Pyogenic liver abscesses

Pyogenic liver abscess is a classic clinical entity whose presentation and management have evolved significantly with the advent of potent antimicrobials and the availability of improved diagnostic imaging. The classic triad of fever, upper right quadrant pain or fullness, and jaundice resulting from advanced pylephlebitis is now seldom seen. Despite these changes, pyogenic liver abscess remains an important clinical entity for which prompt recognition and treatment are essential to achieve a favorable outcome. This article discusses the presentation and diagnosis of and current therapy for liver abscesses.     

Pyogenic liver abscesses: mortality-related factors

GOAL: To analyse the characteristics and mortality-related factors in a series of patients hospitalized for pyogenic liver abscess (PLA). BACKGROUND: Pyogenic liver abscesses are infrequent but potentially life threatening. Factors related to mortality have been less studied. STUDY: The medical records of 84 patients, 56 men and 28 women, mean age of 64.4 years (SD: 14) who were hospitalized between 1992 and 2005 owing to a PLA were reviewed. The past medical history, clinical signs and symptoms, laboratory values, imaging studies, microbiological features, treatment, complications and mortality were recorded. Factors related to complications and mortality were analysed. RESULTS: One or more bacteria were isolated in 65 patients (77.4%), being Streptococcus spp. (40.5%), Escherichia coli (27.4%), Klebsiella spp. (14.3%) and anaerobics (17.9%) the most frequent isolates. Complications developed in 60.7% of the cases, the most common one being a right pleural effusion (34.5%). Mortality rate was 19% (95% confidence interval: 10-28%). Mortality was associated with age (P=0.005), a previous history of coronary heart disease (P=0.016), absence of fever (P=0.001), development of sepsis and/or septic shock (P<0.001), raise of bilirubin levels (P=0.004), a biliary (P=0.035), or cryptogenetic origin (P=0.039), infection owing to E. coli (P=0.01) or to Candida (P=0.009) and development of pneumonia (P<0.001). Logistic regression revealed sepsis and/or septic shock as an independent risk factor for mortality. CONCLUSIONS: Mortality associated with PLA is high. The main risk factor for mortality is the development of sepsis and/or septic shock.     

Pyogenic abscesses and parasitic diseases

Parasitic diseases which during their course in the host switch the immune system from a T helper 1 to a T helper 2 response may be detrimental to the host, contributing to granuloma formation, eosinophilia, hyper-IgE, and increased susceptibility to bacterial and fungal infections. Patients and animals with acute schistosomiasis and hyper-IgE in their serum develop pyogenic liver abscess in the presence of bacteremia caused by Staphylococcus aureus. The Salmonella-S. mansoni association has also been well documented. The association of tropical pyomyositis (pyogenic muscle abscess) and pyogenic liver abscess with Toxocara infection has recently been described in the same context. In tropical countries that may be an interesting explanation for the great morbidity of bacterial diseases. If the association of parasitic infections and pyogenic abscesses and/or fungal diseases are confirmed, there will be a strong case in favor of universal treatment for parasitic diseases to prevent or decrease the morbidity of superinfection with bacteria and fungi.     

Pyogenic liver abscesses: a comparison of older and younger patients

BackgroundPyogenic liver abscess is a life-threatening disease. Few studies have specifically explored the way in which the clinical features and management of elderly patients with pyogenic liver abscess differ from those of younger individuals.MethodsA retrospective study was undertaken to evaluate whether older patients with pyogenic liver abscess have distinctive presenting features or whether their management and outcome differ from that of younger patients. A total of 133 patients with liver abscess treated in five hospitals during 13 years comprised two groups: 78 patients aged 60 years or above (older group) and 55 patients below age 60 years (younger group). Clinical features, laboratory data, imaging and microbiological findings, management and outcome were determined in each group.ResultsThe older group contained more patients with associated diseases (p=0.03), nausea and vomiting at presentation (p=0.02), higher APACHE II (Acute Physiological and Chronic Health Evaluation II scale) score (p<0.00l) and blood urea nitrogen (p<0.001) and serum creatinine levels (p=0.002). Multiple abscess (p=0.05) and bilobar (p=0.03) abscess were also commoner in this group. By contrast, in the younger group men predominated (p=0.01), and there was a higher overall complication rate (p=0.05).Time to diagnosis, hospital mortality rate and other variables analysed were similar in both groups.DiscussionElderly patients with pyogenic liver abscess have some subtle differences in clinical and laboratory presentation, but these do not appear to delay diagnosis. Active management is tolerated well, with a lower morbidity rate than in younger patients and no difference in the mortality rate.     

Fulminant hepatic failure secondary to amebic abscesses

Summary A patient presented with fulminant hepatic failure which rapidly led to his death. At postmortem examination, he had several amebic abscesses secondarily infected with bacteria, one of which had ruptured intraperitoneally, and another of which had occluded major hepatic veins of the right lobe of the liver. In addition, pylephlebitis and occlusion of several right portal venous radicies were noted. Microscopic examination of the right lobe revealed marked sinusoidal congestion and large areas of infarction with severe panlobular necrosis. Fuiminant hepatic failure secondary to complications of amebic abscess has been reported infrequently but should be considered in patients with this presentation who have visited or inhabited areas endemic for amebiasis.     

Pyogenic liver abscesses of bacterial origin. A study of 45 cases.

