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Pyogenic Hepatic Abscesses Workup

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

Laboratory Studies

A complete blood count (CBC) should be obtained. Anemia is observed in 50-80% of patients.[8, 9] Leukocytosis of more than 10,000/μL is observed in 75-96% of patients.[8, 9] Bands of more than 10% are observed in 40% of patients.

The erythrocyte sedimentation rate (ESR) is commonly elevated.

Liver function tests are helpful. An elevated alkaline phosphatase level[4] is observed in 95-100% of patients.[8, 9] An elevated serum aspartate aminotransferase level, an elevated serum alanine aminotransferase level, or both are observed in 48-60% of patients. An elevated bilirubin level[14] is observed in 28-73% of patients.[8, 9] A decreased albumin level (<3 g/dL) and an increased globulin value (>3 g/dL) are frequently observed.

The prothrombin time (PT) is elevated in 71-87% of patients.[14]

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Imaging Studies

Although chest and abdominal radiographs are nonspecific, 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. 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 scanning has been completely supplanted by computed tomography (CT) 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.

Real-time ultrasonography findings are 80-100% sensitive.[6, 9, 16, 24, 25, 26] A round or oval hypoechoic mass is consistent with pyogenic abscess.

CT has become the imaging study of choice for detecting liver lesions.[6, 9, 16, 24, 25, 26] 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. (See the image below.)

CT scan of liver abscess reveals large, septated a 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.
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Diagnostic Procedures

Diagnostic aspiration is performed under ultrasonographic or CT guidance[9, 16] and is usually followed by drainage catheter placement. The aspirate is sent for culture and cytology.

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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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