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Liver Abscess - Causes, Symptoms and Treatment

Definition:

A liver abscess occurs when bacteria or protozoa destroy hepatic tissue,


producing a cavity, which fills with infectious organisms, liquelled liver
cells, and leukocytes. Necrotic tissue then walls off the cavity from the rest
of the liver. Liver abscess occurs equally in men and women, usually in
those over age 50. Death occurs in 15% of affected patients despite
treatment.

Causes of Liver Abscess

Underlying causes of liver abscess include benign or malignant biliary


obstruction along with cholangitis, extrahepatic abdominal sepsis, and
trauma or surgery to the right upper quadrant. Liver abscesses also occur
from intra-arterial chemoembolizations or cryosurgery in the liver, which
causes necrosis of tumor cells and potential infection.

The method by which bacteria reach the liver reflects the underlying causes.
Biliary tract disease is the most common cause of liver abscess. Liver
abscess after intra-abdominal sepsis (such as with diverticulitis) is most
likely to be caused by hematogenous spread through the portal bloodstream.
Hematogenous spread by hepatic arterial flow may occur in infectious
endocarditis.

Abscesses arising from hematogenous transmission are usually caused by a


single pathogen; those arising from biliary obstruction are usually caused by
a mixed flora. Patients with metastatic cancer to the liver, diabetes mellitus,
and alcoholism are more likely to develop a liver abscess.

The organisms that predominate in liver abscess are gram-negative aerobic


bacilli, enterococci, streptococci. and anaerobes. Amebic liver abscesses arc
caused by E. histolytica.

Signs and Symptoms of Liver Abscess

The clinical manifestations of a liver abscess depend on the degree of


involvement. Some patients are acutely ill; in others, the abscess is
recognized only at autopsy, after death from another illness.
The onset of symptoms of a pyogenic abscess is usually sudden; in an
amebic abscess, the onset is more insidious. Common signs include
abdominal pain, weight loss, fever, chills, diaphoresis, nausea, vomiting, and
anemia. Signs of right pleural effusion, such as dyspnea and pleural pain,
develop if the abscess extends through the diaphragm. Liver damage may
cause jaundice.

Diagnosis for Liver Abscess

Ultrasonography and computed tomography (CT) scan with contrast


medium can accurately define intrahepatic lesions and allow assessment of
intra-abdominal pathology. Percutaneous needle aspiration of the abscess
can also be performed with diagnostic tests to identify the causative
organism. Contrast-aided magnetic resonance imaging may become an
accurate method for diagnosing hepatic abscesses.

Abnormal laboratory values include: elevated levels of serum aspartate


aminotransferase, alanine aminotransferase, alkaline phosphatase, and
bilirubin; an increased white blood cell count; and decreased serum albumin
levels. In pyogenic abscess, a blood culture can identify the bacterial agent;
in amebic abscess, a stool culture and serologic and hemagglutination tests
can isolate E. histolytica.

Treatment for Liver Abscess

Antibiotic therapy, along with drainage, is the preferred treatment for most
hepatic abscesses. Pereutaneous drainage, either with ultrasound or CT
guidance, is usually sufficient to evacuate pus. Surgery may be performed to
drain pus in unstable patients with continued sepsis (despite attempted non
surgical treatment) and for patients with persistent fevers (lasting longer than
2 weeks) after percutaneous drainage and appropriate antibiotic therapy. A
common combination is ampicillin, an amino glycoside, and either
metronidazole or clindamycin. Third-generation cephalosporins can be
substituted for the aminoglycosides in patients at risk for renal toxicity.
When the causative organisms are identified, the antibiotic regimen should
be modified to match the patient's sensitivities. I.V. antibiotics should be
administered for 14 days and then replaced with oral preparations to
complete a 6 week course. Surgery is reserved for bowel perforation and
rupture into the pericardium.

Special Considerations and Prevention Tips for Liver Abscess


1. Provide supportive care, monitor vital signs (especially temperature), and
maintain fluid and nutritional intake.

2. Administer anti-infective's and antibiotics as necessary, and watch for


possible adverse effects. Stress the importance of compliance with therapy.

3. Explain diagnostic and surgical procedures.

4. Watch carefully for complications of abdominal surgery, such as


hemorrhage or sepsis.

5. Prepare the patient for I.V antibiotic administration as an outpatient with


home care support.