The role of percutaneous transhepatic abscess drainage for liver abscess

To evaluate the efficacy of percutaneous transhepatic abscess drainage (PTAD) as an initial choice of treatment for liver abscess, the medical records of 28 patients with liver abscess were retrospectively analyzed. The patients were predominantly men (23 of 28) with a mean age of 59 years (range, 19—86 years). Their chief complaints were fever (86%), right hypochondralgia (32%), and jaundice (11%). Fifteen of the 28 patients (54%) had hepatobiliary and pancreatic carcinoma, and 31% had postoperative liver abscess. PTAD was performed in 23 patients and surgical drainage in 5. The overall success rate for PTAD was 83%. The success rate for PTAD for patients with multiple abscesses was 83% (5 of 6), compared with a success rate of 82% (14 of 17) for patients with solitary abscess. The prognostic factors for survival were cancer and sepsis and the mortality rate for patients with cancer was 40% (6 of 15) while the mortality rate for patients with sepsis was 56% (5 of 9). As a complication of drainage, 1 patient (4%) in the PTAD group had pleural abscess due to the transpleural puncture. Our findings support the use of PTAD as the primary treatment for liver abscess, as it is safe and effective irrespective of the number of abscesses and the patient's condition.     

Ruptured Klebsiella pneumoniae liver abscess after high-dose cyclophosphamide for severe aplastic anemia

A 19-year-old woman with severe aplastic anemia who had previously failed antithymocyte globulin/cyclosporine A received high-dose cyclophosphamide without bone marrow rescue. On day +14, she complained of right upper quadrant abdominal pain and fever. A CT scan of the abdomen showed multiple liver abscesses with rupture and Klebsiella pneumoniae was isolated from blood. In spite of aggressive antibiotic therapy, she rapidly deteriorated and died of overwhelming sepsis. To our knowledge, our patient is the first case of fatal ruptured liver abscess after high-dose cyclophosphamide in a patient with severe aplastic anemia.     

Hepatectomy for pyogenic liver abscess

BackgroundCommensurate with the advances in diagnostic and therapeutic radiology in the past two decades, percutaneous needle aspiration and catheter drainage have replaced open operation as the first choice of treatment for both single and multiple pyogenic liver abscesses. There has been little written on the place of surgical resection in the treatment of pyogenic liver abscess due to underlying hepatobiliary pathology or after failure of non-operative management.MethodsThe medical records of patients who underwent resection for pyogenic liver abscess over a 15-year period were retrospectively reviewed. The demographics, time from onset of symptoms to medical treatment and operation, site of abscess, organisms cultured, aetiology, reason for operation, type of resection and outcome were analysed. There were 49 patients in whom the abscesses were either single (19), single but multiloculated (11) or multiple (19). The median time from onset of symptoms to medical treatment was 21 days and from treatment to operation was 12 days. The indications for operation were underlying hepatobiliary pathology in 20% and failed non-operative treatment in 76%. Two patients presented with peritonitis from a ruptured abscess.ResultsThe resections performed were anatomic (44) and non-anatomic (5). No patient suffered a recurrent abscess or required surgical or radiological intervention for any abdominal collection. Antibiotics were ceased within 5 days of operation in all but one patient. The median postoperative stay was 10 days. There were two deaths (4%), both following rupture of the abscess.DiscussionExcept for an initial presentation with intraperitoneal rupture and, possibly, cases of hepatobiliary pathology causing multiple abscesses above an obstructed duct system that cannot be negotiated non-operatively, primary surgical treatment of pyogenic liver abscess is not indicated. Non-operative management with antibiotics and percutaneous aspiration/drainage will be successful in most patients. If non-operative treatment fails, different physical characteristics of the abscesses are likely to be present and partial hepatectomy of the involved portion of liver is good treatment when performed by an experienced surgeon.     

Pyogenic liver abscess: is drainage always possible?

The treatment of pyogenic liver abscess generally involves antibiotic therapy and radiological percutaneous drainage or aspiration. Surgical drainage is rarely advisable. We report a case of multiloculated liver abscess that was not suitable for either percutaneous drainage or open surgical drainage. The only successful approach was a left hepatectomy.     

