liver%20abscess
LIVER ABSCESS
Liver abscess may result from peritonitis and bowel leakage via portal circulation, direct spread from biliary disease or from hematogenous seeding.
Classical presentation includes fever, jaundice, and right upper quadrant symptoms (pain, guarding, rocking and rebound tenderness).
Biliary tract disease is the most common cause of bacterial liver abscess.
Most pyogenic liver abscesses are polymicrobial (eg enteric facultative and anaerobic species).

Introduction

  • Liver abscess may result from peritonitis & bowel leakage via portal circulation, direct spread from biliary disease, or from hematogenous seeding

Etiology

Causative Organisms

  • Most pyogenic liver abscesses are polymicrobial (eg enteric facultative & anaerobic species)
  • Common etiologic agents of pyogenic liver abscess are E coli, K pneumoniae, Proteus sp & other Enterobacteriaceae, Pseudomonas sp, Streptococcus sp, S aureus, Enterococci, B fragilis, F necrophorum 
    • Usual pathogens in patients w/ underlying biliary disease: Enterococci, enteric Gram-negative bacilli
    • Usual pathogens in patients w/ underlying colonic or biliary source of infection: Anaerobes, coliforms
    • S aureus may be isolated from patients w/ liver abscess resulting from hematogenous spread of microbes from a distant source
    • Entamoeba histolytica if amoebiasis is a potential consideration

Signs and Symptoms

  • Classical presentation: Fever, jaundice, right upper quadrant symptoms (pain, guarding, rocking & rebound tenderness)
    • Liver abscess diagnosis is not excluded w/ negative right upper quadrant findings
  • Chills, malaise, fatigue, anorexia, weight loss, abdominal pain, vomiting
  • Cough or hiccups from diaphragmatic irritation
  • Pain referred to the right shoulder

Other Clinical Presentations

  • Patients w/ liver abscess may occasionally be afebrile
  • Elderly patients often present insidiously w/ low-grade fever, dull abdominal pain & other non-specific systemic symptoms
  • Patients w/ multiple abscesses tend to present more acutely than those w/ a solitary abscess

Risk Factors

  • Biliary tract disease is the most common cause of bacterial liver abscess
    • Suppurative cholangitis following biliary obstruction (eg from stones, malignancy, stricture, congenital conditions), recurrent pyogenic cholangitis
    • Post-op complication in patients who have undergone endoscopic sphincterotomy for bile duct stones or surgical biliary-intestinal anastomosis
  • Cholecystitis, infections in organs in the portal bed
  • Penetrating & blunt trauma to the liver
  • Subphrenic or perinephric abscess may result in direct spread of infection from a contiguous focus
  • Systemic bacteremia eg endocarditis, pyelonephritis that may result in spread of organisms to the liver through the hepatic artery
  • Systemic illnesses including diabetes mellitus, malignancy, cirrhosis, cardiopulmonary disease, severe malnutrition, inflammatory disease
  • Immune system deficiencies eg chronic granulomatous disease, hematologic malignancy, liver transplant
  • Severe periodontal disease especially in alcoholics
  • Amoebic liver abscess should be considered in patients from endemic areas or have traveled to an endemic area
    • 10 times more common in men as in women
    • Inmates of residential institutions, patients w/ underlying immunosuppression & men who have sex w/ men are at increased risk
  • Other possible factors include pancreatoduodenectomy, chemoembolization or radiofrequency ablation in the presence of infected bile, necrosis of a primary tumor, or superinfection of metastases
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