OBJECTIVE: to determine the clinical, microbiological, diagnostic and therapeutic characteristics of pyogenic liver abscesses of bacterial origin. METHODS: retrospective analysis of pyogenic liver abscesses diagnosed at the Aránzazu Hospital in San Sebastián (northern Spain) between 1989 and 1998. RESULTS: we studied 45 patients with pyogenic liver abscesses of bacterial origin (30 men, 15 women, mean age 61 years 11 months). The site of the liver abscess was biliary in 28.9% of the patients, portal in 11.1%, and unknown in 33.3%. Elevated erythrocyte sedimentation rate (95.5%), leukocytosis (86.7%) and fever (82.2%) were the most frequent clinical and laboratory findings. The abscesses were solitary in 55. 5% of the patients. Echography was diagnostic in 68.4% of patients, and computed tomography was diagnostic in 100%. Cultures of pus from the abscess and blood were positive in 77.1% and 50% respectively. Of the abscesses diagnosed as being of bacterial origin, 44.4% involved multiple organisms. Escherichia coli and Streptococcus milleri were the germs isolated most frequently. Percutaneous drainage was done in 22 patients (48.9%), with satisfactory results in 18. Overall mortality related with abscesses was 15.5%. CONCLUSIONS: the clinical presentation of pyogenic liver abscess did not vary during the study period. Computed tomography is fundamental for diagnosis and treatment. Percutaneous drainage associated with early antibiotic therapy is the treatment of choice.     

Pyogenic liver abscesses associated with nonmetastatic colorectal cancers: an increasing problem in Eastern Asia

AIM: To elaborate the clinicopathologic features of colorectal cancer-related pyogenic liver abscess (PLA).METHODS: Reported cases of colorectal cancer-related PLAs were collected from the literature published up to October 2011 and evaluated for their clinicopathologic features. Data of collected cases included demographics, clinical presentation, microbial findings and treatment. Categorical variables were compared by χ² analysis and continuous variables were evaluated using Student’s t test.RESULTS: A total 96 cases of colorectal cancer-related PLA were collected from the previous literature. Most patients (60%) were male and 40% cases occurred in the age group of 61-70 years. Apart from some special types of PLA, there were significant differences in the microbiological spectrum between Eastern Asia and non-Eastern Asian countries, which implied different risk factors and courses of the disease. Gram negative bacteria especially Klebsiella pneumoniae (K. pneumoniae) PLA was predominant in Eastern Asia (80.0%) in contrast to non-Eastern Asian countries (P < 0.01). Meanwhile, most of the Eastern Asian patients exhibited smaller size of liver abscess and atypical presentation. Sigmoid colon and rectum (72.73%) were the main sites of tumor in Eastern Asian patients, whereas tumor sites were uneven among most of the non-Easter Asian PLA patients.CONCLUSION: K. pneumoniae PLA was strongly associated with colorectal cancer, especially those occurring in sigmoid colon and rectum, in elderly Eastern Asian male patients.     

Pyogenic liver abscess

Opinion statement  

Pyogenic splenic abscesses. A review of 8 cases

PURPOSE: Pyogenic splenic abscess is un uncommon and potentially life-threatening disease. Due to inconspicuous and nonspecific clinical picture, it remains a diagnostic challenge. Medical imaging progresses are helpful for diagnosis and treatment. METHODS: We tried to establish epidemiologic and clinical features and therapeutic possibilities of 8 cases of splenic abscesses occurred between 1993 and 2002. RESULTS: There were 5 male patients and 3 female patients. Aged ranged from 17 to 53 years, with a median of 34 years. One patient was immunocompromised (colonic carcinoma). Common clinical presentations included fever (n=8) and left upper quadrant abdominal pain (n=7). Positive blood cultures were found in only four patients (50%) : Staphylococcus aureus (3) and coagulase negative Staphylococcus (1). Staphylococcus aureus and Bactero?des fragilis were isolated in one abscess pus respectively. The diagnosis was obtained by ultrasonography in all 8 cases. Antibiotics were prescribed in all cases for a mean length of 60 days (30 - 110 days). Splenectomy and percutaneous CT-guided drainage were performed in one case respectively. Evolution was good in all cases. CONCLUSION: Splenic abscesses are increasingly recognized. The combination of clinical features and imaging findings, early diagnosis and treatment can be made.     

Recurrent amebic liver abscess

Recurrence of amebic liver abscess is uncommon. We report a 62-year-old man presenting with amebic liver abscess thrice in last 5?years.     

Outcome of hepatic amebic abscesses managed with three different therapeutic strategies

Three different approaches to hepatic abscesses due toEntamoeba histolytica were compared in 51 patients. The three modes of therapy utilized were: medical therapy with nitroimidazoles(N=11 patients), open surgical drainage (N=9 patients), and percutaneous drainage using ultrasound guidance followed by intralesional nitroimidazole administration (N=31 patients). The results with each form of therapy were assessed clinically and by abdominal ultrasound. Patients receiving combined US-guided drainage and intralesional chemotherapy experienced a faster and overall better clinical response, which was confirmed also by sonographic follow-up of the hepatic lesions. This better response was associated with faster resolution, fewer relapses, and less residual hepatic scarring than either with medical therapy alone or open surgical drainage combined with medical therapy.