Difference between revisions of "Hepatic abscess"

(Types)
 
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*Pyogenic (80%)
 
*Pyogenic (80%)
 
**Most common cause
 
**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
 
**Usually polymicrobial
 
**Usually polymicrobial
*Amebic (10%)
+
*[[amebiasis|Amebic]] (10%)
 
**E. histolytica most common
 
**E. histolytica most common
 
**Usually not septic and sick, rarely needs drainage
 
**Usually not septic and sick, rarely needs drainage
*Fungal (<10%), candidal
+
*[[fungal infections|Fungal]] (<10%), [[candida|candidal]]
*Hydatid cyst (echinococcosis)
+
*Hydatid cyst ([[echinococcosis]])
 
**Associated with sheep farmers
 
**Associated with sheep farmers
  
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*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]]
 
*Amebic and echinococcal serologies
 
*Amebic and echinococcal serologies
*Ultrasound (80-100% sensitivity)
+
*[[RUQ ultrasound|Ultrasound]] (80-100% sensitivity)
*CT ABD/Pelvis ('''Imaging study of choice''')
+
*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
 
**Triphasic CT scan to define the proximity of the [[abscess]] to the major branches of the portal and hepatic veins
  

Latest 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.