Hepatic abscess: Difference between revisions
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==Background== | ==Background== | ||
*Uncommon overall | [[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.]] | ||
*More abscesses | [[File:Sobo 1906 389.png|thumb|Inferior view of the liver with surface showing lobes and impressions.]] | ||
* | [[File:Liver vascular anatomy.png|thumb|Liver vascular anatomy.]] | ||
*Endemic of Midwest | *Uncommon overall - usually occurs in right liver lobe | ||
**More abscesses → more severe disease | |||
*History of camping is common | |||
**Endemic of Midwest | |||
===Types=== | ===Types=== | ||
*Pyogenic | *Pyogenic (80%) | ||
** | **Most common cause | ||
**Associated with biliary tract obstruction (most common), cholangitis, diverticulitis, pancreatic abscess, appendicitis and inflammatory bowel disease. | **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 | **Possible arterial hematogenous seeding: [[sepsis]], direct [[trauma]] or instrumentation | ||
*Amebic | **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 | |||
==Clinical Features== | ==Clinical Features== | ||
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*Clay-colored stool | *Clay-colored stool | ||
*Dark urine | *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 | *Often with right [[pleural effusions]] | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
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{{DDX RUQ}} | {{DDX RUQ}} | ||
== | ==Evaluation== | ||
*CBC | [[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 | *Coags | ||
*[[Blood cultures]] | *[[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 | |||
**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== | ==Management== | ||
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***[[Gram Negs]]: third or fourth generation [[cephalosporin]] ([[ceftriaxone]]) or [[aminoglycoside]] | ***[[Gram Negs]]: third or fourth generation [[cephalosporin]] ([[ceftriaxone]]) or [[aminoglycoside]] | ||
***[[Gram Pos]]: [[penicillin]] for [[streptococcal]] species ([[ampicillin]]) | ***[[Gram Pos]]: [[penicillin]] for [[streptococcal]] species ([[ampicillin]]) | ||
****For | ****For penicillin allergic, use [[fluoroquinolones]] | ||
***[[Anaerobes]]: [[metronidazole]] or [[clindamycin]] | ***[[Anaerobes]]: [[metronidazole]] or [[clindamycin]] | ||
*Diagnostic aspiration and drainage of the abscess followed by placement of drainage catheter | *Diagnostic aspiration and drainage of the [[abscess]] followed by placement of drainage catheter | ||
**Sonographic guidance for small or superficial abscesses | **Sonographic guidance for small or superficial abscesses | ||
**CT guidance for deep or multiple abscesses | **CT guidance for deep or multiple abscesses | ||
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==Disposition== | ==Disposition== | ||
*Admit for IV [[antibiotics]] and drainage | *Admit for IV [[antibiotics]] and surgical drainage | ||
==See Also== | ==See Also== | ||
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.
- Uncommon overall - usually occurs in right liver lobe
- More abscesses → more severe disease
- History of camping is common
- Endemic of Midwest
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
- Amebic (10%)
- E. histolytica most common
- Usually not septic and sick, rarely needs drainage
- Fungal (<10%), candidal
- Hydatid cyst (echinococcosis)
- Associated with sheep farmers
Clinical Features
- RUQ pain
- High fever
- Nausea, vomiting, anorexia
- Clay-colored stool
- Dark urine
- Jaundice - seen with pyogenic, as opposed to amebic[1]
- Often with right pleural effusions
Differential Diagnosis
Hepatic abscess
- Pyogenic abscess
- Aerobic: Escherichia coli, Klebsiella, Pseudomonas
- Anaerobic: Enterococcus, bacteroides, anaerobic streptococci
- Echinococcosis
- Amebiasis
- Benign cysts/malignancy
- Tuberculosis
- Mycosis
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
Evaluation
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
- IV antibiotics[2]
- 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
- 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 surgical drainage
See Also
References
- ↑ 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.
- ↑ 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.