Hepatic abscess

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Please change the Main Title to "Hepatic Abscess"

==Background==^[1]

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

==Causes==^[2]

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
- Symptomatic cholelithiasis (biliary colic)
- Choledocholithiasis
- Acute cholecystitis
- Ascending cholangitis
- Acalculous cholecystitis
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^[3]
- 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

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

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.
↑ 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.
↑ 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.

Authors:

[1] 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.

[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.

[3] 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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