hepatic abscess
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Etiology
- hematogenous spread of extra-hepatic infection
- spread from portal system (portal pyemia)
- seeding from infectious peritonitis
- appendicitis
- cholangitis
- colorectal cancer
- organisms
- Escherichia coli
- anaerobes
- Klebsiella pneumoniae in Japan (Asia)
- often associated with a subsequent diagnosis of colorectal cancer[4]
- Pseudomonas aeruginosa[5]
- Entamoeba histolytica (more common in HIV1 patients)
- risk factors
- *diabetes mellitus
- *hepatobiliary disease
- *pancreatic diseases
- Klebsiella pneumoniae infection due to host factors
- *glucocorticoid therapy
- *alcoholism
- *chronic disease
- malignancy
Pathology
- direct spread to the liver from biliary infection
- transmission of bacteria via the portal vein from abdominal infections (diverticulitis etc)
Clinical manifestations
Laboratory
- complete blood count (CBC)
- liver function tests
- serology for Entamoeba histolytica
- HIV1 testing may be prudent
- culture
- blood culture
- culture of drainage fluid
Diagnostic procedures
- fine needle aspiration
- hepatic abscesses < 5 cm are not amenable to percutaneous drainage[1]
Radiology
- abominal US
- abdominal CT
- abdominal US less sensitive than abdominal CT for pypgenic abscess but equally sensitive for amebic abscess[1]
Complications
- pyogenic hepatic abscess is associated with
- sepsis & septic shock if left untreated
- increased risk of gastrointestinal cancers[3]
- colon cancer (RR=5.5)
- small intestinal cancer (RR=12.7)
- biliary carcinoma (RR=9.6)
- pancreatic cancer (RR-2.5)
Differential diagnosis
Management
- pyogenic hepatic abscesses require drainage
- broad spectrum IV antibiotics that cover Streptococcus, enteric gram-negative bacilli, & anaerobes should be initiated prior to needle aspiration[1]
- ciprofloxacin + metronidazole also covers Entamoeba histolytica
- ceftriaxone + metronidazole
- consider percutaneous drainage for abscesses > 5 cm
- antibiotics for amebic abscess[1]
- surgical resection rarely needed
More general terms
References
- ↑ Jump up to: 1.0 1.1 1.2 1.3 1.4 1.5 Medical Knowledge Self Assessment Program (MKSAP) 15, 16, 18, 19. American College of Physicians, Philadelphia 2009, 2012, 2018, 2021.
- ↑ Nickloes TA et al eMedicine: Pyogenic Heaptic Abscesses http://emedicine.medscape.com/article/193182-overview
- ↑ Jump up to: 3.0 3.1 Lai H-C et al. Increased incidence of gastrointestinal cancers among patients with pyogenic liver abscess: A population-based cohort study. Gastroenterology 2014 Jan; 146:129 PMID: https://www.ncbi.nlm.nih.gov/pubmed/24095786
- ↑ Jump up to: 4.0 4.1 Gharib SD et al Case 21-2015 - A 37-Year-Old American Man Living in Vietnam, with Fever and Bacteremia. N Engl J Med 2015; 373:174-183. July 9, 2015 <PubMed> PMID: https://www.ncbi.nlm.nih.gov/pubmed/26154791 <Internet> http://www.nejm.org/doi/full/10.1056/NEJMcpc1411439
- ↑ Jump up to: 5.0 5.1 5.2 5.3 Rothaus C Overcoming the Barrier. NEJM REsident 360. Dec 5, 2018 https://resident360.nejm.org/content_items/overcoming-the-barrier/
- ↑ Serraino C, Elia C, Bracco C et al Characteristics and management of pyogenic liver abscess: A European experience. Medicine (Baltimore). 2018 May;97(19):e0628 PMID: https://www.ncbi.nlm.nih.gov/pubmed/29742700 PMCID: PMC5959441 Free PMC article