Klebsiella and E. coli liver abscess associated with aerobilia: a case report

Pyogenic liver abscesses are commonly caused by biliary tract infections. We report here a case of liver abscess developed secondary to a biliary-enteric fistula. A 83 year old diabetic woman was admitted because of sepsis due to Klebsiella pneumoniae and E. Coli and with upper right quadrant pain. Six months before admission, a laparoscopic cholecystectomy was performed. The abdominal sonography showed a liver abscess associated with an important aerobilia. The Magnetic Resonance Cholangiography showed a choledocho-colic fistula with an important inflammatory background. There was no evidence of neoplasia or inflammatory bowel disease. The evolution was marked by the development of urinary and bronchial tract infection due to Klebsiella. Septic metastasis are characteristics of Klebsiella liver abscesses. Percutaneous drainage associated with a intravenous antibiotherapy was performed.     

Liver abscess: What determines the prognosis?

Records of all patients with liver abscess who presented to a teaching hospital between 1979 and 1986 were reviewed in order to determine prognostic factors and optimal treatment. Of 32 patients, the diagnosis was made ante-mortem in 30, and 24 patients survived. Patients who died tended to be older and more likely to exhibit confusion and other features of systemic toxicity at presentation. Fine needle aspiration, guided by computerized tomography, provided the correct diagnosis in 18 of 19 patients. Of 24 patients with isolated abscesses (1 or 2) 22 survived, whereas six of eight patients with multiple (more than 2) abscesses died ( P < 0.001). Aspirates from patients who survived appeared to grow anaerobes more commonly (NS), whereas those from non-survivors more often grew multiple organisms which usually included Gram-negative bacilli ( P < 0.01). All patients received broad spectrum antibiotics and a drainage procedure was carried out in 26. Of 19 patients treated by percutaneous drainage, 12 recovered, one required hepatic resection before recovering, and six died (four with multiple abscesses). Of nine patients (all with 1–2 abscesses) treated by open drainage, all eventually recovered, but three needed additional procedures. Six of eight non-survivors compared with four of 24 survivors had predisposing biliary sepsis ( P < 0.01). It is concluded that isolated liver abscesses are relatively benign, commonly grow anaerobes, and are usually resolved with antibiotics and drainage (closed or open), whereas multiple abscesses occur in sicker, older patients who are usually jaundiced with uncontrolled biliary sepsis. The prognosis in patients with multiple liver abscesses is poor irrespective of treatment.     

The prognostic factors of severe amebic liver abscess: a retrospective study of 125 cases.

One hundred twenty-five cases of amebic liver abscess were diagnosed at Chang Gung Memorial Hospital in Taiwan from January 1981 to December 1989. An analysis of possible prognostic factors for severe amebic liver abscess was done retrospectively. The majority of the patients came from the southern part of Taiwan. Severe amebic liver abscess was defined as the rupture of an abscess that was resistant to 72 hr of medical treatment, or complicated by secondary bacterial infection. The results showed significant differences between patients with severe liver abscess and those with more moderate forms of amebic liver abscess in indices such as jaundice, hemoglobin and serum bilirubin levels, and dyspnea, as well as in pulmonary changes (right diaphragm elevation, right pleural effusion) seen on chest radiographs. Those patients with diabetes mellitus also had greater evidence of severe liver abscess. Moderate cases that were treated with amebicides showed excellent responses (no mortality). Severe cases required, in addition to amebicide therapy, either percutaneous or surgical drainage of pus, especially in those patients with ruptured abscesses. Those patients with abscesses that ruptured into the thoracic cavity were treated by either thoracostomy or needle aspiration, and all were cured. Three patients died of abscess rupture into the abdominal cavity, associated with secondary bacterial infection. The overall mortality rate was 2.4%. These symptoms and signs of severe liver abscess are indicators of the need for intensive treatment such as aspiration or surgical drainage.     

