Liver Abscess 829

 9. Incidence increased in patients with DIFFERENTIAL DIAGNOSIS

BASIC INFORMATION
10. 
diabetes and metastatic cancer.
Table 1 summarizes underlying etiology
• Cholangitis
• Cholecystitis
L
DEFINITION and bacteriology of liver abscesses. • Diverticulitis
Liver abscess is a necrotic infection of the liver • Amebic hepatic abscess is caused by the para- • Appendicitis
usually classified as pyogenic or amebic. site Entamoeba histolytica. Amebiasis is usually • Perforated viscus
due to fecal-oral contamination and invades • Mesentery ischemia
SYNONYMS the intestinal mucosa, gaining entry into the • Pulmonary embolism
Pyogenic hepatic abscess portal system to reach the liver. Amebic abscess • Pancreatitis
Amebic hepatic abscess occurs in 3% to 7% of patients with amebiasis.
• A comparison of pyogenic and amebic liver WORKUP
ICD-10CM CODE abscess is summarized in Table 2. • The workup of a liver abscess should focus
Box 1 describes pearls for amebic liver

and Disorders
Diseases
K75.0 Abscess of liver on differentiating between amebic and pyo-
abscesses. The abscess is usually solitary genic causes.
EPIDEMIOLOGY & (85%) and in the right lobe (72%). • Features suggesting an amebic cause
DEMOGRAPHICS include travel to an endemic area, single
INCIDENCE: Incidence of pyogenic liver abscess DIAGNOSIS abscess rather than multiple abscesses,
is 2.3 cases per 100,000 population. subacute onset of symptoms, and absence
PREVALENCE (WORLDWIDE): Amebic liver
abscess is more common than pyogenic liver
The diagnosis of liver abscess requires a high index
of suspicion after a detailed history and physical
of conditions predisposing to pyogen-
ic liver abscess, as highlighted under
I
abscess. examination. Imaging studies and microbiologic, “Etiology.”
PREVALENCE (IN U.S.): Pyogenic liver abscess serologic, and percutaneous techniques (e.g., aspi- • Laboratory studies are not specific but are
is more common than amebic liver abscess. ration) confirm the presence of a liver abscess. useful as adjunctive tests.
PREDOMINANT SEX AND AGE: More common • Imaging studies cannot differentiate between
in men than women; male/female ratio of 2:1; the two, and bacteriologic cultures may be
most common in fourth to sixth decades of life. TABLE 1  Underlying Etiology sterile in 50% of the cases.
and Bacteriology
PHYSICAL FINDINGS & LABORATORY TESTS
CLINICAL PRESENTATION Etiology Bacteriology • Complete blood count: Leukocytosis
• Fever, chills, and sweats Biliary, benign Escherichia coli • Liver function tests: Alkaline phosphatase is
• Weakness/malaise Klebsiella spp. most commonly elevated (95% to 100%);
• Anorexia with weight loss Enterococcus aspartate transaminase (AST) and alanine
• Nausea, vomiting, and diarrhea Biliary, malig- Pseudomonas spp. transaminase (ALT) elevated in 50% of cases;
• Cough with pleuritic chest pain nant Multiply resistant GN aerobes elevated bilirubin (28% to 30%); decreased
