Hepatic abscess: Difference between revisions

m (Rossdonaldson1 moved page Pyogenic Liver Abscess to Pyogenic liver abscess over redirect)
 
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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
*[[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==
*Lower right chest pain or RUQ [[Abdominal Pain]]
*[[RUQ pain]]
*fever, chills
*High [[fever]]
*nausea, vomiting, anorexia
*[[Nausea]], [[vomiting]], anorexia
*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 right [[pleural effusions]]


==Differential Diagnosis==
==Differential Diagnosis==
*[[Gallbladder Disease]]
{{Liver abscess DDX}}
*[[Hepatitis]]
*Primary biliary cirrhosis
*Hepatomegaly due to [[CHF]]
*[[appendicitis]] (retrocecal)
*[[pancreatitis]]
*[[Fitz-Hugh-Curtis Syndrome]]
*PUD/Gastritis/perforated duodenal or gastric ulcer
*Splenic enlargement/rupture/infarction/aneurysm
*[[AAA]]
*[[Bowel Obstruction]]
*bowel perforation


===RUQ Pain===
{{DDX RUQ}}
{{DDX RUQ}}


==Workup==
==Evaluation==
*CBC, CMP, LFTs, bilirubin, coags, blood cultures
[[File:Leberabszess - CT axial PV.jpg|thumb|Liver abscess on axial CT image: a hypodense lesion in the liver with peripherally enhancement.]]
*abdominal ultrasound
[[File:LargeHepaticAbscessMark.png|thumb|A large pyogenic liver abscess.]]
**80-100% sensitivity
===Work-up===
*abdominal CT
*CBC - Elevated white blood count (70-80%)
**imaging study of choice
*BMP
**triphasic CT scan to define the proximity of the abscess to the major branches of the portal and hepatic veins
*[[LFTs]] - Elevated alkaline phosphatase levels (90%)
*Coags
*[[Blood cultures]]
*Amebic and echinococcal serologies
*[[RUQ ultrasound|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==
==Management==
*IV antibiotics
*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
**Two or more antibiotics
***Flagyl and Clindamycin provide wide anaerobic coverage and penetration into the abscess
***[[Gram Negs]]: third or fourth generation [[cephalosporin]] ([[ceftriaxone]]) or [[aminoglycoside]]
***A 3rd generation Cephalosporin or Aminoglycoside for gram negative coverage
***[[Gram Pos]]: [[penicillin]] for [[streptococcal]] species ([[ampicillin]])
***For PCN allergic, use Fluoroquinolones
****For penicillin allergic, use [[fluoroquinolones]]
***This modality has been shown to be effective in patients with unilocular abscesses that are less than 3 cm in size.
***[[Anaerobes]]: [[metronidazole]] or [[clindamycin]]
*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.
*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
*Surgical drainage
**for abscesses > 5cm
**Abscesses > 5cm
**abscesses not amenable to percutaneous drainage due to location
**Abscesses not amenable to percutaneous drainage due to location
**failure of percutaneous aspiration and drainage
**Failure of percutaneous aspiration and drainage
**coexistence of inra-abdominal disease that requires surgical management
**Coexistence of inra-abdominal disease that requires surgical management


==Disposition==
==Disposition==
*Admit for IV antibiotics and drainage/sugery
*Admit for IV [[antibiotics]] and surgical drainage


==See Also==
==See Also==
[[Abdominal Pain]]
*[[Right upper quadrant abdominal pain]]
*[[Amebiasis]]


==Sources==
==References==
UpToDate
MedlinePlus
Medscape
<references/>
<references/>


[[Category:GI]]
[[Category:GI]]
[[Category:ID]]
[[Category:ID]]

Latest revision as of 19:05, 8 July 2021

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

Liver abscess on axial CT image: a hypodense lesion in the liver with peripherally enhancement.
A large pyogenic liver abscess.

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.