Pyogenic liver abscess

The objective of this study was to investigate and report changes in presentation, management and outcome of patients with pyogenic liver abscess (PLA). Between 01.01.1995-31.12.1999, 27 patients with PLA were treated in the General Surgical Service of the Fundeni Clinical Hospital. The incidence of cryptogenic abscesses was dominant (55.5%). The symptoms and the biological status are frequently nonspecific. The CT scan and echographic examination sensibility in the diagnosis of the PLA was 89.5% and 78.3%. The aerobe germs are most involved. All patients received antibiotic treatment in preoperative as in postoperative period. The surgical treatment was performed in 24 patients: in 9 patients (33.3%), the abscess was surgically evacuated and drained and in 15 patients (55.5%), a liver resection was performed. Percutaneous catheter drainage under CT or echo-guidance was performed in three patients (11.1%). The clinical evolution was good in 21 patients (77.7%). There was four complications (14.8%) and two death (7.4%). Although with a better prognostic, the PLA remains an important pathology.     

Pyogenic liver abscess

Pyogenic liver abscess has been recognized since ancient times and it continues to be associated with substantial morbidity and mortality. This paper is a summary of the clinical manifestations of pyogenic hepatic abscess.

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Résumé Les abcès pyogènes du foie sont connus depuis l’antiquité. La morbidité et la mortalité sont lourdes. L’article résume les manifestations cliniques de ces abcès.

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Dr. Howard is the recipient of Research Career Award Number 7 KO4 AI 00394-04.     

Pyogenic liver abscess

Experience with 34 patients with pyogenic liver abscess is reviewed to evaluate the impact of percutaneous drainage and duration of antibiotic therapy on results of treatment. Patients with shock, adult respiratory distress syndrome, disseminated intravascular coagulation, jaundice, severe hypoalbuminemia, and diabetes had a poor prognosis. Percutaneous drainage was used successfully in 4 of 6 patients, but its use did not affect mortality rate or length of hospital stay. Percutaneous drainage may be the procedure of choice for selected patients. Half of our patients received antibiotics for 2 weeks or less with no abscess recurrences in this group. Long-term antibiotics may not be necessary after adequate surgical or percutaneous abscess drainage.

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Resumen Se revisó la experiencia con treinta y cuatro pacientes con absceso piogénico del hígado con el fin de evaluar el impacto del drenaje percutáneo y la duración de la terapia antibiótica sobre los resultados del tratamiento. Los pacientes con shock, síndrome de dificultad respiratoria del adulto, coagulación diseminada intravascular, ictericia, hipoalbuminemia severa, y diabetes exhibieron un mal pronóstico. El drenaje percutáneo fue utilizado exitosamente en 4 de 6 pacientes pero su uso no modificó la tasa de mortalidad ni la duración de la hospitalización. El drenaje percutáneo puede ser el procedimiento de elecctión en casos seleccionados. La mitad de nuestros pacientes recibió antibióticos por 2 semanas o menos, sin que se presentara recurrencia del absceso. La antibioticoterapia a largo plazo puede ser innecesaria una vez realizado un adecuado drenaje, quirúrgico o percutáneo, del absceso.

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Résumé Nous avons analysé notre expérience des abcès hépatiques pyogènes pour déterminer l'influence du drainage percutané et de la durée de l'antibiothérapie sur les résultats du traitement. On observait un mauvais pronostic chez les patients ayant eu un choc, un syndrome de détresse respiratoire de l'adulte, une coagulopathie vasculaire disséminée, un ictère, une hypoalbuminémie et/ou un diabète. Le drainage percutané a été utilisé avec succès chez 4 des 6 patients mais n'a influencé ni la mortalité ni la durée d'hospitalisation. Le drainage percutané a été le procédé de choix chez un groupe de patients sélectionnés. La moitié des patients avaient reçu des antibiotiques 2 semaines ou moins sans récidive. Une utilisation prolongée des antibiotiques n'est pas nécessaire si l'abcès a été correctement drainé chirurgicalement ou par voie percutanée.