Efficacy of color sonography and harmonic scalpel in laparoscopic management of multiple/lobulated liver cysts and abscesses

BACKGROUND/AIMS: Major concerns of multiple/lobulated liver cysts and abscesses managed by laparoscopic approach are inadequate deroofing/ drainage and hemorrhage. The aim of this study was to test the efficacy of color sonography and ultrasonically activated scalpel employed in this field. METHODOLOGY: Ten patients with multiple/lobulated liver cysts and eight patients with lobulated pyogenic liver abscesses were managed laparoscopically with the aid of laparoscopic color sonography and harmonic scalpel. Clinicopathological data, operative results, complications, and follow-up were retrospectively analyzed. RESULTS: Ten patients with liver cysts underwent laparoscopic deroofing, in addition to hepatectomy (n=3), cholecystectomy and adrenalectomy (n=l), and Nissen fundoplication (n=1). The number of multiple/lobulated liver cysts deroofed was 5.8 +/- 3.3 (range, 4 to 12). There was no mortality and morbidity in these 10 patients. Eight patients with multilobulated liver abscess underwent laparoscopic drainage, in addition to cholecystectomy (n=3), without conversion. There was no need of blood transfusion perioperatively. The major complications of eight liver abscess cases included residual abscess and prolonged ventilator in one each. Followed-up with a mean time period of 26 +/- 8 months, all patients except one were well without symptomatic recurrence. CONCLUSIONS: Color sonography and harmonic scalpel made laparoscopic management of multiple/lobulated liver cysts and abscesses more efficacious in terms of precise localization, adequate deroofing/drainage, and better hemostasis.     

Iliopsoas abscesses: Diagnostic,aetiologic and therapeutic approach in five patients with a literature review

Objective. Iliopsoas abscess is a relatively rare disease. Many cases present atypical clinical characteristics. Iliopsoas abscess can be primary or secondary to gastrointestinal and genitourinary infections and in developed countries most of these abscesses are of non-tuberculous aetiology. A high index of clinical suspicion, the past and recent history of the patient and imaging studies can be helpful in diagnosing the disease. Early treatment with drainage, surgery or appropriate antibiotic therapy is necessary before the sepsis becomes lethal. The purpose of the study was to present five cases with iliopsoas abscesses based on the rarity of this clinical entity. Material and methods. Five cases with iliopsoas abscess, treated during the past 10 years were analysed retrospectively, with emphasis on the diagnostic and therapeutic approach to the disease. Results. Three out of five cases were primary abscesses; one was of tuberculous aetiology and one secondary to bowel perforation due to a tumour. Staphylococcus aureus was the main bacterium in primary abscesses. Percutaneous drainage with administration of appropriate antibiotics was the main treatment. The secondary psoas abscess was treated successfully with surgery. Owing to long-standing septic and atypical symptoms before admission, one case had a lethal course, despite the early hospital diagnosis and treatment. Conclusions. The aetiology of iliopsoas abscess can vary, disposing to a high index of suspicion. Imaging studies can confirm the diagnosis early, and differentiation between primary and secondary type determines the most appropriate kind of treatment.     

Pyogenic liver abscess caused by Fusobacterium in a 21-year-old immunocompetent male

A 21-year-old male with no significant past medical history, presented with right upper quadrant(RUQ) abdominal pain along with fevers and chills. Lab work revealed leukocytosis, anemia, and slightly elevated alkaline phosphatase. Viral serology for hepatitis B virus, hepatitis C virus, and human immunodeficiency virus were negative and he was immunocompetent.Computed tomography imaging revealed hepatic abscesses, the largest measuring 9.5 cm. Empiric antibiotics were started and percutaneous drains were placed in the abscesses. Anaerobic cultures from the abscesses grew Fusobacterium nucleatum. This is a gram negative anaerobic bacteria; a normal flora of the oral cavity. Fusobacterium is most commonly seen in Lemiere’s disease, which is translocation of oral bacteria to the internal jugular vein causing a thrombophlebitis and subsequent spread of abscesses. Our patient did not have Lemiere’s, and is the first case described of fusobacterium pyogenic liver abscess in a young immunocompetent male with good oral hygiene. This case was complicated by sepsis, empyema, and subsequent abscesses located outside the liver. These abscesses’ have the propensity to flare abruptly and can be fatal. This case not only illustrates fusobacterium as a rare entity for pyogenic liver abscess, but also the need for urgent diagnosis and treatment. It is incumbent on physicians to diagnose and drain any suspicious hepatic lesions. While uncommon, such infections may develop without any overt source and can progress rapidly. Prompt drainage with antibiotic therapy remains the cornerstone of therapy.     