• Right upper quadrant abdominal pain VRE albumin
• Hepatomegaly Yeast • Prothrombin time (INR): Prolonged (70%)
• Splenomegaly Diverticulitis/ GN aerobes • Blood cultures: Positive in 50% of cases
• Jaundice appendicitis Bacteroides fragilis • Aspiration (50% sterile)
• Pleural effusions, rales, and friction rubs may Severe chole- See Biliary, benign • Stool samples for E. histolytica trophozoites
be present cystitis Clostridium perfringens (positive in 10% to 15% of amebic liver abscess
Bacteroides spp. cases)
• Most abscesses occur on the right lobe of the
liver Subcutaneous Staphylococcus spp. • Serologic testing for E. histolytica should be
abscess MRSA done on all patients, but it is important to
ETIOLOGY Endocarditis Enterococcus spp. remember that it does not differentiate acute
Staphylococcus spp. from old infections
• 
Pyogenic liver abscess is usually polymi-
crobial (Klebsiella pneumoniae [43%], Cryptogenic Anaerobes
IMAGING STUDIES
Escherichia coli [33%], Streptococcus spp. GN, Gram-negative; MRSA, methicillin-resistant Staphylococ-
[37%], Pseudomonas aeruginosa, Proteus
• 
Ultrasound (80% to 100% sensitivity in
cus aureus; VRE, Vancomycin-resistant Enterococcus.
spp., Bacteroides spp. [24%], Fusobacterium From Cameron, JL, Cameron AM: Current surgical therapy, ed detecting abscesses) shows round or oval
spp., Actinomyces spp., gram-positive anaer- 10, Philadelphia, 2011, Saunders. hypoechogenic mass (Fig. E1, A).
obes, and Staphylococcus aureus).
• Pyogenic liver abscess occurs from:
1. Biliary disease with cholangitis (accounts TABLE 2  Comparisons of Pyogenic and Amebic Liver Abscess
for approximately 40% to 60%).
2.  Gallbladder disease with contiguous Parameter Pyogenic Liver Abscess Amebic Liver Abscess
spread to the liver. Number Often multiple Usually single
3. Diverticulitis or appendicitis with spread Location Either lobe of liver Usually right hepatic lobe, near the diaphragm
via the portal circulation. Presentation Subacute Acute
4.  Hematogenous spread via the hepatic Jaundice Mild Moderate
artery, though uncommon; if a solitary
Diagnosis US or CT ± aspiration US or CT and serology
organism is isolated, a distant source of
Treatment Drainage (if technically feasible) Metronidazole, 750 mg 3 times daily for 7-10 days orally
hematogenous seeding should be sought.
+ IV antibiotics (see text) or IV; or tinidazole, 2 g orally for 3 days, followed by
5. Penetrating wounds. iodoquinol, 650 mg orally 3 times daily for 20 days;
6. Cryptogenic. diloxanide furoate, 500 mg orally 3 times daily for 10
7. Infection by way of portal system (portal days; or aminosidine (paromomycin) 25-35 mg/kg/day
pyemia). orally in 3 divided doses for 7-10 days
8. No causes found in approximately half of
cases. CT, Computed tomography; IV, intravenous; US, ultrasonography.
From Feldman M, Friedman LS, Brandt LJ: Sleisenger and Fordtran’s gastrointestinal and liver disease, ed 10, Philadelphia, 2016, Elsevier.

