Difference between revisions of "Hepatic abscess"

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==Background==
 
==Background==
*Uncommon overall, usually right liver lobe
+
*Uncommon overall - usually occurs in right liver lobe
*More abscesses -> more severe disease
+
**More abscesses more severe disease
*Camping history
+
*History of camping is common
*Endemic of Midwest
+
**Endemic of Midwest
*Two types: pyogenic and amebic
 
**Pyogenic
 
***More common of the two
 
***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
 
**Amebic
 
  
{{Liver abscess DDX}}
+
===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==
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*Clay-colored stool
 
*Clay-colored stool
 
*Dark urine
 
*Dark urine
*[[Jaundice]]
+
*[[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>
*Often with R [[pleural effusions]]
+
*Often with right [[pleural effusions]]
  
 
==Differential Diagnosis==
 
==Differential Diagnosis==
 +
{{Liver abscess DDX}}
 +
 
{{DDX RUQ}}
 
{{DDX RUQ}}
  
==Diagnosis==
+
==Evaluation==
*CBC
+
===Work-up===
**Elevated white blood count (70-80%)
+
*CBC - Elevated white blood count (70-80%)
*CMP
+
*BMP
*Liver Panel
+
*Liver Panel - Elevated alkaline phosphatase levels (90%)
**Elevated alkaline phosphatase levels (90%)
 
 
*Coags
 
*Coags
 
*[[Blood cultures]]
 
*[[Blood cultures]]
*Ultrasound
+
*Amebic and echinococcal serologies
**80-100% sensitivity
+
*Ultrasound (80-100% sensitivity)
*ABD/Pelvis CT
+
*CT ABD/Pelvis ('''Imaging study of choice''')
**Imaging study of choice
+
**Triphasic CT scan to define the proximity of the [[abscess]] to the major branches of the portal and hepatic veins
**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==
 
==Management==
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***[[Gram Negs]]: third or fourth generation [[cephalosporin]] ([[ceftriaxone]]) or [[aminoglycoside]]
 
***[[Gram Negs]]: third or fourth generation [[cephalosporin]] ([[ceftriaxone]]) or [[aminoglycoside]]
 
***[[Gram Pos]]: [[penicillin]] for [[streptococcal]] species ([[ampicillin]])
 
***[[Gram Pos]]: [[penicillin]] for [[streptococcal]] species ([[ampicillin]])
****For PCN allergic, use [[fluoroquinolones]]
+
****For penicillin allergic, use [[fluoroquinolones]]
 
***[[Anaerobes]]: [[metronidazole]] or [[clindamycin]]
 
***[[Anaerobes]]: [[metronidazole]] or [[clindamycin]]
  
*Diagnostic aspiration and drainage of the abscess followed by placement of drainage catheter
+
*Diagnostic aspiration and drainage of the [[abscess]] followed by placement of drainage catheter
 
**Sonographic guidance for small or superficial abscesses
 
**Sonographic guidance for small or superficial abscesses
 
**CT guidance for deep or multiple abscesses
 
**CT guidance for deep or multiple abscesses
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==Disposition==
 
==Disposition==
*Admit for IV [[antibiotics]] and drainage/sugery
+
*Admit for IV [[antibiotics]] and surgical drainage
  
 
==See Also==
 
==See Also==

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.