The American Journal of Surgery (2015) -, -–-

Percutaneous drainage for giant pyogenic liver

abscessdis it safe and sufficient?
Saleem Ahmed, M.B.B.S., M.R.C.S.a,b,
Clement L. K. Chia, M.B.B.S., M.R.C.S.a,b,
Sameer P. Junnarkar, M.D., F.R.C.S.a,
Winston Woon, M.B.B.S., F.R.A.C.S.a,
Vishal G. Shelat, M.B.B.S., F.R.C.S., F.E.B.S.a,*

a
Department of General Surgery, Tan Tock Seng Hospital, Singapore 308433, Singapore; bMinistry of
Health Holdings, 1 Maritime Square, Singapore, Singapore

KEYWORDS: Abstract
Abscess; BACKGROUND: Large size is a predictor of failure of percutaneous drainage (PD) for pyogenic liver
Giant; abscess (PLA). This article serves to establish the safety and sufficiency of PD in giant PLA (GPLA).
Operative drainage; METHODS: A retrospective review of all GPLA patients treated at a tertiary care academic hospital
Percutaneous drainage; from 2001 to 2011 was performed. A GPLA is defined as an abscess greater than or equal to 10 cm size
Pyogenic liver abscess based on imaging.
RESULTS: Forty patients (24 men, 60%) were treated for GPLA. All but 1 patient (98%) was
managed with PD and the mean duration of drainage was 9 days (range 1 to 23 days). One patient un-
derwent operative drainage. Three patients (7.7%) needed secondary procedures after the initial PD.
One patient (2.6%) failed PD and subsequently underwent operative drainage. Among the patients
who underwent PD, the overall morbidity was 25%; the median length of hospital stay was 13 days
(range 5 to 31 days) and 1 (2.6%) mortality.
CONCLUSIONS: Large size itself is not a contraindication for PD. PD is safe and sufficient even in
GPLA patients.
Ó 2015 Elsevier Inc. All rights reserved.

Pyogenic liver abscess (PLA) is an uncommon but
potentially life-threatening infection with up to 19% mortal-
ity.1–10 Over the last decade, there has been a reduction in
mortality because of earlier and improved diagnosis, ad-
vances in intensive care, and widespread adoption and avail-
ability of expertise for percutaneous drainage (PD).11–13
The authors declare no conflicts of interest.
* Corresponding author. Tel.: 165-635-77807; fax: 165-635-77809.
E-mail address: vgshelat@gmail.com
Manuscript received October 19, 2014; revised manuscript January 22,
2015
Parenteral antibiotics by itself is insufficient to treat large
liver abscess because of the higher bacterial load, inadequate
penetration of antibiotics, and ineffective medium for bacte-
rial elimination.13,14 The duration of parenteral antibiotics
may be shortened with effective drainage.15 For these reasons
it is generally accepted that the treatment of large liver ab-
scess should include intravenous (IV) antibiotics and some
form of drainage.13,16 IV antibiotics together with PD have
been considered to be effective for PLA and such treatment
is considered adequate.17,18 There has been much debate
regarding the size of abscess that necessitates drainage and
modality of drainage in large abscess. Many authors have

0002-9610/$ - see front matter Ó 2015 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.amjsurg.2015.03.002
2 The American Journal of Surgery, Vol -, No -, - 2015

