Liver Abcess

Dr.dr. H. Chudahman Manan SpPD-KGEH

CLASSIFICATIONS
PYOGENIC

Gram Positive
Gram Negative
Anaerobic
(Polymicrobial)

AMEBIC
CANDIDA
TB (rare)

EPIDEMIOLOGY
Pyogenic Abscesses
o
o
o

Bacterial
Most common
M > F 3:1

Entamoeba
M > F 7:1
40-50 million amoeba infections/year
worldwide
o Age Extremes
o Endemic Areas most susceptible
o
o

Country of origin or Travel

RISK FACTORS
PYOGENIC
DM
Cancer
Liver Transplant

ENTAMOEBA

Pregnancy
Steroids
Cancer
Endemic area travel (short
or long term)
EtOH?

PATHOPHYS.
PYOGENIC:
o

Peritonitis
To liver via portal circulation

Direct Spread
o

Hematogenous Seeding
o

Biliary infections

Look for bacteremia!

Sites: R lobe most common

o

Blood supply

PATHOPHYS.
ENTAMOEBA:
o

Fecal-Oral transmission into GI Tract

To liver via portal circulation

Can also spread to other

extraintestinal sites
o
o
o

Heart
Brain
Lungs

CLINICAL MANIFESTATIONS
o

SYMPTOMS
o
o
o
o

Fever (90%)
RUQ pain (50-75%)
Constitutional Sx
Diarrhea (<30%)

SIGNS
o
o
o
o

Hepatomegaly (50%)
RUQ tenderness
Jaundice
Acute abdomen
(<7%)

WORKUP
CBC (leukocytosis)
LFTs

AlkPhos elevated (67-90%)

AST/ALT elevated (50%)
TBili elevated (50%)

Blood Cultures

Bacteremia (50%)
E Histolytica Ab
Echinococcus Ab

Imaging- US, CT, MRI

Can not differentiate types of abscess

ULTRASOUND

CT/MRI

Fluid Collection w/ surrounding stranding,

edema, and inflammation

DIAGNOSTIC PROCEDURE

***

IMAGING-GUIDED DRAINAGE***

***SEND FOR CULTURE***

WHAT MAY GROW

POLYMICROBIAL (including anaerobes)
GRAM NEGATIVES (think gut bugs)
E. Histolytica

Money is in the serum Ab (95%)

Less yield with wet-mount of abscess or fecal microscopy
(<20%)

OTHERS

Strep Milleri group

S Aureus (chemoembo)
S Pyogenes (chemoembo)
Candida (s/p chemo)
Klebsiella
TB
Burkholderia

TREATMENT
TO DRAIN OR NOT TO DRAIN:

<5cm, single abscess- needle aspiration or catheter

>5cm- catheter
Also: Surgery, ERCP
Amoeba: drainage not usually required
Exceptions:
Verge of rupture
Abx not working
Imminent need to exclude other dx

TREATMENT-ABX
Pyogenic: Gram Neg + Anaerobe cov.

Unasyn
Zosyn
3rd gen Ceph (Rocephin) + Flagyl
PCN Allergy: FQ + Flagyl, Carbapenem

Course: 4-6 weeks

IV duration depends on f/u imaging

Suitable PO Abx: Augmentin OR FQ + Flagyl

Amoeba: Flagyl 500-750mg TID 7-10days

Then follow with lumenal antiamebic

Usually Paromomycin TID 10d

PROGNOSIS & NATURAL

HISTORY
Mortality 2-12%

Often due to comorbidities, not necessarily

abscess itself

Summary
Think Pyogenic (usually gram
neg/anaerobe) or E.Histolytica
Broad Spectrum Abx at first
Image Image Image
Imaging-Guided Culture +/- JP Drain
Treat for 4-6 weeks