Pyogenic Hepatic Abscesses Treatment & Management

Updated: Oct 16, 2018
  • Author: Todd A Nickloes, DO, FACOS; Chief Editor: John Geibel, MD, MSc, DSc, AGAF  more...
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Treatment

Approach Considerations

The most dramatic change in the treatment of pyogenic liver abscess to date was the emergence of computed tomography (CT)-guided drainage. 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.

Although at present, most liver abscesses are treated with antibiotics and catheter drainage under the guidance of ultrasonography (US) or CT, surgical drainage is still indicated in some cases. Indications for surgical drainage include the following:

  • 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

The current accepted approach includes the following three steps:

  • Initiation of antibiotic therapy [4, 5, 6, 7, 30]
  • Diagnostic aspiration and drainage of the abscess [3, 4, 5, 6, 7, 30]
  • Surgical drainage in selected patients [7, 30]

A retrospective cohort study by Ke et al provided preliminary evidence to suggest that radiofrequency (RF) ablation (RFA) is a safe, feasible, and effective treatment for huge multiloculated pyogenic hepatic abscesses and that it should be considered as a therapeutic alternative for patients with such abscesses who are unresponsive to or unsuitable for percutaneous drainage plus antibiotics and who refuse surgical intervention. [31]

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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. [32]

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Percutaneous Drainage

Diagnostic aspiration should be performed as soon as the diagnosis is made. It can be performed under the guidance of US [24, 33]  (if small or superficial) or CT and is usually followed by placement of a drainage catheter. Multiple abscesses necessitate CT-guided drainage. [24]

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 Drainage

Surgical drainage was once considered to be the criterion standard in treating liver abscesses. [34] Currently, it is indicated for the following:

  • Abscesses larger than 5 cm [32]
  • 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 [32]
  • Failure of antibiotic therapy
  • Failure of percutaneous aspiration [35, 36]
  • Failure of percutaneous drainage [35, 36]

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. [35, 36, 37]

The laparoscopic approach eliminates access trauma and can help detect predisposing pathology. Intraoperative laparoscopic US can accurately detect the location of the abscess to allow drainage under US guidance. There is evidence to suggest that it is a relatively safe alternative, [37, 38]  and as experience with this use of the laparoscope increases, its application to the management of hepatic abscess will continue to evolve. [16, 35]

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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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