advocated drainage in liver abscess above 3 to 6 cm.19–22 It is 12-Fr size drains (Navarre Drainage Catheters; Bard Pe-
also believed that PD is inadequate for large PLA and some ripheral Vascular, Inc, Tempe, AZ, USA) were routinely
groups have advocated an operative drainage (OD) used. All the drains are monitored for the quality and
instead.13,23 Liao et al24 have shown that abscess size greater quantity of effluents and occasionally flushed with saline to
than 7.3 cm predicts failure of PD. The standardization of ter- ensure patency. A contrast dye study via the drain is
minology ‘‘large’’ and ‘‘giant’’ is not clear and we define an routinely obtained when the drain output is less than
abscess greater than or equal to 10 cm in size as a giant 10 mL/day for at least 2 consecutive days. Depending on
PLA. There is no study to report safety and sufficiency of the drainogram, the tube is either repositioned, upsized, or
PD in giant pyogenic liver abscess (GPLA). More evidence withdrawn. The drains are removed upon resolution of
is needed on this topic to establish if PD is safe and sufficient sepsis as evidenced by stable vital parameters, total white
for the management of GPLA. As PLA is uncommon and cell count down trending, C-reactive protein levels down
GPLA is even rarer, it is difficult to conduct a randomized trending, and less than 10 mL/day drain effluent for at least
control trial to address this issue and hence we present an 2 consecutive days. All the patients undergo a repeat
experience from a busy tertiary care academic university- imaging at 2- to 3-week intervals and antibiotic therapy is
affiliated hospital that has a high caseload of PLA. discontinued when there is a clinical resolution and near
complete to complete radiological resolution. In instances
where a patient has completed at least 6 weeks of
Patients and Methods
antibiotics and shows resolution of sepsis, antibiotics are
discontinued despite a small residual persistent abscess on
A retrospective medical record review of all PLA patients
imaging. Fig. 1 shows the radiological diagnosis, drainage,
admitted at a university-affiliated tertiary hospital from
January 2001 to December 2011 was performed. The list of
patients was generated by accessing the International Classi-
fication of Diseases 9 and 10 codes of the hospital discharge
database. The patient’s case notes, electronic medical records,
and radiological images were reviewed. The largest diameter
on radiological imaging was considered for measuring the
size. The clinical presentation, past medical history, laboratory
and radiological investigations for each patient were reviewed.
Summary statistics were constructed for the baseline values,
using frequencies and proportions for categorical data, and
means for continuous variables. The concept of PLA ‘‘care
bundle’’ has been introduced.

Treatment protocol

All PLAs have been uniformly managed with antibiotics

and PD throughout the study period. All patients with
radiological confirmation of PLA had at least one set of
blood culture (mix of Microbact 12A [Oxoid, Basingstoke,
UK], VITEK 2 system [bioMérieux, Singapore, Singapore],
and the Bruker Biotyper [version 2.0] matrix-assisted laser
desorption/ionization time-of- flight [MALDI-TOF] mass
spectrometry system; susceptibility testing was performed
using the VITEK 2 system [bioMérieux] and Kirby–Bauer
method) taken before the initiation of empirical broad-
spectrum IV antibiotics, usually a combination of a third-
generation cephalosporin along with metronidazole. This
practice is monitored and revised annually by antibiotic
stewardship committee since 2011. Antibiotic therapy is
subsequently tailored according to culture and sensitivity
results of blood or pus. All the patients with positive blood
culture are treated with 10 to 14 days of IV antibiotics
either as an inpatient or as an outpatient. Total duration of Figure 1 CT scan images of a 35-year-old male patient who was
antibiotic therapy varied according to the clinical and admitted with abdominal pain and fever. He underwent PD of
radiological response. All the patients with GPLA are GPLA along with intravenous antibiotics (Panel A). Panel B
considered for PD in the absence of free rupture. Ten- to scan demonstrates improvement at 1-month interval.
S. Ahmed et al. Giant pyogenic liver abscess 3

and resolution of a patient treated for GPLA. All patients

with Klebsiella pneumoniae or Candida infection are
routinely screened for endopthalmitis and cardiac valvular
vegetations. All patients with biliary origin of PLA are
offered cholecystectomy on resolution of PLA. All patients
with cryptogenic PLA are offered a screening colonoscopy
for possible colonic pathology.

Definitions

A GPLA is defined as an abscess greater than or equal to

10 cm in diameter. Multiloculation is defined as an abscess
with 2 or more septations within its cavity. Secondary
procedure is defined as a repeat procedure performed
because of persistence or recurrence of abscess on imaging,
persistent features of sepsis, and problems related to drains
such as dislodgement or blockage. Failure of nonoperative
therapy is defined as patients having persistent signs of
sepsis after 5 days of IV antibiotics and PD, hence requiring
escalation of therapy (ie, repercutaneous intervention or
OD) or death. Acute kidney injury is defined as per the
Kidney Disease: Improving Global Outcomes criteria.25
Readmission is defined as patient requiring admission
related to the diagnosis of PLA within 30 days from
discharge. Mortality is defined as death because of any
cause during hospitalization or within 30 days of discharge.

