abscesses necessitate CT guided drainage.14 Once positioned, the catheter should be irrigated with isotonic sodium chloride solution and placed to allow gravity drainage. The drain is removed when the abscess cavity collapses, as confirmed on CT scan images. Presence of ascites and proximity to vital structures are contraindications to percutaneous drainage. Coagulopathy can be corrected with transfusion of fresh frozen plasma prior to drainage.

The success rate of percutaneous drainage ranges from 80-87%.2 Consider percutaneous drainage to have failed if no improvement occurs, if the condition worsens within 72 hours of drainage, or if the abscess recurs despite adequate initial drainage. Percutaneous drainage failure can be treated by either inserting a second catheter or performing open surgical drainage.

Complications of percutaneous drainage include perforation of adjacent abdominal organs, pneumothorax, hemorrhage, and leakage of the abscess cavity into the peritoneum. Immunocompromised patients with multiple diffuse microabscesses are not candidates for either percutaneous or open surgical drainage and are best treated with high-dose antibiotics. Such patients have the highest mortality rate.

Surgical Therapy

Surgical drainage was once considered to be the criterion standard in treating liver abscesses. Currently, surgical drainage is indicated as follows:

  • Abscesses larger than 5 cm20
  • Abscess not amenable to percutaneous drainage secondary to location
  • Coexistence of intra-abdominal disease that requires operative management6
  • Concominant biliary/intra-abdominal disease20
  • Failure of antibiotic therapy
  • Failure of percutaneous aspiration22,23
  • Failure of percutaneous drainage22,23

The presence of peritoneal signs in a patient with pyogenic liver abscess mandates emergent laparotomy because free rupture of the abscess into the peritoneal cavity may have occurred.

Liver resection should be considered, when the following are present:

  • Liver carbuncle
  • Hepatolithiasis
  • Suspicious lesion that would require control of sepsis prior to surgical procedure9

Intraoperative Details

The 3 approaches to open drainage of pyogenic liver abscess are transpleural, extraperitoneal, and transperitoneal. Prior to antibiotics, the extraperitoneal approach was often used to avoid contamination of the peritoneal cavity. Presently, with the availability of broad-spectrum antibiotics, the transperitoneal approach is safe and is considered the preferred approach because it allows thorough inspection of the peritoneal cavity and permits the mobilization necessary for adequate drainage. Hepatic resection has been advocated when drainage and antibiotics are unlikely to be curative. Examples include secondary infection of a hepatic malignancy or hepatic abscesses associated with chronic granulomatous diseases of childhood. A necrotic right lobe from vascular injury during laparoscopic cholecystectomy, with recurrent abscesses secondary to intrahepatic biliary strictures, is another situation that could require a partial hepatic lobectomy.

Complications

The complications of liver abscess result from rupture of the abscess into adjacent organs or body cavities. These include pleuropulmonary and intra-abdominal types.

Pleuropulmonary complications are the most common and have been reported in 15-20% of early series. These include pleurisy and pleural effusion, empyema, and broncho-hepatic fistula.1

Intra-abdominal complications are also common. These complications include subphrenic abscess and rupture into the peritoneal cavity, stomach, colon, vena cava, or kidney. A large abscess compressing the inferior vena cava and the hepatic veins may result in Budd-Chiari syndrome.

Rupture into the pericardium or brain abscess from hematogenous spread is rare.

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

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  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].

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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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