Liver: Abscess

Pyogenic Abscess

Basics

  • Most Common Visceral Abscess
  • Source:
    • From Biliary Tract (Most Common)
    • From Portal Vein After Bowel Perforation & Peritonitis
    • From Arteries with Bacteremia
  • Most Common in Right Lobe

Organisms

  • Most Polymicrobial
  • Organisms:
    • E. coli (Most Common)
    • Klebsiella (Most Common in Asia)
    • Streptococci
    • Staphylococcus

Presentation

  • Fever
  • Abdominal Pain
  • Leukocytosis
  • Elevated LFT’s

CT Findings

Treatment

  • Tx: ABX & Drainage
    • Single & Unilocular: Percutaneous Drainage
      • If Fails: Upsize Drain
      • Recurrence Most Likely from Clogged or Migrated Drain
    • Multiple or Multilocular: Surgical Drainage
      • Multiple Small Abscesses: Consider Long-Term ABX (4-6 Weeks)
      • *Although Surgical Drainage is the Traditional Approach Some Now Consider Percutaneous Drainage First & Surgical Drainage Only if Fails

Pyogenic Liver Abscess 1

Amebic Abscess

Basics

  • Parasite: Entamoeba histolytica
    • Amebic Colitis (Primary Infection) Transmits Through Portal Vein to Liver
  • Generally Migrants/Travelers From Endemic Areas
    • Endemic Areas: Mexico, Central/South America, Africa & India Mn
  • Most Common in Posterior Right Lobe

Risk Factors

  • Adult Men (Most Common)
  • HIV/Immunosuppressed
  • Alcoholism
  • Pregnancy
  • Malnutrition

Presentation

  • Abdominal Pain
  • Fever
  • Weight Loss
  • History of Dysentery

Diagnosis

  • Dx: CT/US & Serology
  • Stool Cx Usually Negative (Simultaneous Liver Abscess & Colitis is Uncommon)
  • Aspirate Cx Can be Negative (Parasite Only in Peripheral Rim)
    • Anchovy Past Fluid

CT Findings

Treatment

  • Primary Tx: Metronidazole Mn
  • If > 10 cm, Risk of Rupture or ABX Failure: Percutaneous Drainage
  • If Ruptures: Surgery

Amebic Abscess 2

Hydatid Cyst

Basics

  • Parasite: Echinococcus
  • Source: Dogs; Sheep are Carriers
  • Rupture Will Cause Anaphylactic Shock

Diagnosis

  • Dx: Serology & US
  • Double Wall – Inner Cyst Wall/Hydatid Sand Separate from Hydatid Membrane

CT Findings

Treatment

  • Primary Treatment: Albendazole Mn
  • Definitive Treatment:
    • Unilocular < 5 cm: Albendazole Alone
    • Multilocular, > 10 cm or High Rupture Risk: Surgical Excision (Need Entire Wall)
    • *May Consider PAIR (Puncture, Aspiration, Injection, Reaspiration) if Unilocular 5-10 cm

Hydatid Cyst of the Liver 3

Hydatid Cyst of the Liver 3

Fungal Abscess

Basics

  • Most Common in Immunocompromised (Often Following Chemotherapy for Hematologic Malignancy)
  • Most Common Fungi:
    • Candida – Most Common
    • Aspergillus
    • Cryptococcus
  • Often Mixed Fungi & Bacteria
  • Presentation:
    • Fever
    • Jaundice
    • RUQ Pain

Treatment

  • Primary Tx: Percutaneous Drainage & Antifungals
  • First-Line Antifungals: Micafungin or Caspofungin

Mnemonics

Entamoeba vs Echinococcus Abscesses

  • “Mexican Fire Ants & Bent Rhino Horns”
  • Amebic/Entamoeba:
    • Mexican: “Mexico Connection”
    • Fire: (F-F) Flagyl Treatment
    • Ants: (A-A) Amebic & (Ant:Ent) Entamoeba
  • Hydatid/Echinococcus:
    • Bent: Al-BEND-azole
    • R-HINO: Ec-HINO-coccus
    • Horns: (H-H) Hydatid

References

  1. Livingston LV, Perez-Colon E. Streptococcus intermedius Bacteremia and Liver Abscess following a Routine Dental Cleaning. Case Rep Infect Dis. 2014;2014:954046. (License: CC BY-3.0)
  2. Garvin KW, Willig JH. Amebic liver abscess. Am J Trop Med Hyg. 2010 Nov;83(5):961. (License: CC BY-2.5)
  3. Ma Z, Yang W, Yao Y, Liu Q. The adventitia resection in treatment of liver hydatid cyst: a case report of a 15-year-old boy. Case Rep Surg. 2014;2014:123149. (License: CC BY-3.0)