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Pyogenic Hepatic Abscesses:

Pyogenic Hepatic Abscesses Vic V. Vernenkar,D.O. St. Barnabas Hospital Bronx, N.Y.


Introduction Described since age of Hippocrates In 1883 Koch described the amoeba as a cause of liver abscess. In 1938 Debakey published largest series in the lierature. Over last 2 decades,percutaneous drainage has becaome a therapeutic option.


Frequency Uncommon, prevalence in autopsy series 0.29-1.47%. Incidence in the US is 8-15 per 100,000. Male to female ratio is 2:1 in recent studies. 4 th -6 th decades of life.


Etiology Biliary disease accounts for 21-30%, with extrahepatic obstruction leading to ascending cholangitis and abscess. Also CBD stones, benign and malignant tumors, biliary enteric anastamoses.


Etiology Infection via portal system Infectious process originates in abdomen, reaches liver by embolization of portal system. Appendicitis, diverticulitis, IBD, proctitis


Etiology Hematogenous. Via hepatic artery. From systemic septicemia. No cause in 50% of cases, but increased in diabetics and metastatic cancer.


Pathophysiology Access to liver by direct extension from nearby organs. Through portal vein and hepatic artery. Hepatic clearance of bacteria via portal system is a normal phenomena, but organism proliferation, tissue invasion and abscess can occur with biliary obstruction, poor perfusion, microembolization.


Microbiology Most contain more than one organism, with source biliary or enteric. Blood cultures positive in 33-65%. E.Coli 33%. Klebsiella 18%. Bacteroides 24%. Streptococcal 37%.


Clinical Fever, right upper quadrant pain (80%). Right shoulder pain, pleuritic chest pain. Fever 87-100%. Anorexia, weight loss, mental confusion. Physical exam shows RUQ tenderness, hepatomegaly, liver mass, jaundice.

Indications For Open Drainage:

Indications For Open Drainage Abscess not amenable to percutaneous drainage Co-existing intra-abdominal disease that requires operative management. Failure of antibiotic therapy. Failure of percutaneous aspiration or drainage.

Relative Contraindications:

Relative Contraindications Age older than 70. Multiple abscesses. Polymicrobial infection. Presence of associated malignancy or immunosupressive disease. Multiple medical problems.


Workup Lab studies include CBC: anemia in 50-80%, leukocytosis in 75-96%. LFTs: elevated alkaline phosphatase 95-100%, elevated AST, ALT 40-60%. Elevated bilirubin in 28-73%. Decreased albumin in 71-87%.

Imaging Studies:

Imaging Studies Chest film abnormal in 50%. Abdominal film can show intrahepatic air, air-fluid levels, pneumobilia. Ultrasound 80-100% sensitive, round hypoechoic mass consistent with abscess. CT scan is study of choice, abscesses are non enhancing with contrast.

Medical Therapy:

Medical Therapy Most dramatic change has been CT guided percutaneous drainage. Previously, open surgical procedures had a mortality rate as high as 70%. Current approach has three steps.

Medical Therapy:

Medical Therapy Initiation of antibiotic therapy. Diagnostic aspiration and drainage of abscess. Surgical drainage in selected patients.

Antibiotic Therapy:

Antibiotic Therapy Diagnostic aspiration should be employed prior to antibiotic therapy. Coverage should include aerobic gram negatives, streptococcus, anerobic, including bacteroides. Flagyl and clindamycin is usually good.

Percutaneous Drainage:

Percutaneous Drainage CT or US guided placement of a catheter. Drain is removed once abscess cavity collapses. Success 80-87%. Consider open drainage if fails, or patient worsens over 72 hrs.

Complications of Percutaneous Drainage:

Complications of Percutaneous Drainage Perforation of a viscous. Pneumothorax. Bleeding. Leakage of pus into the abdomen. Immunocompromised patients with multiple abscesses are best treated with high dose antibiotics rather than open or percutaneous drainage.

Surgical Therapy:

Surgical Therapy Five indications as previously discussed. Presence of peritoneal signs mandates emergent exploration. Transthoracic, extraperitoneal, transperitoneal. Transperitoneal is preferred as intra-abdominal pathology can be dealt with.


Complications Result from rupture of abscess into adjacent organs or cavities. These include both pleuropulmonary and intrabdominal types. Pleuropulmonary are themost common 15-20%, include effusions, empyema, bronch-hepatic fistula. Intraabdominal include subphrenic abscess, rupture into peritoneal cavity, stomach, colon, vena cava, or kidney.

Outcome andPrognosis:

Outcome andPrognosis Untreated, pyogenic abscess has a 100% mortality rate. Now with early drainage and antibiotics, mortality ranges 15-20%. The four poor prognostic factors are, age over 70, multiple abscesses, polymicrobial infection, presence of associated malignancy or immunosupression.

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