Hepatic abscess: Difference between revisions

(workup for liver abscess)
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==Background==
==Background==
Pus filled area in the liver. Usually develops following peritonitis due to leakage of intraabdominal bowel contents that subsequently spread to liver via the portal circulation or via direct spread from biliary infection. It may also result from arterial hematogenous seeding in the setting of sepsis or from direct trauma to the liver.
[[File:Biliary system multilingual.png|thumb|Bile duct and pancreas anatomy. 1. Bile ducts: 2. Intrahepatic bile ducts; 3. Left and right hepatic ducts; 4. Common hepatic duct; 5. Cystic duct; 6. Common bile duct; 7. Sphincter of Oddi; 8. Major duodenal papilla; 9. Gallbladder; 10-11. Right and left lobes of liver; 12. Spleen; 13. Esophagus; 14. Stomach; 15. Pancreas: 16. Accessory pancreatic duct; 17. Pancreatic duct; 18. Small intestine; 19. Duodenum; 20. Jejunum; 21-22: Right and left kidneys.]]
==Clinical Features==
[[File:Sobo 1906 389.png|thumb|Inferior view of the liver with surface showing lobes and impressions.]]
--Lower right chest pain or RUQ abdominal pain
[[File:Liver vascular anatomy.png|thumb|Liver vascular anatomy.]]
*Uncommon overall - usually occurs in right liver lobe
**More abscesses → more severe disease
*History of camping is common
**Endemic of Midwest


--fever, chills
===Types===
*Pyogenic (80%)
**Most common cause
**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
**Usually polymicrobial
*[[amebiasis|Amebic]] (10%)
**E. histolytica most common
**Usually not septic and sick, rarely needs drainage
*[[fungal infections|Fungal]] (<10%), [[candida|candidal]]
*Hydatid cyst ([[echinococcosis]])
**Associated with sheep farmers


--nausea, vomiting, anorexia
==Clinical Features==
 
*[[RUQ pain]]
--clay-colored stool
*High [[fever]]
 
*[[Nausea]], [[vomiting]], anorexia
--dark urine
*Clay-colored stool
 
*Dark urine
--jaundice
*[[Jaundice]] - seen with pyogenic, as opposed to amebic<ref>Oyama LC. 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 8. St. Louis, Mosby, Inc., 2013, (Ch) 90: p 1186-1205.</ref>
*Often with right [[pleural effusions]]


==Differential Diagnosis==
==Differential Diagnosis==
{{Liver abscess DDX}}


==Workup==
{{DDX RUQ}}
--CBC, CMP, LFTs, bilirubin, blood culture


--abdominal ultrasound
==Evaluation==
[[File:Leberabszess - CT axial PV.jpg|thumb|Liver abscess on axial CT image: a hypodense lesion in the liver with peripherally enhancement.]]
[[File:LargeHepaticAbscessMark.png|thumb|A large pyogenic liver abscess.]]
===Work-up===
*CBC - Elevated white blood count (70-80%)
*BMP
*[[LFTs]] - Elevated alkaline phosphatase levels (90%)
*Coags
*[[Blood cultures]]
*Amebic and echinococcal serologies
*[[RUQ ultrasound|Ultrasound]] (80-100% sensitivity)
*CT abd/pelvis ('''Imaging study of choice''')
**Triphasic CT scan to define the proximity of the [[abscess]] to the major branches of the portal and hepatic veins


--abdominal CT with IV contrast
===Evaluation===
*Diagnosis usually made on imaging studies


==Management==
==Management==
*IV antibiotics<ref>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.</ref>
**Two or more antibiotics
***[[Gram Negs]]: third or fourth generation [[cephalosporin]] ([[ceftriaxone]]) or [[aminoglycoside]]
***[[Gram Pos]]: [[penicillin]] for [[streptococcal]] species ([[ampicillin]])
****For penicillin allergic, use [[fluoroquinolones]]
***[[Anaerobes]]: [[metronidazole]] or [[clindamycin]]
*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==
==Disposition==
*Admit for IV [[antibiotics]] and surgical drainage


==See Also==
==See Also==
*[[Right upper quadrant abdominal pain]]
*[[Amebiasis]]


==Sources==
==References==
UpToDate
MedlinePlus
<references/>
<references/>
[[Category:GI]]
[[Category:ID]]

Latest revision as of 23:12, 13 November 2024

Background

Bile duct and pancreas anatomy. 1. Bile ducts: 2. Intrahepatic bile ducts; 3. Left and right hepatic ducts; 4. Common hepatic duct; 5. Cystic duct; 6. Common bile duct; 7. Sphincter of Oddi; 8. Major duodenal papilla; 9. Gallbladder; 10-11. Right and left lobes of liver; 12. Spleen; 13. Esophagus; 14. Stomach; 15. Pancreas: 16. Accessory pancreatic duct; 17. Pancreatic duct; 18. Small intestine; 19. Duodenum; 20. Jejunum; 21-22: Right and left kidneys.
Inferior view of the liver with surface showing lobes and impressions.
Liver vascular anatomy.
  • Uncommon overall - usually occurs in right liver lobe
    • More abscesses → more severe disease
  • History of camping is common
    • Endemic of Midwest

Types

Clinical Features

Differential Diagnosis

Hepatic abscess

RUQ Pain

Evaluation

Liver abscess on axial CT image: a hypodense lesion in the liver with peripherally enhancement.
A large pyogenic liver abscess.

Work-up

  • CBC - Elevated white blood count (70-80%)
  • BMP
  • LFTs - Elevated alkaline phosphatase levels (90%)
  • Coags
  • Blood cultures
  • Amebic and echinococcal serologies
  • Ultrasound (80-100% sensitivity)
  • CT abd/pelvis (Imaging study of choice)
    • Triphasic CT scan to define the proximity of the abscess to the major branches of the portal and hepatic veins

Evaluation

  • Diagnosis usually made on imaging studies

Management

  • 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

See Also

References

  1. ↑ Oyama LC. 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 8. St. Louis, Mosby, Inc., 2013, (Ch) 90: p 1186-1205.
  2. ↑ 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.
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