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830 Liver Abscess
CHRONIC Rx
BOX 1  Pearls for Amebic Liver Abscesses
• If fever persists for 2 wk despite percutane-
• Only 10%-20% of patients with amebic liver abscess have a history of diarrhea. ous drainage and antibiotic therapy as out-
• Treat the intestinal infection to prevent relapse of amebic liver abscess. Failure to lined under “Acute General Rx,” or if there is
use luminal amebicidal agents after metronidazole in cases of amebic abscess failure of aspiration or failure of percutaneous
results in a 10% relapse rate. drainage, surgery is indicated.
• Failure to show response to antiamebic medication requires evaluation for polymi- • In patients not responding to intravenous
crobial infection with bacteria. antibiotics and percutaneous drainage,
• Amebic abscess usually responds clinically to antimicrobial therapy in 3 to 7 days, hepatic artery antibiotic infusion can be
although imaging takes several months to show resolution.
considered.
• Percutaneous drainage is rarely required.
• In patients with evidence of metastatic dis-
From Cameron, JL, Cameron AM: Current surgical therapy, ed 10, Philadelphia, 2011, Saunders. ease that is causing biliary obstruction, a
gastroenterology consultation for endoscopic
retrograde cholangiopancreatography and
stenting should be considered.

FIG. 2  Pyogenic liver abscess. A liver abscess containing Escherichia coli has irregular septations and
contains a few bubbles of air (arrows). Because of the multiple loculations, this abscess did not respond to a
percutaneous catheter for drainage and required surgical debridement. (From Webb WR, Brant WE, Major NM:
Fundamentals of body CT, ed 4, Philadelphia, 2015, Saunders.)
• CT scan is more sensitive in detecting hepat-
ic abscesses and contiguous organ extension
and is the imaging study of choice (Fig. E1, B,
and Fig. 2).
• Chest x-ray: Abnormal in 50% of the cases,
may reveal elevated right hemidiaphragm,
subdiaphragmatic air-fluid levels, pleural
effusions, and consolidating infiltrates.
• Most liver abscesses are single; however,
multiple liver abscesses can occur with sys-
temic bacteremia.
TREATMENT
NONPHARMACOLOGIC THERAPY
• The management of pyogenic liver abscess
differs from that of amebic liver abscess.
• Medical management is the cornerstone of
therapy in amebic liver abscess, whereas early
intervention in the form of surgical therapy or
catheter drainage and parenteral antibiotics is
the rule in pyogenic liver abscess greater than
3 cm. Smaller abscesses (<3 cm) can generally
be treated with broad-spectrum antibiotics.
ACUTE GENERAL Rx
• 
Percutaneous drainage under CT or ultra-
sound guidance is essential in the treatment
of pyogenic liver abscesses.
• Aspiration of hepatic amebic abscesses is
not required unless there is no response
to treatment or a pyogenic cause is being
considered.
• Empiric broad-spectrum antibiotics are rec-
ommended initially until culture results are
available. Common choices include:
1. Metronidazole (500 mg IV q8h) plus cef-
triaxone or levofloxacin.
2.  Monotherapy with a beta-lactam/beta-
lactamase inhibitor, such as piperacillin/
tazobactam (4.5 g q6h), ticarcillin-clavu-
lanate (3.1 g q4h), or ampicillin-sulbac-
tam (3 g q6h).
3. Monotherapy with a carbapenem, such as
imipenem (500 mg IV q6h), meropenem
(1 g q8h), or ertapenem (1 g daily).
4. Duration of antibiotic treatment is usually
4 to 6 wk with IV antibiotics used for the
first 1 to 2 wk or until a favorable clinical
response, followed thereafter with oral
antibiotics (e.g., metronidazole 500 mg
PO q8h plus ciprofloxacin 500 mg PO
q12h).
5.  Third-generation cephalosporins should
not be used as single agents for empiric
therapy because of risk of the emergence
of beta-lactamase-producing bacteria.
• Antibiotic coverage for amebic liver abscess-
es includes:
1. Metronidazole 750 mg PO tid for 10 days
or tinidazole.
2.  Eradication of the coexistent intestinal
infection with paromomycin for 10 days.
DISPOSITION
• Most patients with pyogenic liver abscesses
defervesce within 2 wk of treatment with
antibiotics and drainage.
• No randomized controlled studies have
evaluated the optimal duration of antibiotic
therapy for pyogenic liver abscess. Typical
duration of antibiotic therapy is at least 4 to
6 wk.
• Pyogenic liver abscess cure rates using
percutaneous drainage and antibiotics have
been reported to be between 88% and 100%.
• Mortality rate of untreated pyogenic liver
abscess is nearly 100%.
• Most patients with amebic liver abscesses
defervesce within 4 to 5 days of treatment.
• Amebic liver abscess mortality rate
is <1% unless complications occur (see
“Comments”).
• Follow-up imaging should be used to monitor
response to therapy; continue treatment until
CT scan shows complete or near-complete
resolution of cavity.
REFERRAL
Infectious disease, gastroenterology, interven-
tional radiology, and general surgical consulta-
tions are recommended in any patient with
hepatic abscess.
PEARLS AND
CONSIDERATIONS
COMMENTS
• Complications of pyogenic and amebic liver
abscesses include:
1. Pleuropulmonary extension, resulting in
empyema, abscess, and fistula formation
2. Peritonitis
3. Purulent pericarditis
4. Sepsis
• Amebic liver abscesses complicate amebic
colitis in nearly 10% of cases.
RELATED CONTENT
Liver Abscess (Patient Information)
Amebiasis (Related Key Topic)
AUTHOR: FRED F. FERRI, M.D.

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Liver Abscess 830.e1

A B
FIG. E1  A, Amebic abscess. Sonogram demonstrates a hypoechogenic mass in the right lobe of the liver with
a more hypoechoic surrounding rim. B, Computed tomography scan demonstrates a low-attenuation mass in
the right lobe of the liver with a prominent halo. (From Kuhn JP et al: Caffrey’s pediatric diagnostic imaging, vol
2, ed 10, Philadelphia, 2004, Mosby.)

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