Results Figure 2 Workflow of the patients admitted to our hospital with

During January 2001 to December 2011, a total of 741
patients were treated for PLA as shown in Fig. 2. The over-
all experience of management of all 741 patients has been
previously published.26 Forty GPLA patients (24 male,
60%) with a mean age of 57 years (range 35 to 89 years)
were included in the analysis. Diabetes and hypertension
were the commonest comorbid conditions (n 5 14, 35%
each). The most common presenting symptom was fever
(n 5 35, 88%). The demographic, clinical, laboratory,
and radiological data are reported in Table 1. The mean
size of the liver abscess was 12 cm (range 10 to 22 cm).
Most cases were considered cryptogenic in origin (n 5
25, 62.5%), followed by biliary origin (n 5 11, 27.5%),
liver cancer (n 5 2, 5%), and direct spread (n 5 2, 5%).
One patient underwent OD. A 58-year-old lady presented
with abdominal pain and fever. Computerized tomography
(CT) scan revealed a GPLA along with perforated chole-
cystitis. Emergency laparotomy, cholecystectomy, and hep-
atotomy with drainage of segment IVb and V liver abscess
was performed. Patient was discharged well 18 days later.
Thirty-nine patients (98%) were managed with PD and
the mean duration of drainage was 9 days (range 1 to
23 days). In these patients, IV antibiotics were administered
for a median of 13 days (range 5 to 38 days) and 6 (15%)
patients were managed with outpatient parenteral antibiotic
therapy (OPAT). One (2.6%) patient who underwent PD
required intensive care unit monitoring postprocedure.
PLA. Forty-nine patients had abscess greater than 10 cm but 5
were excluded because of missing data. Of the remaining, 3 pa-
tients were excluded because of miscoding and 1 because of
discharge against medical advice. Forty patients were included
in the analysis.
The median length of hospital stay (LOHS) was 13 days
(range 5 to 31 days).
There were 2 readmissions. The first patient was a 44-
year-old male diagnosed with K. pneumoniae PLA initially
treated with IV antibiotics and PD; subsequently, the patient
had a tube review, had the drain removed, and continued
OPAT. Patient was readmitted electively for persistent
abdominal pain. Imaging showed a subphrenic abscess,
which was treated with IV antibiotics and repeat PD and pa-
tient recovered. The second patient was a 53-year-old
female, who was also initially treated for K. pneumoniae
PLA with IV antibiotics and PD, subsequently discharged
with oral antibiotics. However, patient presented to emer-
gency unit 22 days later with abdominal pain. Imaging
showed that the abscess did not resolve. The patient was re-
treated for K. pneumoniae and started on IV antibiotics. A
repeat CT scan after 6 weeks showed resolution of abscess.
Three patients (7.7%) among those who underwent PD
required secondary procedures in the same admission. In 2
of the patients the tube was accidentally dislodged and
required re-PD. The third patient failed PD and subse-
quently underwent OD. She was 54-year-old who initially
4 The American Journal of Surgery, Vol -, No -, - 2015

