Difference between revisions of "Hepatic abscess"

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==Background==
 
==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.
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*Uncommon overall - usually occurs in right liver lobe
==Clinical Features==
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**More abscesses → more severe disease
--Lower right chest pain or RUQ abdominal pain
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*History of camping is common
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**Endemic of Midwest
  
--fever, chills
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===Types===
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*Pyogenic (80%)
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**Most common cause
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**Associated with biliary tract obstruction (most common), cholangitis, diverticulitis, pancreatic abscess, appendicitis and inflammatory bowel disease.
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**Possible arterial hematogenous seeding: sepsis, direct trauma or instrumentation
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**Usually polymicrobial
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*Amebic (10%)
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**E. histolytica most common
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**Usually not septic and sick, rarely needs drainage
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*Fungal (<10%), candidal
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*Hydatid cyst (echinococcosis)
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**Associated with sheep farmers
  
--nausea, vomiting, anorexia
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==Clinical Features==
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*[[RUQ pain]]
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*High [[fever]]
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*[[Nausea]], [[vomiting]], anorexia
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*Clay-colored stool
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*Dark urine
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*[[Jaundice]] - seen with pyogenic, as opposed to amebic<ref>Oyama LC. Disorders of the Liver and Biliary Tract, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2013, (Ch) 90: p 1186-1205.</ref>
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*Often with right [[pleural effusions]]
  
--clay-colored stool
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==Differential Diagnosis==
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{{Liver abscess DDX}}
  
--dark urine
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{{DDX RUQ}}
  
--jaundice
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==Evaluation==
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===Work-up===
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*CBC - Elevated white blood count (70-80%)
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*BMP
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*Liver Panel - Elevated alkaline phosphatase levels (90%)
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*Coags
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*[[Blood cultures]]
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*Amebic and echinococcal serologies
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*Ultrasound (80-100% sensitivity)
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*CT ABD/Pelvis ('''Imaging study of choice''')
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**Triphasic CT scan to define the proximity of the [[abscess]] to the major branches of the portal and hepatic veins
  
==Differential Diagnosis==
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===Evaluation===
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*Diagnosis usually made on imaging studies
  
==Workup==
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==Management==
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*IV antibiotics<ref>Guss DA, Oyama LA: Disorders of the Liver and Biliary Tract, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 7. St. Louis, Mosby, Inc., 2010, (Ch) 88: p 1153-1171.</ref>
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**Two or more antibiotics
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***[[Gram Negs]]: third or fourth generation [[cephalosporin]] ([[ceftriaxone]]) or [[aminoglycoside]]
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***[[Gram Pos]]: [[penicillin]] for [[streptococcal]] species ([[ampicillin]])
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****For penicillin allergic, use [[fluoroquinolones]]
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***[[Anaerobes]]: [[metronidazole]] or [[clindamycin]]
  
==Management==
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*Diagnostic aspiration and drainage of the [[abscess]] followed by placement of drainage catheter
 +
**Sonographic guidance for small or superficial abscesses
 +
**CT guidance for deep or multiple abscesses
 +
*Surgical drainage
 +
**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==
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*Admit for IV [[antibiotics]] and surgical drainage
  
 
==See Also==
 
==See Also==
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*[[Right upper quadrant abdominal pain]]
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*[[Amebiasis]]
  
==Sources==
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==References==
UpToDate
 
MedlinePlus
 
 
<references/>
 
<references/>
 +
 +
[[Category:GI]]
 +
[[Category:ID]]

Revision as of 01:13, 7 October 2018

Background

  • Uncommon overall - usually occurs in right liver lobe
    • More abscesses → more severe disease
  • History of camping is common
    • Endemic of Midwest

Types

  • Pyogenic (80%)
    • Most common cause
    • Associated with biliary tract obstruction (most common), cholangitis, diverticulitis, pancreatic abscess, appendicitis and inflammatory bowel disease.
    • Possible arterial hematogenous seeding: sepsis, direct trauma or instrumentation
    • Usually polymicrobial
  • Amebic (10%)
    • E. histolytica most common
    • Usually not septic and sick, rarely needs drainage
  • Fungal (<10%), candidal
  • Hydatid cyst (echinococcosis)
    • Associated with sheep farmers

Clinical Features

Differential Diagnosis

Hepatic abscess

RUQ Pain

Evaluation

Work-up

  • CBC - Elevated white blood count (70-80%)
  • BMP
  • Liver Panel - Elevated alkaline phosphatase levels (90%)
  • Coags
  • Blood cultures
  • Amebic and echinococcal serologies
  • Ultrasound (80-100% sensitivity)
  • CT ABD/Pelvis (Imaging study of choice)
    • Triphasic CT scan to define the proximity of the abscess to the major branches of the portal and hepatic veins

Evaluation

  • Diagnosis usually made on imaging studies

Management

  • Diagnostic aspiration and drainage of the abscess followed by placement of drainage catheter
    • Sonographic guidance for small or superficial abscesses
    • CT guidance for deep or multiple abscesses
  • Surgical drainage
    • 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

See Also

References

  1. Oyama LC. Disorders of the Liver and Biliary Tract, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2013, (Ch) 90: p 1186-1205.
  2. Guss DA, Oyama LA: Disorders of the Liver and Biliary Tract, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 7. St. Louis, Mosby, Inc., 2010, (Ch) 88: p 1153-1171.