Pyogenic Hepatic Abscesses

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Pyogenic Hepatic Abscesses

• Vic V. Vernenkar,D.O.
• St. Barnabas Hospital
• Bronx, N.Y.

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Introduction

• Described since age of Hippocrates
• In 1883 Koch described the amoeba as a cause of
  liver abscess.
• In 1938 Debakey published largest series in the
  lierature.
• Over last 2 decades,percutaneous drainage has
  becaome a therapeutic option.

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Frequency

• Uncommon, prevalence in autopsy series
  0.29-1.47.
• Incidence in the US is 8-15 per 100,000.
• Male to female ratio is 21 in recent studies.
• 4th-6th decades of life.

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Etiology

• Biliary disease accounts for 21-30, with
  extrahepatic obstruction leading to ascending
  cholangitis and abscess. Also CBD stones, benign
  and malignant tumors, biliary enteric anastamoses.

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Etiology

• Infection via portal system
• Infectious process originates in abdomen, reaches
  liver by embolization of portal system.
• Appendicitis, diverticulitis, IBD, proctitis

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Etiology

• Hematogenous.
• Via hepatic artery.
• From systemic septicemia.
• No cause in 50 of cases, but increased in
  diabetics and metastatic cancer.

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Pathophysiology

• Access to liver by direct extension from nearby
  organs.
• Through portal vein and hepatic artery.
• Hepatic clearance of bacteria via portal system
  is a normal phenomena, but organism
  proliferation, tissue invasion and abscess can
  occur with biliary obstruction, poor perfusion,
  microembolization.

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Microbiology

• Most contain more than one organism, with source
  biliary or enteric.
• Blood cultures positive in 33-65.
• E.Coli 33.
• Klebsiella 18.
• Bacteroides 24.
• Streptococcal 37.

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Clinical

• Fever, right upper quadrant pain (80).
• Right shoulder pain, pleuritic chest pain.
• Fever 87-100.
• Anorexia, weight loss, mental confusion.
• Physical exam shows RUQ tenderness, hepatomegaly,
  liver mass, jaundice.

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Indications For Open Drainage

• Abscess not amenable to percutaneous drainage
• Co-existing intra-abdominal disease that requires
  operative management.
• Failure of antibiotic therapy.
• Failure of percutaneous aspiration or drainage.

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Relative Contraindications

• Age older than 70.
• Multiple abscesses.
• Polymicrobial infection.
• Presence of associated malignancy or
  immunosupressive disease.
• Multiple medical problems.

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Workup

• Lab studies include CBC anemia in 50-80,
  leukocytosis in 75-96.
• LFTs elevated alkaline phosphatase 95-100,
  elevated AST, ALT 40-60.
• Elevated bilirubin in 28-73.
• Decreased albumin in 71-87.

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Imaging Studies

• Chest film abnormal in 50.
• Abdominal film can show intrahepatic air,
  air-fluid levels, pneumobilia.
• Ultrasound 80-100 sensitive, round hypoechoic
  mass consistent with abscess.
• CT scan is study of choice, abscesses are non
  enhancing with contrast.

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Medical Therapy

• Most dramatic change has been CT guided
  percutaneous drainage.
• Previously, open surgical procedures had a
  mortality rate as high as 70.
• Current approach has three steps.

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Medical Therapy

• Initiation of antibiotic therapy.
• Diagnostic aspiration and drainage of abscess.
• Surgical drainage in selected patients.

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Antibiotic Therapy

• Diagnostic aspiration should be employed prior to
  antibiotic therapy.
• Coverage should include aerobic gram negatives,
  streptococcus, anerobic, including bacteroides.
• Flagyl and clindamycin is usually good.

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Percutaneous Drainage

• CT or US guided placement of a catheter.
• Drain is removed once abscess cavity collapses.
• Success 80-87.
• Consider open drainage if fails, or patient
  worsens over 72 hrs.

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Complications of Percutaneous Drainage

• Perforation of a viscous.
• Pneumothorax.
• Bleeding.
• Leakage of pus into the abdomen.
• Immunocompromised patients with multiple
  abscesses are best treated with high dose
  antibiotics rather than open or percutaneous
  drainage.

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Surgical Therapy

• Five indications as previously discussed.
• Presence of peritoneal signs mandates emergent
  exploration.
• Transthoracic, extraperitoneal, transperitoneal.
• Transperitoneal is preferred as intra-abdominal
  pathology can be dealt with.

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Complications

• Result from rupture of abscess into adjacent
  organs or cavities. These include both
  pleuropulmonary and intrabdominal types.
• Pleuropulmonary are themost common 15-20,
  include effusions, empyema, bronch-hepatic
  fistula.
• Intraabdominal include subphrenic abscess,
  rupture into peritoneal cavity, stomach, colon,
  vena cava, or kidney.

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Outcome andPrognosis

• Untreated, pyogenic abscess has a 100 mortality
  rate.
• Now with early drainage and antibiotics,
  mortality ranges 15-20.
• The four poor prognostic factors are, age over
  70, multiple abscesses, polymicrobial infection,
  presence of associated malignancy or
  immunosupression.

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