Table 1 Demographic, clinical, laboratory, and radiological Table 2 General and specific complications of patients
data of patients with giant pyogenic liver abscess treated by percutaneous drainage
Demographics Patients (n)
Mean age (years) 57 (35–89) General complications
Sex ratio (male:female) 1:5 AMI 0
Patients, n (%) Pneumonia 1
AKI 2
Comorbidity DIC 1
ASA . 2 4 (10) Endopthalmitis 1
Diabetes mellitus 14 (35) Septic emboli 1
Hypertension 14 (35) Pleural effusion requiring drainage 4
Hyperlipidemia 6 (15) Specific complications
Renal impairment 2 (5) Tube dislodgement* 3
Clinical presentation Tube blockage 0
Fever 35 (88) Empyema or pneumothorax related 0
Abdominal pain 20 (50) to procedure
Jaundice 3 (7.5) Bile leak 0
Septic shock 2 (5) Bleeding 0
Investigations* Number of patient with complications† 10 (25%)
Leucocytes . 109/L 30 (75)
AKI 5 acute kidney injury; AMI 5 acute myocardial infarction; DIC
Hemoglobin , 12 g/dL 25 (62.5)
5 disseminated intravascular coagulation; PD 5 percutaneous
Albumin , 35 g/L 36 (90)
drainage.
Bilirubin . 31 mmol/L 12 (30) *Two patients required repeat PD.
AST . 41 U/L 28 (70) †
Some patients had more than one complication.
ALT . 63 U/L 24 (60)
GGT . 50 U/L 36 (90)
CRP . 6 mg/L 40 (100) and PD for PLA. The patient demonstrated clinical
Microbiology† improvement and a repeat imaging before discharge
Klebsiella pneumonia 26 (65) showed reduction in abscess size. However, the patient
Streptococcus spp 4 (10) presented again to hospital with septic shock 13 days post
Escherichia coli 3 (7.5) discharge and initial investigations showed a possible
Enterococcus spp 2 (5) pneumonia. No further imaging of the liver was done as
Bacteroides spp 1 (2.5) patient passed away soon after admission.
Bifidobacterium spp 1 (2.5)
Culture negative 4 (10)
Fungus 1 (2.5) Comments
Radiology
Solitary abscess 34 (85) The 1938 study by Ochsner et al27 recommended OD as
Multiloculation 22 (55) the definitive treatment for PLA. In the years following the
Presence of gas in abscess 4 (10) study, OD was routinely carried out for PLA with mortality
ALT 5 alanine transaminase; ASA 5 American Society of Anesthe- rates as high as 40%.28 However, significant improvement
siologists; AST 5 aspartate transaminase; CRP 5 C-reactive protein; in mortality for PLA was established with availability of an-
GGT 5 gamma-glutamyl transpeptidase.
tibiotics after 1980s. In addition, the improved quality and
*The cut-off values for laboratory data are based on upper limit of
range given by the hospital laboratory. access to diagnostic imaging, advances in intensive care,
†
The absolute numbers do not add to 40 because of the presence of and importantly the availability and expertise for PD has
polymicrobial infection in some patients. helped to further drive down mortality rates to below
10% in the last decade.11–13,28 Together with the notion
that OD causes manipulation of liver causing severe bacter-
underwent PD for a 10.4 ! 9.3 cm multiloculated GPLA. emia and exposes the patient to attendant risks of anesthesia
However, as the patient continued to spike temperature, OD further contributed to rise in popularity of PD and helped to
was performed 6 days later and this revealed GPLA establish IV antibiotics and PD as the mainstay of treatment
secondary to a perforated gastric ulcer. A partial gastrec- for PLA.28–30 However, safety and sufficiency of PD in
tomy, jejunal serosal patch of duodenal stump, and lateral GPLA has not been established previously and large size
tube duodenostomy were performed. The patient was of PLA has been a predictor of treatment failures and
discharged well 23 days later. The overall morbidity in need for secondary procedures.23,24 In our study, we have
the patients who underwent PD is 25%. The general and demonstrated that PD is a safe and sufficient treatment
specific complications are shown in Table 2. for GPLA and OD is only rarely needed.
One patient died. An 88-year-old, nursing home resident Although the standardization of terminology and defi-
with multiple comorbidities was treated with IV antibiotics nition of what constitutes a large or a giant abscess is a
S. Ahmed et al. Giant pyogenic liver abscess
matter of international collaboration; we believe that an
abscess of greater than or equal to 10 cm in size should be
termed as giant. GPLA deserves a special recognition as
many would believe that PD would fail in such situations.
This conclusion is based on studies done on abscess less
than 10 cm in size. Tan et al23 reported that, in patients with
abscess greater than 5 cm, OD has less treatment failures
and shorter hospital stay compared with PD. The mean
size of abscess in their study was 7.19 and 7.68 cm, for
the PD and OD group, respectively. Size along with multi-
loculation was the predictors of failure of PD in their series,
which had a failure rate of 27.7% (10/36). In a study by
