Difference between revisions of "Hepatic abscess"

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==Clinical Features==
 
==Clinical Features==
--Lower right chest pain or RUQ abdominal pain
+
*Lower right chest pain or RUQ [[Abdominal Pain]]
 
+
*fever, chills
--fever, chills
+
*nausea, vomiting, anorexia
 
+
*clay-colored stool
--nausea, vomiting, anorexia
+
*dark urine
 
+
*jaundice
--clay-colored stool
 
 
 
--dark urine
 
 
 
--jaundice
 
  
 
==Differential Diagnosis==
 
==Differential Diagnosis==
--Gallbladder Disease
+
*[[Gallbladder Disease]]
 
+
*[[Hepatitis]]
--Hepatitis
+
*Primary biliary cirrhosis
 
+
*Hepatomegaly due to [[CHF]]
--Primary biliary cirrhosis
+
*[[appendicitis]] (retrocecal)
 
+
*[[pancreatitis]]
--Hepatomegaly due to CHF
+
*[[Fitz-Hugh-Curtis Syndrome]]
 
+
*PUD/Gastritis/perforated duodenal or gastric ulcer
--appendicitis (retrocecal)
+
*Splenic enlargement/rupture/infarction/aneurysm
 
+
*[[AAA]]
--pancreatitis
+
*[[Bowel Obstruction
 
+
*bowel perforation
--Fitz-Hugh-Curtis Syndrome
 
 
 
--PUD/Gastritis/perforated duodenal or gastric ulcer
 
 
 
--Splenic enlargement/rupture/infarction/aneurysm
 
 
 
--AAA
 
 
 
--bowel obstruction
 
 
 
--bowel perforation
 
  
 
==Workup==
 
==Workup==
--CBC, CMP, LFTs, bilirubin, coags, blood cultures
+
*CBC, CMP, LFTs, bilirubin, coags, blood cultures
 
+
*abdominal ultrasound
--abdominal ultrasound- 80-100% sensitivity
+
**80-100% sensitivity
 
+
*abdominal CT
--abdominal CT- imaging study of choice - triphasic CT scan to define the proximity of the abscess to the major branches of the portal and hepatic veins
+
**imaging study of choice
 +
**triphasic CT scan to define the proximity of the abscess to the major branches of the portal and hepatic veins
  
 
==Management==
 
==Management==
--IV antibiotics- combination of 2 or more antibiotics- Flagyl and Clindamycin provide wide anaerobic coverage and penetration into the abscessA 3rd generation Cephalosporin or Aminoglycoside for gram negative coverage. For PCN allergic, use Fluoroquinolones. This modality has been shown to be effective in patients with unilocular abscesses that are less than 3 cm in size.
+
*IV antibiotics
 
+
**combination of 2 or more antibiotics
--Diagnostic aspiration and drainage of the abscess followed by placement of drainage catheterIt is done under sonographic guidance for small or superficial abscesses or CT guidance for deep or multiple abscesses.  
+
***Flagyl and Clindamycin provide wide anaerobic coverage and penetration into the abscess
 
+
***A 3rd generation Cephalosporin or Aminoglycoside for gram negative coverage
--Surgical drainage- for abscesses > 5cm, abscesses not amenable to percutaneous drainage due to location, failure of percutaneous aspiration and drainage, coexistence of inra-abdominal disease that requires surgical management.
+
***For PCN allergic, use Fluoroquinolones
 +
***This modality has been shown to be effective in patients with unilocular abscesses that are less than 3 cm in size.
 +
*Diagnostic aspiration and drainage of the abscess followed by placement of drainage catheter
 +
**It is done under sonographic guidance for small or superficial abscesses or CT guidance for deep or multiple abscesses.  
 +
*Surgical drainage
 +
**for abscesses > 5cm
 +
**abscesses not amenable to percutaneous drainage due to location
 +
**failure of percutaneous aspiration and drainage
 +
**coexistence of inra-abdominal disease that requires surgical management
  
 
==Disposition==
 
==Disposition==
--Admit for IV antibiotics and drainage/sugery
+
*Admit for IV antibiotics and drainage/sugery
  
 
==See Also==
 
==See Also==

Revision as of 01:24, 13 January 2014

Background

Pus filled area in the liver. Usually develops following peritonitis due to leakage of intraabdominal bowel contents that subsequently spread to liver via the portal circulation or via direct spread from biliary infection. It may also result from arterial hematogenous seeding in the setting of sepsis or from direct trauma to the liver or instrumentation.

Clinical Features

  • Lower right chest pain or RUQ Abdominal Pain
  • fever, chills
  • nausea, vomiting, anorexia
  • clay-colored stool
  • dark urine
  • jaundice

Differential Diagnosis

Workup

  • CBC, CMP, LFTs, bilirubin, coags, blood cultures
  • abdominal ultrasound
    • 80-100% sensitivity
  • abdominal CT
    • imaging study of choice
    • triphasic CT scan to define the proximity of the abscess to the major branches of the portal and hepatic veins

Management

  • IV antibiotics
    • combination of 2 or more antibiotics
      • Flagyl and Clindamycin provide wide anaerobic coverage and penetration into the abscess
      • A 3rd generation Cephalosporin or Aminoglycoside for gram negative coverage
      • For PCN allergic, use Fluoroquinolones
      • This modality has been shown to be effective in patients with unilocular abscesses that are less than 3 cm in size.
  • Diagnostic aspiration and drainage of the abscess followed by placement of drainage catheter
    • It is done under sonographic guidance for small or superficial abscesses or CT guidance for deep or multiple abscesses.
  • Surgical drainage
    • for abscesses > 5cm
    • abscesses not amenable to percutaneous drainage due to location
    • failure of percutaneous aspiration and drainage
    • coexistence of inra-abdominal disease that requires surgical management

Disposition

  • Admit for IV antibiotics and drainage/sugery

See Also

Abdominal Pain

Sources

UpToDate MedlinePlus Medscape