     

Pyogenic liver abscess: Changing patterns in approach

AIM: To define optimum management of the pyogenic liver abscess and assess new trends in treatment.METHODS: One hundred and sixty nine patients with pyogenic liver abscess managed at Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Kashmir (India) from July 2001 to August 2006 were studied to evaluate and define the optimum treatment.RESULTS: Mortality in the surgically treated group of patients was 9.4% (12/119), while those treated non-surgically had a fatality rate of 16.66% (7/42). Multiple liver abscesses treated surgically had a surprisingly low mortality of 30%. The biliary tract (64.97%) was the most common cause of liver abscess. Multiple abscesses, mixed organisms and abscess complications are all associated with a significantly increased mortality. However, the lethality of the primary disease process was the most important factor in determining survival.CONCLUSION: Transperitoneal surgical drainage and antibiotics are the mainstay of treatment. Percutaneous drainage is recommended for high risk patients only.     

Pyogenic liver abscess. Modern treatment

Historically, open surgical drainage has been the treatment of choice for pyogenic liver abscess. The records of 54 patients with pyogenic liver abscess were reviewed to determine whether earlier diagnosis with current imaging tests and definitive treatment with antibiotics, aspiration, or catheter drainage was an effective alternative to open drainage. Twenty-nine patients were treated with broad-spectrum antibiotics and diagnostic aspiration. Twenty-three (79%) recovered uneventfully, and six required catheter or operative drainage. Twenty-three patients (including five who failed aspiration) underwent drainage with percutaneously placed catheters. Nineteen (83%) recovered; four required open surgical drainage. Of seven patients who required open surgical drainage, six recovered. One (2%) of the 54 patients died following failed aspiration and catheter and surgical drainage. Four patients were successfully treated with antibiotics alone without aspiration. These results confirm that pyogenic liver abscess can be successfully treated with broad-spectrum antibiotics and aspiration or percutaneous catheter drainage. Open surgical drainage is reserved for patients in whom treatment fails or who require celiotomy for concurrent disease.     

Pyogenic liver abscess secondary to Streptococcus anginosus in an adolescent

Pyogenic liver abscess in the pediatric population is a rare entity and can be difficult to manage. Surgical infections caused by Streptococcus anginosus are exceedingly rare. Here we present a case of pyogenic liver abscess caused by S anginosus in an adolescent presenting with fever, nausea, emesis, and right upper quadrant abdominal discomfort.     

Pyogenic liver abscess complicated by endogenous endophthalmitis

Background: Endogenous endophthalmitis is an inflammation of ocular tissues that can lead to deterioration of and loss of vision. Rarely, this can complicate the course of a patient with pyogenic liver abscess. Methods: Over an 18‐month period, 68 patients were treated for pyogenic liver abscesses. Three patients, all of whom were male and with diabetes, were diagnosed with a Klebsiella pneumoniae liver abscess complicated by endogenous endophthalmitis. Open surgical or percutaneous drainage of the liver abscess was undertaken and the symptomology and outcome of the endophthalmitis reviewed. Results: There was no mortality in our series. Two patients presented with simultaneous abdominal and ocular symptoms and one patient had ocular symptoms 3 days after surgical drainage of the liver abscess. Despite aggressive treatment, all patients had permanent deterioration of visual function with one patient becoming blind and requiring evisceration of the infected eye. Conclusion: Ocular symptoms in patients treated for pyogenic abscesses must be dealt with urgently with an ophthalmologic consultation. Increased awareness of this complication and a high index of suspicion are paramount for salvage of visual function.     

Pyogenic liver abscess: Multivariate analysis of risk factors

Seventy-three patients with pyogenic liver abscess during the year 1978–1988 were studied in the Kaohsiung Medical College Hospital. The overall mortality rate was 19.2% in this study. By using univariate analysis, it was revealed that clinical jaundice, pleural effusion, bilobar abscess, profound hypoalbuminemia (<2.5 g/dl), hyperbilirubinemia (>2 mg/dl), elevated level of serum AST (>100 IU/L), alkaline phosphatase (>150 IU/L), and marked leukocytosis (>20,000 mm³) were associated with a higher mortality rate. Multivariate stepwise logistic regression analysis detected only 3 factors of marked leukocytosis (>20,000 mm³), profound hypoalbuminemia (<2.5 g/dl), and presence of pleural effusion with independent significance in predicting mortality. Meanwhile, it was also revealed that the laboratory data could not predict a risk factor to mortality unless they became markedly abnormal.

