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 or instrumentation.
+
*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==
 
==Clinical Features==
--Lower right chest pain or RUQ abdominal pain
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*[[RUQ pain]]
 
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*High [[fever]]
--fever, chills
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*[[Nausea]], [[vomiting]], anorexia
 
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*Clay-colored stool
--nausea, vomiting, anorexia
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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>
--clay-colored stool
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*Often with right [[pleural effusions]]
 
 
--dark urine
 
 
 
--jaundice
 
  
 
==Differential Diagnosis==
 
==Differential Diagnosis==
 +
{{Liver abscess DDX}}
  
==Workup==
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{{DDX RUQ}}
--CBC, CMP, LFTs, bilirubin, coags, blood cultures
 
  
--abdominal ultrasound- 80-100% sensitivity
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==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
  
--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
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===Evaluation===
 +
*Diagnosis usually made on imaging studies
  
 
==Management==
 
==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.
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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
--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.
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***[[Gram Negs]]: third or fourth generation [[cephalosporin]] ([[ceftriaxone]]) or [[aminoglycoside]]
 +
***[[Gram Pos]]: [[penicillin]] for [[streptococcal]] species ([[ampicillin]])
 +
****For penicillin allergic, use [[fluoroquinolones]]
 +
***[[Anaerobes]]: [[metronidazole]] or [[clindamycin]]
  
--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.
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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==
--Admit for IV antibiotics and drainage/sugery
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*Admit for IV [[antibiotics]] and surgical drainage
  
 
==See Also==
 
==See Also==
 +
*[[Right upper quadrant abdominal pain]]
 +
*[[Amebiasis]]
  
==Sources==
+
==References==
UpToDate
 
MedlinePlus
 
Medscape
 
 
<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.