Hepatic abscess: Difference between revisions
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*Pyogenic (80%) | *Pyogenic (80%) | ||
**Most common cause | **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 | ||
**Usually polymicrobial | **Usually polymicrobial | ||
*Amebic (10%) | *[[amebiasis|Amebic]] (10%) | ||
**E. histolytica most common | **E. histolytica most common | ||
**Usually not septic and sick, rarely needs drainage | **Usually not septic and sick, rarely needs drainage | ||
*Fungal (<10%), candidal | *[[fungal infections|Fungal]] (<10%), [[candida|candidal]] | ||
*Hydatid cyst (echinococcosis) | *Hydatid cyst ([[echinococcosis]]) | ||
**Associated with sheep farmers | **Associated with sheep farmers | ||
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*CBC - Elevated white blood count (70-80%) | *CBC - Elevated white blood count (70-80%) | ||
*BMP | *BMP | ||
* | *[[LFTs]] - Elevated alkaline phosphatase levels (90%) | ||
*Coags | *Coags | ||
*[[Blood cultures]] | *[[Blood cultures]] | ||
*Amebic and echinococcal serologies | *Amebic and echinococcal serologies | ||
*Ultrasound (80-100% sensitivity) | *[[RUQ ultrasound|Ultrasound]] (80-100% sensitivity) | ||
*CT | *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 | ||
Revision as of 21:00, 29 September 2019
Background
- 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.