Difference between revisions of "Hepatic abscess"

(Differential Diagnosis)
(grammar, additional info, restructuring, references)
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==Background==
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Please change the Main Title to "Hepatic Abscess"
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.
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==Background==<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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*Uncommon overall, usually right liver lobe
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*More abscesses -> more severe disease
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*Camping history
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*Endemic of Midwest
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*Two types: pyogenic and amebic
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**Pyogenic
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***More common of the two
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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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**Amebic
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==Causes==<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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*Pyogenic abscesses
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**Aerobic: Escherichia coli, Klebsiella, Pseudomonas
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**Anaerobic: Entercoccus, bacteroides, anaerobic streptococci
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*Amebic
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**Entamoeba histolytica
  
 
==Clinical Features==
 
==Clinical Features==
*Lower right chest pain or RUQ [[Abdominal Pain]]
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*RUQ Pain
*fever, chills
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*High fever
*nausea, vomiting, anorexia
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*Nausea, vomiting, anorexia
*clay-colored stool
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*Clay-colored stool
*dark urine
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*Dark urine
*jaundice
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*Jaundice
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*Often with R pleural effusions
  
 
==Differential Diagnosis==
 
==Differential Diagnosis==
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==Workup==
 
==Workup==
*CBC, CMP, LFTs, bilirubin, coags, blood cultures
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*CBC
*abdominal ultrasound
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**Elevated white blood count (70-80%)
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*CMP
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*Liver Panel
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**Elevated alkaline phosphatase levels (90%)
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*Coags
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*Blood cultures
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*Ultrasound
 
**80-100% sensitivity
 
**80-100% sensitivity
*abdominal CT
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*ABD/Pelvis CT
**imaging study of choice
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**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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**Triphasic CT scan to define the proximity of the abscess to the major branches of the portal and hepatic veins
  
 
==Management==
 
==Management==
*IV antibiotics
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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>
**combination of 2 or more antibiotics
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**Two or more antibiotics
***Flagyl and Clindamycin provide wide anaerobic coverage and penetration into the abscess
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***Gram Negs: third or fourth generation cephalosporin (ceftriaxone) or aminoglycoside
***A 3rd generation Cephalosporin or Aminoglycoside for gram negative coverage
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***Gram Pos: penicillin for streptococcal species (ampicillin)
***For PCN allergic, use Fluoroquinolones
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****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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***Anaerobes: metronidazole or clindamycin
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*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
**It is done under sonographic guidance for small or superficial abscesses or CT guidance for deep or multiple abscesses.
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**Sonographic guidance for small or superficial abscesses
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**CT guidance for deep or multiple abscesses
 
*Surgical drainage
 
*Surgical drainage
**for abscesses > 5cm
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**Abscesses > 5cm
**abscesses not amenable to percutaneous drainage due to location
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**Abscesses not amenable to percutaneous drainage due to location
**failure of percutaneous aspiration and drainage
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**Failure of percutaneous aspiration and drainage
**coexistence of inra-abdominal disease that requires surgical management
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**Coexistence of inra-abdominal disease that requires surgical management
  
 
==Disposition==
 
==Disposition==

Revision as of 14:47, 2 February 2015

Please change the Main Title to "Hepatic Abscess"

==Background==[1]

  • Uncommon overall, usually right liver lobe
  • More abscesses -> more severe disease
  • Camping history
  • 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

==Causes==[2]

  • Pyogenic abscesses
    • Aerobic: Escherichia coli, Klebsiella, Pseudomonas
    • Anaerobic: Entercoccus, bacteroides, anaerobic streptococci
  • Amebic
    • Entamoeba histolytica

Clinical Features

  • RUQ Pain
  • High fever
  • Nausea, vomiting, anorexia
  • Clay-colored stool
  • Dark urine
  • Jaundice
  • Often with R pleural effusions

Differential Diagnosis

RUQ Pain

Workup

  • CBC
    • Elevated white blood count (70-80%)
  • CMP
  • Liver Panel
    • Elevated alkaline phosphatase levels (90%)
  • Coags
  • Blood cultures
  • Ultrasound
    • 80-100% sensitivity
  • ABD/Pelvis 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[3]
    • Two or more antibiotics
      • Gram Negs: third or fourth generation cephalosporin (ceftriaxone) or aminoglycoside
      • Gram Pos: penicillin for streptococcal species (ampicillin)
        • For PCN allergic, use Fluoroquinolones
      • Anaerobes: metronidazole or clindamycin
  • 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

  • Admit for IV antibiotics and drainage/sugery

See Also

Abdominal Pain

Sources

UpToDate MedlinePlus Medscape

  1. 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.
  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.
  3. 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.