Liao et al,24 multidetector CT scan was used to analyze fac-
tors that predict failure of PD. One of the factors was size
of abscess greater than 7.3 cm. In their study of 175 pa-
tients, there was an overall failure rate of 18.3%. Contrary
to these results, a 2011 study involving 63 patients who un-
derwent PD found that there was no significant difference
in size of abscess in the group with successful treatment
and that with treatment failure.31 The mean size of abscess
was 6 and 6.5 cm in ‘‘treatment successful’’ and ‘‘treatment
failure groups,’’ respectively. In our series, only one patient
underwent OD because of failure of PD, failure rate of
2.6% (1/39), although the mean size of abscess in our study
is significantly larger at 12 cm.
Our results show that IV antibiotics and PD in GPLA are
comparable in terms of LOHS and mortality reported by
others. The median LOHS reported for PD in literature
varies between 11 and 39 days.6,16,23,24 This is significant
as the other reports include patients with all size of PLA
and our study includes only patients with size greater
than or equal to 10 cm. The relatively shorter LOHS of
13 days in our study despite greater than or equal to
10 cm size of abscess could be attributed to standard treat-
ment protocol, rigorous drain management, dedicated
Figure 3 Concept of pyogenic liver abscess care bundle.
5
hepatobiliary nurse practitioner support, good caregiver
training, and strong collaboration with infectious diseases
department in identifying patients for OPAT, good primary
care support, and early review in specialist clinics. The
mortality rate reported in literature has been on a steady
decline with advances in cross-sectional imaging and use
of effective antibiotics.31 The mortality rate for liver ab-
scess reported in studies during and after the 1990s is be-
tween 0% and 10% showing a significant drop.9,16,23,31–34
Our mortality rate of PD treatment is comparable with
others despite the larger size of abscess in our series.23
Previously, authors have tried to outline approaches to
ensure best possible outcome in patients undergoing PD for
PLA.10 These include initiation of parenteral broad-
spectrum antibiotics, early ultrasound or CT to confirm
diagnosis, obtaining tissue culture from aspiration, and to
repeat scans early if features of sepsis persist.10 We believe
that, in addition to the above, there are other measures espe-
cially centered on the care of drainage tubes and multidis-
ciplinary care of patients who may contribute to even better
outcomes. The success of PD is dependent on various fac-
tors and requires close coordination of a multidisciplinary
team including general surgeons, infectious disease special-
ists, specially trained nurses, and allied staff, as well as a
rigorous drain management protocol. This collective care
can be conceptualized as a ‘‘Liver abscess care bundle’’
and we believe that good outcomes in our study are because
of rigorous implementation of such protocols. Fig. 3 sum-
marizes individual components of our management proto-
cols and these components need to be further validated
and studied. Our institution has an experienced team of in-
terventional radiology colleagues who perform percuta-
neous interventions after office hours, weekends, and
even on public holidays. In our opinion, this dedication
and commitment from our radiology colleagues is also
6 The American Journal of Surgery, Vol -, No -, - 2015
responsible for low mortality in our series. In a setting
where there is limited access to interventional radiology
service, our results may not be replicable.
Despite the many factors that may account for the success
of PD in our setting as described above, it must be noted that
the population of patients might not be entirely comparable.
Mezhir et al35 reported their experience of management of 58
patients with PLA and 88% of their patients had underlying
malignancy, while only 2 patients in current series had malig-
nancy. The wide variations in outcomes with regards to suc-
cess of PD and mortality are not solely determined by liver
abscess care bundle concept but the geographic and demo-
graphic diversity.26,35 When comparing mortality rates and
choice of drainage modality, the severity of illness at presen-
tation should also be considered. For this reason, the use of
scoring systems such as Acute Physiology and Chronic
Health Care Evaluation II and the simplified acute physi-
ology score II scoring system to estimate the risk of hospital
mortality have become increasingly popular.36 A limitation
of our study is the absence of use of such scoring systems.
In Singapore, given the easy access to tertiary care, patients
might have presented earlier in the course of disease lending
themselves more suitable to PD and better clinical outcomes.
Therefore, comparison with another Singapore-based study
might mitigate these differences in access to health care.
