Hepatic abscess: Difference between revisions
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==Differential Diagnosis== | ==Differential Diagnosis== | ||
{{Liver abscess DDX}} | {{Liver [[abscess]] DDX}} | ||
{{DDX RUQ}} | {{DDX RUQ}} | ||
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*Ultrasound (80-100% sensitivity) | *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 | ||
===Evaluation=== | ===Evaluation=== | ||
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***[[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 10:57, 10 March 2017
Background
- Uncommon overall - usually occurs in right liver lobe
- More abscesses → more severe disease
- History of camping is common
- Endemic of Midwest
Types
- 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
- E. histolytica most common
- Usually not septic and sick, rarely needs drainage
Clinical Features
- RUQ pain
- High fever
- Nausea, vomiting, anorexia
- Clay-colored stool
- Dark urine
- Jaundice - seen with pyogenic, as opposed to amebic[1]
- Often with right pleural effusions
Differential Diagnosis
{{Liver abscess DDX}}
RUQ Pain
- Gallbladder disease
- Pancreatitis
- Acute hepatitis
- Pancreatitis
- GERD
- Appendicitis (retrocecal)
- Pyogenic liver abscess
- Bowel obstruction
- Cirrhosis
- Budd-Chiari syndrome
- GU
- Other
- Hepatomegaly due to CHF
- Peptic ulcer disease with or without perforation
- Pneumonia
- Herpes zoster
- Myocardial ischemia
- Pulmonary embolism
- Abdominal aortic aneurysm
Evaluation
Work-up
- CBC - Elevated white blood count (70-80%)
- BMP
- Liver Panel - Elevated alkaline phosphatase levels (90%)
- Coags
- Blood cultures
- 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
- IV antibiotics[2]
- Two or more antibiotics
- Gram Negs: third or fourth generation cephalosporin (ceftriaxone) or aminoglycoside
- Gram Pos: penicillin for streptococcal species (ampicillin)
- For penicillin allergic, use fluoroquinolones
- Anaerobes: metronidazole or clindamycin
- Two or more antibiotics
- 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 surgical drainage
See Also
References
- ↑ 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.
- ↑ 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.