Medical Care
An untreated hepatic abscess is nearly uniformly fatal as a result of complications that include sepsis, empyema, or peritonitis from rupture into the pleural or peritoneal spaces, and retroperitoneal extension. Treatment should include drainage, either percutaneous or surgical.
Antibiotic therapy as a sole treatment modality is not routinely advocated, though it has been successful in a few reported cases. It may be the only alternative in patients too ill to undergo invasive procedures or in those with multiple abscesses not amenable to percutaneous or surgical drainage. In these instances, patients are likely to require many months of antimicrobial therapy with serial imaging and close monitoring for associated complications.
Antimicrobial treatment is a common adjunct to percutaneous or surgical drainage.
Surgical Care
Surgical drainage was the standard of care until the introduction of percutaneous drainage techniques in the mid-1970s. With the refinement of image-guided techniques, percutaneous drainage and aspiration have become the standard of care.
Current indications for the surgical treatment of pyogenic liver abscess are for the treatment of underlying intra-abdominal processes, including signs of peritonitis; existence of a known abdominal surgical pathology (eg, diverticular abscess); failure of previous drainage attempts; and the presence of a complicated, multiloculated, thick-walled abscess with viscous pus.
Shock with multisystem organ failure is a contraindication for surgery.
Open surgery can be performed by either of the following two approaches:
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A transperitoneal approach allows for abscess drainage and abdominal exploration to identify previously undetected abscesses and the location of an etiologic source
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For high posterior lesions, a posterior transpleural approach can be used; although this affords easier access to the abscess, the identification of multiple lesions or a concurrent intra-abdominal pathology is lost
A laparoscopic approach is also commonly used in select cases. This minimally invasive approach affords the opportunity to explore the entire abdomen and to significantly reduce patient morbidity. A growing literature is defining the optimal population for this mode of intervention.
A retrospective chart review compared surgery versus percutaneous drainage for liver abscesses greater than 5 cm. Morbidity was comparable for the two procedures, but those treated with surgery had fewer secondary procedures and fewer treatment failures.
Postoperative complications are not uncommon and include recurrent pyogenic liver abscess, intra-abdominal abscess, hepatic or renal failure, and wound infection.
Consultations
Obtain an interventional radiology consultation as soon as the diagnosis is considered to allow rapid collection of cavity fluid and the potential for early therapeutic drainage of abscess.
Immediately seek a consultation with a general surgeon if the source of the abscess is a known underlying abdominal pathology or in cases with peritonitis. In cases undergoing percutaneous drainage, seek the involvement of a general surgeon if drainage of the abscess cavity is unsuccessful.
Gastroenterology involvement may be useful after successful drainage to evaluate for underlying gastrointestinal disease using colonoscopy or endoscopic retrograde cholangiopancreatography (ERCP).
Infectious disease consultation should be considered in complicated cases and when the involved pathogens are unusual or difficult to treat, such as in fungal abscesses.
Long-Term Monitoring
Aggressively seek an underlying source of the abdominal pathology.
Perform weekly serial computed tomography (CT) or ultrasound examinations to document adequate drainage of the abscess cavity. Continue radiologic evaluation to document progress of therapy after discharge.
Drain care may be required. Maintain drains until the output is less than 10 mL/day.
Monitor fever curves. Persistent fever after 2 weeks of therapy may indicate the need for more aggressive drainage.
For patients with an underlying malignancy, definitive treatment, such as surgical removal of the mass, should be pursued if at all possible.
Patients will require prolonged parenteral antimicrobial therapy that may continue after discharge. Monitoring of medication levels, renal function, and blood counts may be needed. Enteral nutrition is the preferred route unless it is clinically contraindicated.
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Table 1: Presenting symptoms and signs in 715 patients diagnosed with liver abscess.
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Table 2: Microbiologic results from 312 cases of liver abscess compiled from the literature.
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Table 3: Comparison of the radiologic procedures used in the diagnosis of liver abscess.
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Table 4: Underlying etiology of 1086 cases of liver abscess compiled from the literature.
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Computed tomography (CT) scan findings of liver abscess are shown. A large, septated abscess of the right hepatic lobe is revealed. Abscess was successfully treated with percutaneous drainage and antimicrobial therapy.
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Computed tomography (CT) scan findings of liver abscess are shown. A large anterior abscess involving the left hepatic lobe is revealed. Abscess was successfully treated with percutaneous drainage and antimicrobial therapy.
