Hepatic abscess: Difference between revisions

No edit summary
No edit summary
(6 intermediate revisions by 6 users not shown)
Line 6: Line 6:


===Types===
===Types===
*Pyogenic
*Pyogenic (80%)
**More common of the two
**Most common cause
**Associated with biliary tract obstruction (most common), cholangitis, diverticulitis, pancreatic abscess, appendicitis and inflammatory bowel disease.  
**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
**Possible arterial hematogenous seeding: [[sepsis]], direct [[trauma]] or instrumentation
*Amebic
**Usually polymicrobial
*[[amebiasis|Amebic]] (10%)
**E. histolytica most common
**Usually not septic and sick, rarely needs drainage
*[[fungal infections|Fungal]] (<10%), [[candida|candidal]]
*Hydatid cyst ([[echinococcosis]])
**Associated with sheep farmers


==Clinical Features==
==Clinical Features==
Line 26: Line 32:
{{DDX RUQ}}
{{DDX RUQ}}


==Diagnosis==
==Evaluation==
===Work-up===
===Work-up===
*CBC - Elevated white blood count (70-80%)
*CBC - Elevated white blood count (70-80%)
*BMP
*BMP
*Liver Panel - Elevated alkaline phosphatase levels (90%)
*[[LFTs]] - Elevated alkaline phosphatase levels (90%)
*Coags
*Coags
*[[Blood cultures]]
*[[Blood cultures]]
*Ultrasound (80-100% sensitivity)
*Amebic and echinococcal serologies
*CT ABD/Pelvis ('''Imaging study of choice''')
*[[RUQ ultrasound|Ultrasound]] (80-100% sensitivity)
**Triphasic CT scan to define the proximity of the abscess to the major branches of the portal and hepatic veins
*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===
===Evaluation===
Line 45: Line 52:
***[[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

Revision as of 21:00, 29 September 2019

Background

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

Types

Clinical Features

Differential Diagnosis

Hepatic abscess

RUQ Pain

Evaluation

Work-up

  • CBC - Elevated white blood count (70-80%)
  • BMP
  • LFTs - 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.