Hepatic abscess

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

Differential Diagnosis

Hepatic abscess

RUQ Pain

Evaluation

Work-up

  • CBC - Elevated white blood count (70-80%)
  • BMP
  • Liver Panel - 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.