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Pyogenic Hepatic Abscesses Treatment & Management

  • Author: Todd A Nickloes, DO, FACOS; Chief Editor: John Geibel, MD, DSc, MSc, MA  more...
 
Updated: Jul 22, 2016
 

Approach Considerations

At present, most liver abscesses are treated with antibiotics and catheter drainage under the guidance of ultrasonography or computed tomography (CT). In some cases, however, surgical drainage is indicated.

The five indications for surgical drainage are as follows:

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

Relative contraindications for 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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Medical Therapy

The most dramatic change in the treatment of pyogenic liver abscess has been the emergence of drainage guided by computed tomography (CT). Before this development, open surgical drainage was the treatment most often employed, with mortality figures as high as 70%. If the abscess is multiloculated, multiple catheters might be needed to achieve adequate drainage.

The current accepted approach includes the following three steps:

Antibiotic therapy

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 two or more antibiotics is given.

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 smaller than 3 cm.[28]

Percutaneous drainage

Diagnostic aspiration should be performed as soon as the diagnosis is made. It can be performed under ultrasonographic guidance[21, 29] (if small or superficial) or CT guidance and is usually followed by placement of a drainage catheter. Multiple abscesses necessitate CT-guided drainage.[21]

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 by CT. Presence of ascites and proximity to vital structures are contraindications for percutaneous drainage. Coagulopathy can be corrected with transfusion of fresh frozen plasma prior to drainage.

The success rate of percutaneous drainage is in the range of 80-87%.[3] Percutaneous drainage should be considered 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. Failure of percutaneous drainage can be treated by either inserting a second catheter or performing open surgical drainage.

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Surgical Therapy

Surgical drainage was once considered to be the criterion standard in treating liver abscesses.[30] Currently, surgical drainage is indicated for the following:

  • Abscesses larger than 5 cm [28]
  • Abscesses that are not amenable to percutaneous drainage secondary to location
  • Coexistence of intra-abdominal disease that requires operative management [7]
  • Concominant biliary/intra-abdominal disease [28]
  • Failure of antibiotic therapy
  • Failure of percutaneous aspiration [31, 32]
  • Failure of percutaneous drainage [31, 32]

The presence of peritoneal signs in a patient with pyogenic liver abscess mandates emergency 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 before a surgical procedure [9]

Operative details

Open drainage of pyogenic liver abscess may be accomplished via three approaches, as follows:

  • Transpleural
  • Extraperitoneal
  • Transperitoneal

Before the antibiotic era, the extraperitoneal approach was often used to avoid contamination of the peritoneal cavity. Currently, 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 in situations where drainage and antibiotics are unlikely to be curative. Examples include secondary infection of a hepatic malignancy and 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 necessitate a partial hepatectomy.

Laparoscopic drainage

Now that practitioners have gained greater increased experience with the laparoscopic approach to liver lesions, laparoscopic drainage of pyogenic hepatic abscesses is being performed safely, and the time required to carry out the procedure has been reduced.[31, 32, 33]

The laparoscopic approach eliminates access trauma and can help detect predisposing pathology. Intraoperative laparoscopic ultrasonography can accurately detect the location of the abscess to allow drainage under ultrasonographic guidance. Findings to date suggest that it is a relatively safe alternative,[33, 34]  and as experience with this use of the laparoscope increases, its application to the management of hepatic abscess will continue to evolve.[15, 31]

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Complications

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.

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Contributor Information and Disclosures
Author

Todd A Nickloes, DO, FACOS Associate Professor, Department of Surgery, Division of Trauma/Critical Care, University of Tennessee Medical Center-Knoxville

Todd A Nickloes, DO, FACOS is a member of the following medical societies: American Medical Association, American Osteopathic Association, Association for Academic Surgery, Society of Critical Care Medicine, Society of Laparoendoscopic Surgeons, Southeastern Surgical Congress, Southern Medical Association, Eastern Association for the Surgery of Trauma, American College of Osteopathic Surgeons

Disclosure: Nothing to disclose.

Coauthor(s)

Mohamed Akoad, MD Liver Transplant Surgeon, Division of Hepatobiliary and Liver Transplantation, Department of Surgery, Veterans Administration Pittsburgh Healthcare System

Disclosure: Nothing to disclose.

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, American Medical Association

Disclosure: Nothing to disclose.

LaMar O Mack, MD Resident 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, Student National Medical Association

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.

David L Morris, MD, PhD, FRACS Professor, Department of Surgery, St George Hospital, University of New South Wales, Australia

David L Morris, MD, PhD, FRACS is a member of the following medical societies: British Society of Gastroenterology

Disclosure: Received none from RFA Medical for director; Received none from MRC Biotec for director.

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.

Acknowledgements

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.

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CT scan of liver abscess reveals large, septated abscess of right hepatic lobe. Abscess was successfully treated with percutaneous drainage and antimicrobial therapy. Image courtesy of Michelle V Lisgaris, MD.
CT scan of liver abscess reveals large anterior abscess involving left hepatic lobe. Abscess was successfully treated with percutaneous drainage and antimicrobial therapy. Image courtesy of Michelle V Lisgaris, MD.
Table 1. Symptoms and Signs of Pyogenic Liver Abscess [9, 21]
Symptoms Percentage Signs Percentage
Abdominal pain 89-100 Normal findings 38
Fever 67-100 Right-upper-quadrant tenderness 41-72
Chills 33-88 Hepatomegaly 51-92
Anorexia 38-80 Mass 17-18
Weight loss 25-68 Jaundice 23-43
Cough 11-28 Chest findings 11-48
Pleuritic chest pain 9-24
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