Hepatic abscess
Revision as of 13:10, 3 February 2015 by Rossdonaldson1 (talk | contribs) (Rossdonaldson1 moved page Pyogenic liver abscess to Hepatic abscess)
Please change the Main Title to "Hepatic Abscess"
Background
- Uncommon overall, usually right liver lobe
- More abscesses -> more severe disease
- Camping history
- Endemic of Midwest
- Two types: pyogenic and amebic
- Pyogenic
- More common of the two
- Associated with biliary tract obstruction (most common), cholangitis, diverticulitis, pancreatic abscess, appendicitis and inflammatory bowel disease.
- Possible arterial hematogenous seeding: sepsis, direct trauma or instrumentation
- Amebic
- Pyogenic
Causes
- Pyogenic abscesses
- Aerobic: Escherichia coli, Klebsiella, Pseudomonas
- Anaerobic: Entercoccus, bacteroides, anaerobic streptococci
- Amebic
- Entamoeba histolytica
Clinical Features
- RUQ Pain
- High fever
- Nausea, vomiting, anorexia
- Clay-colored stool
- Dark urine
- Jaundice
- Often with R pleural effusions
Differential Diagnosis
RUQ Pain
- Gallbladder disease
- Pancreatitis
- Acute hepatitis
- Pancreatitis
- GERD
- Appendicitis (retrocecal)
- Pyogenic liver abscess
- Bowel obstruction
- Cirrhosis
- Budd-Chiari syndrome
- GU
- Other
- Hepatomegaly due to CHF
- Peptic ulcer disease with or without perforation
- Pneumonia
- Herpes zoster
- Myocardial ischemia
- Pulmonary embolism
- Abdominal aortic aneurysm
Workup
- CBC
- Elevated white blood count (70-80%)
- CMP
- Liver Panel
- Elevated alkaline phosphatase levels (90%)
- Coags
- Blood cultures
- Ultrasound
- 80-100% sensitivity
- ABD/Pelvis CT
- Imaging study of choice
- Triphasic CT scan to define the proximity of the abscess to the major branches of the portal and hepatic veins
Management
- IV antibiotics[1]
- Two or more antibiotics
- Gram Negs: third or fourth generation cephalosporin (ceftriaxone) or aminoglycoside
- Gram Pos: penicillin for streptococcal species (ampicillin)
- For PCN allergic, use Fluoroquinolones
- Anaerobes: metronidazole or clindamycin
- Two or more antibiotics
- Diagnostic aspiration and drainage of the abscess followed by placement of drainage catheter
- Sonographic guidance for small or superficial abscesses
- CT guidance for deep or multiple abscesses
- Surgical drainage
- Abscesses > 5cm
- Abscesses not amenable to percutaneous drainage due to location
- Failure of percutaneous aspiration and drainage
- Coexistence of inra-abdominal disease that requires surgical management
Disposition
- Admit for IV antibiotics and drainage/sugery
See Also
Sources
UpToDate MedlinePlus Medscape
- ↑ Guss DA, Oyama LA: Disorders of the Liver and Biliary Tract, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 7. St. Louis, Mosby, Inc., 2010, (Ch) 88: p 1153-1171.