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).

Diagnosis

  • Diagnosis of liver abscess is made by history, physical examination, imaging, & culture of abscess material

History

  • Inquire about patient’s medical history, recent procedures, place of residence, history of travel

Physical Examination

  • Fever, jaundice
  • Tender, enlarged liver w/ or w/o a palpable mass
  • Epigastric tenderness may be found in patients w/ left hepatic lobe abscess
  • Decreased breath sounds on the base of the right lung w/ signs of atelectasis & pleural effusion
  • Pleural or hepatic friction rub
  • Rare: Ascites, splenomegaly

Laboratory Tests

Cultures

Culture of Abscess Fluid

  • Aspirated abscess fluid should be Gram stained & cultured to establish the microbiologic diagnosis
    • Other causes of liver abscess are amoeba & fungi, most commonly Candida species
  • Culture from drains is not recommended due to contamination w/ skin flora

Blood Culture

  • Positive in about half of patients w/ liver abscess
  • Samples should be taken for both aerobic & anaerobic cultures
  • Results of blood & abscess fluid cultures are not always concordant

Other Laboratory Examinations

Tests to Detect Amoebic Infection

  • Enzyme-linked immunosorbent assay (ELISA) should be done to detect E histolytica in patients who are from endemic areas or have traveled to endemic areas
  • Indirect hemagglutination may also be used in serologic diagnosis, but is less sensitive than enzyme-linked immunosorbent assay (ELISA)
  • Other serologic tests include indirect immunofluorescence & Latex agglutination technique
  • Fecal exam to detect E histolytica trophozoites & cysts

Liver Function Tests

  • Alkaline phosphatase elevation is seen in two-thirds of patients & tends to deviate from the normal range more than the other liver function tests
  • Hypoalbuminemia is also common
  • Abnormalities in alanine aminotransferase (ALT), aspartate aminotransferase (AST) & bilirubin levels are variable

Complete Blood Count

  • Leukocytosis w/ neutrophil predominance
  • May reveal anemia of chronic disease

Imaging

  • Imaging of the liver is essential in making the diagnosis of liver abscess
  • Ultrasound & computed tomography (CT) scan are the initial imaging procedures of choice
  • Cannot distinguish pyogenic liver abscess from amoebic abscess

Ultrasound

  • Inexpensive & accurate
  • Recommended for patients w/ suspected biliary disorders & those who cannot be exposed to radiation or receive contrast dyes
  • Useful for guiding needle aspiration of abscess
  • Abscesses are seen as hypoechoic masses w/ irregularly shaped borders, w/ or w/o internal septations

Computed Tomography (CT)  Scan

  • More sensitive than ultrasound
    • Can detect abscesses smaller than 1 cm better than ultrasound
  • Superior to ultrasound for guiding complex drainage procedures
  •  Can be used to assess the relationship of an abscess to adjacent structures, to evaluate for a concurrent disorder in the abdomen & pelvis & to detect gas in the abscess
  •  Abscesses are seen as hypodense structures w/ or w/o a rim of contrast enhancement

Chest X-ray

  • About half of patients will have basilar atelectasis, elevation of the right hemidiaphragm, & right pleural effusion
  • May initially lead to a wrong diagnosis of pneumonia or pleural disease

Evaluation

  • Monitor patient’s clinical response & follow-up imaging studies to decide duration of antibiotic therapy & need for other interventions
    • May follow temperature, white blood cell count, & serum C-reactive protein (CRP)
    • Resolution of abnormalities on imaging lag behind clinical or lab marker improvement
  • Surgical drainage may be needed in a patient w/ failed percutaneous drainage, persistent jaundice, renal impairment, multiloculated abscess
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