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Pyogenic liver abscess

Last updated: April 22, 2020

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A pyogenic liver abscess is a rare disease characterized by solitary/multiple collections of pus within the liver. The infection is caused by bacteria and is usually polymicrobial, with E. coli and K. pneumoniae being the common causative organisms. The majority of cases are caused by ascending infection from a biliary tract pathology (e.g., cholangitis due to choledocholithiasis, i.e. biliary strictures). Due to the liver's dual blood supply from the portal vein and the hepatic artery, an infectious focus in the gastrointestinal tract or bacteremia exposes the liver to high bacterial loads. Patients, typically middle-aged/elderly males, present with non-specific symptoms, such as fever, malaise, and weight loss. Right upper quadrant pain and tender hepatomegaly are specific features of a liver abscess but are often absent. Diagnosis is confirmed on abdominal imaging (ultrasound or CT), which demonstrates intrahepatic fluid-filled lesions with surrounding edema. Broad-spectrum IV antibiotics (ampicillin + sulbactam) and percutaneous/surgical drainage of the abscess cavity is the mainstay of treatment. Complications include sepsis, pneumonia, and abscess rupture into the peritoneum/thorax. Advancements in diagnostics and treatment have reduced the complications and mortality rates of pyogenic liver abscesses.

  • Incidence: 2–3 cases per 100,000 people in the United States
  • Peak incidence: 50–60 years
  • Sex: slight male predominance

References:[1][2][3][4]

Epidemiological data refers to the US, unless otherwise specified.

Risk factors

Etiology by source

Source Etiology

Biliary tract (∼ 60%): Most common cause

Portal vein (∼ 20%)

Hepatic artery (∼ 15%)

Contiguous area (< 5%)

Trauma (Rare)

Others

  • Cryptogenic (∼ 20%)
  • Secondary infection of hepatic tumors
  • Secondary bacterial infection of amebic liver abscess
  • Secondary infection of hydatid cyst of the liver
  • Hepatic chemoembolization

Microbiology

References:[1][2][5][6][7][8][9][10][11][12][13]

The symptoms of pyogenic liver abscess are often non-specific (e.g., fever, weight loss, etc.).
References:[1][2][6]

Laboratory tests

Imaging

Percutaneous aspiration and culture of the aspirate

  • Both diagnostic and therapeutic (see “Treatment” section below)
  • Performed under US or CT guidance
  • Aspirated material is cultured to determine the organism and its antibiotic-susceptibility profile.

References:[1][2][6][13][14]

Pyogenic liver abscesses need to be differentiated from other space-occupying lesions of the liver.

References:[15]

The differential diagnoses listed here are not exhaustive.

Pyogenic liver abscesses are generally treated with both IV antibiotics and percutaneous drainage of the abscess. Some patients may require surgical drainage.

Antibiotics

Drainage of the abscess cavity

The underlying etiology (e.g, choledocholithiasis, biliary stricture, etc.) should also be treated to prevent recurrent pyogenic liver abscesses.
References:[1][6][16][17]

References:[1][6][18][19]

We list the most important complications. The selection is not exhaustive.

References:[1][20][21]

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  10. Venous Drainage of the Abdomen. http://teachmeanatomy.info/abdomen/vasculature/venous-drainage/. Updated: January 22, 2017. Accessed: March 15, 2017.
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