LIVER ABSCESS

Marc Richards
Morning Report
September 8th, 2009
 CLASSIFICATIONS
• PYOGENIC
• Gram Positive
• Gram Negative
• Anaerobic
• (Polymicrobial)

• AMEBIC

• CANDIDA

• TB (rare)
 EPIDEMIOLOGY
• Pyogenic Abscesses
o Bacterial
o Most common
o M > F 3:1

• Entamoeba
o M > F 7:1
o 40-50 million amoeba infections/year
worldwide
o Age Extremes
o Endemic Areas most susceptible
o Country of origin or Travel
 RISK FACTORS
• PYOGENIC
• DM
• Cancer
• Liver Transplant

• ENTAMOEBA
• Pregnancy
• Steroids
• Cancer
• Endemic area travel (short
or long term)
• EtOH?
 PATHOPHYS.
• PYOGENIC:
o Peritonitis
 To liver via portal circulation

o Direct Spread
o Biliary infections

o Hematogenous Seeding
o Look for bacteremia!

o Sites: R lobe most common

o Blood supply
 PATHOPHYS.
• ENTAMOEBA:
o Fecal-Oral transmission into GI Tract
 To liver via portal circulation

o Can also spread to other

extraintestinal sites
o Heart
o Brain
o Lungs
CLINICAL MANIFESTATIONS
o SYMPTOMS o SIGNS
o Fever (90%) o Hepatomegaly (50%)
o RUQ pain (50-75%) o RUQ tenderness
o Constitutional Sx o Jaundice
o Diarrhea (<30%) o Acute abdomen
(<7%)
 WORKUP
• CBC (leukocytosis)

• LFTs
• AlkPhos elevated (67-90%)
• AST/ALT elevated (50%)
• TBili elevated (50%)

• Blood Cultures
• Bacteremia (50%)
• E Histolytica Ab
• Echinococcus Ab

• Imaging- US, CT, MRI

• Can not differentiate types of abscess
ULTRASOUND
 CT/MRI

Fluid Collection w/ surrounding stranding,

edema, and inflammation
 DIAGNOSTIC PROCEDURE

*** IMAGING-GUIDED DRAINAGE***

***SEND FOR CULTURE***

 WHAT MAY GROW…
• POLYMICROBIAL (including anaerobes)
• GRAM NEGATIVES (think gut bugs)
• E. Histolytica
• Money is in the serum Ab (95%)
• Less yield with wet-mount of abscess or fecal microscopy
(<20%)

• OTHERS
• Strep Milleri group
• S Aureus (chemoembo)
• S Pyogenes (chemoembo)
• Candida (s/p chemo)
• Klebsiella
• TB
• Burkholderia
 TREATMENT
• TO DRAIN OR NOT TO DRAIN:
• <5cm, single abscess- needle aspiration or catheter
• >5cm- catheter
• Also: Surgery, ERCP

• Amoeba: drainage not usually required

• Exceptions:
• Verge of rupture
• Abx not working
• Imminent need to exclude other dx
 TREATMENT-ABX
• Pyogenic: Gram Neg + Anaerobe cov.
• Unasyn
• Zosyn
• 3rd gen Ceph (Rocephin) + Flagyl
• PCN Allergy: FQ + Flagyl, Carbapenem

• Course: 4-6 weeks

• IV duration depends on f/u imaging
• Suitable PO Abx: Augmentin OR FQ + Flagyl

• Amoeba: Flagyl 500-750mg TID 7-10days

• Then follow with lumenal antiamebic
• Usually Paromomycin TID 10d
 PROGNOSIS & NATURAL
HISTORY
• Mortality 2-12%
• Often due to comorbidities, not necessarily
abscess itself
 TAKE HOME MESSAGE
• Think Pyogenic (usually gram
neg/anaerobe) or E.Histolytica
• Broad Spectrum Abx at first
• Image Image Image
• Imaging-Guided Culture +/- JP Drain
• Treat for 4-6 weeks

• MIAMI > FLORIDA STATE

REFERENCES
eMedicine

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