Tan et al23 reported an overall mortality rate of 2.8% for
the PD arm which is comparable with our own mortality
rate of 2.6% (1/39) despite the significantly larger mean
size of abscess (7.19 vs 12 cm). However, more importantly,
the failure rate and number of secondary procedures are
significantly lower in our study (2.6% vs 27.7% and 7.7%
vs 36.1%, respectively), making a strong case favoring PD
over OD in GPLA. In the same series, among the 9 patients
who failed PD, 3 were because of catheter blockage. We
believe that the meticulous drain care management and lib-
eral use of tube reviews helped to avoid these problems in
our patients.
Multiloculation has been postulated to contribute to poorer
drainage via PD because of compartmentalization of abscess
and has also been associated with increased morbidity and
hospital stay.3,37 Multilocations can be a subjective finding
and depends on the modality of imaging. All our patients
had a CT scan and the senior author (V.G.S.) reviewed all
the CT scan images to verify for multiloculations in our study.
In the series by Tan et al,23 80% of the abscess above 5 cm
were multiloculated as opposed to only 55% in our own series.
Lower percentage of patients with multiloculated abscess in
our series could have also contributed to better outcomes
and lower failure rates, although it must also be noted that
the percentage of patients with multiloculated abscess is var-
iable with one Singapore study reporting rates as low as 16%.
Gas-forming PLA has been shown to be an important prog-
nostic factor in determining mortality, the presence of which
is associated with higher mortality (27.7% to 30.4%).9,24,38,39
In the study by Liao et al,24 the presence of gas was the most
important radiological predictor for PD failure. The percent-
age of gas-forming PLA in our series is similar to that of other
series.9,10,36 The 4 patients in our series who had gas-forming
PLA all had successful PD. From our experience, gas-forming
PLA should not be a contraindication to PD but rather the
threshold to escalate therapy must be lower if the patient is
not responding with PD.
In our experience, OD is absolutely indicated in patients
with free rupture of abscess and presenting with peritonitis
regardless of the size. Size in itself is a marker of interplay
between invasiveness of microorganism and host immune
response and not a predictor of treatment failure if adequate
drainage is performed. A good PD can ensure good clinical
outcomes and the need for salvage OD is limited only to
selected patients in whom treatment fails.
Our study shows that IV antibiotics together with PD
remain an effective and safe treatment option in most
patients; however, we believe that there is a small group of
patients for whom OD might be beneficial. Based on our
own experience and review of literature, patients with
ruptured liver abscess, secondary liver abscess with
concomitant surgical conditions (eg, perforated gastric
ulcer), nonresolution of liver abscess despite PD, and
suspected malignancy in the liver abscess may represent
absolute indications for surgery.23,40 In our study, there was
one patient with secondary liver abscess who needed OD
because of nonresolution with PD. Some other indications
for surgical drainage proposed by other authors include
the following: thick walled abscess with viscous pus and
multiple, large, and multiloculated abscess.16 Surgery per-
mits breaking down loculations, placement of soft large-
bore drainage tubes from all angles with liver mobilization,
and completion of concomitant biliary procedures.13,23
Recent studies have also suggested that patients with high
Acute Physiology and Chronic Health Care Evaluation II
scores (R15) might do better with OD upfront.28 In the sit-
uation of failed PD drainage, laparoscopic drainage is an
attractive option. In a recent study, Aydin et al41 described
53 cases of liver abscess treated laparoscopically. They re-
ported overall high success rate of 90.5% and there were no
cases of conversion to open. The minimal invasiveness of
this procedure, shorter surgery time, less blood loss, faster
recovery, and shorter hospital stays are likely to enhance
the role of laparoscopic drainage in the future.42
Conclusion
Our results show that GPLA can be treated with IV
antibiotics and PD safely. Fig. 3 highlights the essentials
pillars of PD based on our experience and practice in our
hospital, to ensure good outcome in PLA. The strength of
our article is mainly from the large number of GPLA pa-
tients treated with PD. The limitation of our study is that
it is a retrospective study with few patients being excluded
because of lack of data. In conclusion, we believe that PD is
safe and sufficient in the treatment of GPLA in majority of
the patients.
S. Ahmed et al. Giant pyogenic liver abscess
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