liver abscess.docx

7/27/2019 Liver Abscess.docx

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Liver Abscess

Gastroenterology> Liver Abscess

Key points

A liver abscess is a pus-filled cavity within the liver, usually caused by a biliary tractsource; occasionally, multiple cavities are seen

Origin may be pyogenic, amebic, or (rarely, and usually in severelyimmunocompromised patients) fungal

Clinical presentation is with fever and abdominal pain but is frequently nonspecific,without localized right upper quadrant symptoms

Computed tomography (CT), both with and without intravenous and oral contrast, andultrasound are the imaging studies of choice

Treatment involves antimicrobial therapy with or without percutaneous or surgicaldrainage Liver abscess is almost uniformly fatal if left untreated. Timely treatment reduces

mortality to 5% to 30%

Background

Description

The most common source of liver abscess is the biliary tree in patients withcholecystitis, choledocholithiasis, or cholangitis

Less common sources include other intra-abdominal processes, such as appendicitisor diverticulitis, and hematogenous spread from sources such as an infected heart

valve or the oral cavity

Amebic liver abscess should be considered in endemic areas or patients who havebeen to the tropics

Fungal microabscesses are seen primarily in patients with compromised immunesystems

Rarely, liver abscess may be due to trauma, secondary infection from an amebicabscess or a necrotic malignant hepatic tumor, or direct extension from local

structures

Common pathogens include Streptococcus spp.,Escherichia coli,Klebsiella, andBacteroides spp. Polymicrobial infections occur in 15% to 20% of patients;

approximately the same percentage have multiple abscesses

Amebic liver abscess follows vascular spread ofEntamoeba histolytica from thecolon in patients with the intestinal infection amebiasis. Amebic abscesses may be

very large; they contain aspirate with 'anchovy-sauce' color and consistency

Liver abscess in a child suggests immunocompromise A single abscess is the most common presentation; spread to the liver via the vascular

route is associated with multiple abscesses

The right hepatic lobe is affected more than twice as frequently as the left, due tovascular anatomy

Aspiration of abscess fluid and subsequent culture guide antibiotic choice
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Failure to culture pathogenic organism(s) may be due to prior antibiotic treatment orinadequate anaerobic culture

Treatment includes antibiotics and often either percutaneous or surgicaldrainage/debridement, depending on the size, number, and complexity of the

abscess(es)

Epidemiology

Incidence and prevalence

Incidence:

Approximately 3.6 per 100,000 in the U.S., based on the Nationwide Inpatient Sampledatabase from 1994 to 2005

Reported incidence ranges from 1.1 and 2.3 per 100,000 in Denmark and Canada,respectively, to 17.6 per 100,000 in Taiwan

Amebic abscesses are significantly more common in countries with endemicamebiasis and poor healthcare

Prevalence:

Prevalence rates from autopsy data: 300 to 1,500 per 100,000 of populationDemographics

Age:

A slight peak in incidence is seen in neonates, when liver abscess may be associatedwith umbilical vein catheterization and sepsis

A gradual increase is seen beyond age 60 years, due to the average age of patientswith biliary disease

Liver abscess in children and adolescents suggests underlying immunocompromise ortrauma

Gender:

Pyogenic liver abscess shows no gender difference Amebic abscess is 10 times more common in men than in women

Race:

No racial differences other than those related to the geographic distribution ofpopulations with endemic amebiasis

Geography:

Incidence of amebic abscess is higher in areas of endemic amebiasis, such as Mexico,India, East and South Africa, and parts of Central and South America

Pyogenic liver abscess shows no geographic influence


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Socioeconomic status:

Malnutrition, immunocompromise, and excess alcohol intake (which is believed toimpair immunologic response) predispose to amebic liver abscess in those exposed to

Entamoeba histolytica

Causes and risk factors

Causes

Common causes:

Biliary tract infection (30%-60%): secondary to biliary obstructive and inflammatoryconditions (eg,cholecystitis,choledocholithiasis, andcholangitis, especially in

patients with biliary tract malignancies with biliary stents)

Infection from gastrointestinal or pelvic organs drained via the portal circulation(24%): examples includeappendicitis, diverticulitis, and perforated bowel

Unknown (20%) Hematogenous spread secondary to bacteremia (15%):infective endocarditis,

pyelonephritis, untreated oral infections, any cause of immunocompromise in children

(eg, leukemia)

Pathogens causing infection:

Most common bacterial causes:Escherichia coli,Klebsiella spp.,Proteus,Enterococcus, Staphylococcus aureus, and Streptococcus faecalis. Streptococcus

milleri and anaerobes such asBacteroides spp. are increasingly common ConsiderEntamoeba histolytica if the patient has recently traveled to the tropics or is

from an endemic area or HIV-positive

Candida albicans is the likely pathogen in patients with compromised immunesystems

Amebic liver abscess is significantly more common in men than womenRare causes:

Secondary infection from amebic liver abscess, primary and secondary malignanthepatic tumors

Direct spread of infection from local organs (empyema of the gallbladder, perinephricabscess)

Fistula between the liver and infected intra-abdominal organs, such as the hepaticflexure of the colon

Penetrating or blunt trauma to the liver Fungal pathogens in patients with compromised immune systems

Contributory or predisposing factors

Inflammatory bowel disease, particularlyCrohn disease, due to loss of integrity of themucosal barrier

Liver cirrhosis Hepatic transplant
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Hepatic artery embolization (usually in patients with a symptomatic but unresectablehepatocellular carcinoma)

Institutionalization Immunocompromise Older age (particularly associated with biliarysepsis) Malnutrition, malignancy, pregnancy, steroid use, and excessive alcohol intake

predispose to liver abscess formation

Associated disorders

Infectious and inflammatory disorders:

Abscesses caused by Streptococcus milleri may be seen in patients withCrohn disease Candidiasis:Candida albicans infection of the liver may occur in patients with

compromised immune systems

Tuberculosis Pyrexia of unknown origin Abscesses caused byKlebsiella spp. may be associated withendophthalmitis Abscesses caused by Staphylococcus aureus may be associated withinfective

endocarditisand other distant sources of infection

Empyema,peritonitis, andsepsissecondary to abscess rupture Hemorrhoidal abscess Pleural effusion Liver cirrhosis Peptic ulcer Hepatitis

Malaria

Metabolic disorders:

Alcoholism Diabetes (type 1ortype 2)

Immune deficiencies:

Neutrophil deficiencies (leukemia, chronic granulomatous disease) Severe immunocompromise in children Any cause of significant immunocompromise, for example,HIV/AIDS

Screening

Not applicable.

Primary prevention

Summary approach

Prompt treatment of biliary, gastrointestinal, pelvic, and systemic infections that mayspread to the liver is the best means of primary prevention of pyogenic abscess
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