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Resumen Setenta y tres pacientes con absceso hepático piógeno manejados en el período 1978–1988 fueron estudiados en el Hospital del Colegio Médico de Kaohsiung. La mortalidad global fue de 19.2 por ciento. Mediante el análisis univariable, se encontró que la ictericia clínica, la efusión pleural, los abscesos bilobares, la hipoalbuminemia profunda (<2.5 g/dl), la hiperbilirrubinemia (>2 mg/dl), la elevación del nivel de la AST sérica (>100 IU/L), la elevación de la fosfatasa alcalina (>150 IU/L), y la leucocitosis pronunciada (>20,000 mm³) aparecieron como factores asociados con una alta tasa de mortalidad. El análisis multivariable de regresión logística détectó solo 3 factores con significatión independiente en cuanto a la predictión de mortalidad: leucocitosis pronunciada (>20,000 mm³), hipoalbunemia profunda (<2.5 g/dl), y efusión pleural. El estudio también reveló que los datos de laboratorio no tienen capacidad para predecir riesgo a menos que los valores se hagan notoriamente anormales.

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Résumé Soixante-treize patients ayant un abcès pyogène du foie observé pendant les années 1978–1988 ont été étudiés à l'Hôpital de l'Ecole de Médecine Kaohsiung. La mortalité globale a été de 19.2%. En analyse monofactorielle, un plus fort taux de mortalité a été noté lorsqu'étaient associés ictère clinique, épanchement pleural, abcès dans les deux lobes, hypo-albuminémie (<2.5 g/dL), bilirubinémie (>2 mg/dL), sérum AST (>100 IU/L), phosphatases alcalines (>150 UI/L), et hyperleucocytose (>20,000 mm³). L'analyse multifactorielle pas à pas n'a détecté que 3 facteurs, hyperleucocytose, hyperleucocytose (>20,000 mm³), hypoalbuminémie (<2.5 g/dL), et l'existence d'un épanchement pleural, ayant une valeur significative dans la prédiction de mortalité. Il a été démontré qu'un seul facteur de risque n'avait de valeur prédictive que lorsque sa valeur était très anormale.

     

Pyogenic liver abscess – 20 years' experience

BACKGROUND AND AIMS: Our aim is to give an audit of our experience over the past two decades in the form of a retrospective study. PATIENTS/METHODS: In two equal periods between 01.01.1982 and 31.03.2001, 56 patients (37 males and 19 females) with pyogenic liver abscess were treated. Image-guided percutaneous drainage was performed in 22.2%/20.6% of the patients; the remainder were treated with open drainage with or without biliary tract reconstruction and liver resection. For antibiotic perfusion of the liver an umbilical vein cannula was inserted in 40.7%/24.1%. Microbiological findings, types of therapy, complications and mortality, etiology, patient characteristics, symptoms, and laboratory data were investigated. The results in the two groups were compared and analyzed statistically. RESULTS: The most common cause of abscess, biliary disease, was seen more often in the second period. Solitary liver abscesses were more frequent. The only characteristic biochemical finding was an elevated alkaline phosphatase level. There were more positive cultures in the second period (70.4%/79.3%), and the number of Escherichia coli or Enterobacter aerogenes infections also increased. In the first period the mortality was 18.5%, whereas in the second no patients were lost. CONCLUSION: We suggest the importance of individualized therapy based on an early and exact diagnosis. The first treatment step should be image-guided drainage, but under well-defined circumstances open drainage can also be performed with good results.     

Pyogenic liver abscess after hepatobiliary and pancreatic surgery

From 1984 to 1998, a total of 2158 patients underwent hepatobiliary and pancreatic surgery, and 12 patients developed liver abscess after hepatobiliary and pancreatic surgery; thus, the incidence of liver abscess was 0.6%. The main reasons for liver abscess were anastomotic stricture in 5 patients, obstruction of percutaneous transhepatic biliary drainage (PTBD) tube in 3 patients, and portal vein and hepatic artery obstruction due to intraoperative radiation in 1 patient, transportal chemotherapy in 1 patient, chemo-lipiodolization in 1 patient, and unknown in 1 patient. Ten of the 12 patients initially underwent percutaneous transhepatic abscess drainage of whom 2 patients subsequently received surgical drainage. The other 2 patients were treated with antibiotics only. Eight of the 12 patients were cured, but 4 patients died. The reasons for death were sepsis in 3 patients and liver failure due to portal vein and hepatic artery obstruction in 1 patient. Our results indicate that liver abscess should be taken into consideration for patients with risk factors.