Pyogenic Hepatic Abscesses Workup

  • Author: Todd A Nickloes, DO, FACOS; Chief Editor: John Geibel, MD, DSc, MA   more...
 
Updated: Jan 6, 2012
 

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 level[3] 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 level[8] 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 time[8] : This is elevated in 71-87% of patients.
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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.
  • Ultrasonography[5, 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 scanning[5, 9, 15, 16]
    • CT scanning has become the imaging study of choice for detecting liver lesions.[17, 18] See the image below. Computed tomography scan of liver abscess revealinComputed 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.
    • 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.
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Diagnostic Procedures

  • Diagnostic aspiration is performed under ultrasonographic or CT guidance[9, 15] 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  Assistant 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 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  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, 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.

Specialty Editor Board

Alex Jacocks, MD  Program Director, Professor, Department of Surgery, University of Oklahoma School of Medicine

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

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: RFA Medical None Director; MRC Biotec None Director

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 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

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 Consulting; ARdelyx Ownership interest Board membership

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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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.
Computed tomography scan of liver abscess revealing a large anterior abscess involving the left hepatic lobe. Abscess was successfully treated with percutaneous drainage and antimicrobial therapy. Image courtesy of Michelle V. Lisgaris, MD.
Table. Symptoms and Signs of Pyogenic Liver Abscess[9, 14]
SymptomsPercentageSignsPercentage
Abdominal pain89-100Normal findings38
Fever67-100Right upper quadrant tenderness41-72
Chills33-88Hepatomegaly51-92
Anorexia38-80Mass17-18
Weight loss25-68Jaundice23-43
Cough11-28Chest findings11-48
Pleuritic chest pain9-24––
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