Single and multiple pyogenic liver abscesses. Natural history, diagnosis and treatment, with emphasis on percutaneous drainage

The presenting features, modes of treatment and clinical course were reviewed for 55 patients with pyogenic liver abscess, seen at Duke University Medical Center over a 15-year period. Thirty-three patients had a solitary abscess and 22 had multiple abscesses. Most patients were between the ages of 40 and 60 years. Males predominated, 2.4:1. Major underlying conditions included biliary tract disease, malignancy and colonic disease. Eight patients, each with a solitary abscess, had no identifiable underlying condition. Symptoms and signs were nonspecific: fever, chills, focal abdominal tenderness and hepatomegaly were common. A raised serum alkaline phosphatase level was the most consistent abnormal laboratory finding. CT with contrast enhancement, radioisotope scanning and ultrasonography all accurately defined solitary hepatic abscesses. However, CT scan was more successful than other imaging techniques in detecting multiple abscesses. In seven patients the diagnosis was made only at laparotomy. Overall, a diagnosis of liver abscess was made in 50 living patients (91%). Microorganisms were recovered from pus and/or blood cultures of 44 patients (80%). Most common were enteric gram-negative facultative rods, anaerobic gram-negative rods, and microaerophilic streptococci. Single abscesses were more likely than multiple abscesses to contain more than one organism. All patients received antibiotics; the choice of antibiotic does not appear to be critical provided the regimen has a broad spectrum including activity against anaerobes. Surgical or percutaneous drainage was successful when attempted in all patients with a single abscess, but the outcome was less favorable in those with multiple abscesses. Percutaneous drainage is currently replacing open operative drainage as the method of choice. Overall mortality in patients with single abscesses was 15% (5/33) and in those with multiple abscesses 41% (9/22).     

Amebic Liver Abscess: A Study of 11 Cases Compared with a Series of 38 Patients with Pyogenic Liver Abscess

Amebic liver abscess is an uncommon disease in the northern states of North America with 11 cases seen among approximately 500,000 Mount Sinai Hospital admissions over a 16-year period. Five of 11 cases originated in, or had recently visited South America. In three of these, and two patients with concomitant intestinal amebiasis, the diagnosis was suspected on admission. Diagnosis after admission was rapid, mean 5 days, compared with a mean of 13 days in pyogenic liver abscess. There was a higher incidence of male patients, nine males versus two females which was greater than the excess found in our pyogenic abscesses, 22 versus 16. Multiplicity was less common than in pyogenic abscess, 27 versus 50%, respectively. All three patients with multiple abscesses survived with surgical drainage and antibiotic therapy despite numerous complicating factors, including secondary bacterial infection. One patient resolved with drug treatment only; all others were treated with drugs and concomitant drainage; surgical drainage in earlier cases, and percutaneous drainage more recently. There was a single postoperative death. Drug treatment is the first therapeutic modality, and if recovery is delayed more than 2 days percutaneous aspiration should be carried out. This was successful in four cases. Surgery should seldom be required with present methods of accurately localizing amebic liver abscess, but is essential for ruptured abscess with peritonitis, and liver abscess with associated intestinal problems such as toxic megacolon, colonic perforation, or fulminating colitis. There has been a significant reduction in mortality of amebic liver abscess over the past 50 years and particularly within the past decade.(ABSTRACT TRUNCATED AT 250 WORDS)     

A case report of a lung abscess as a rare complication of a pyogenic liver abscess

Rationale:A hepatobronchial fistula and lung abscess following a pyogenic liver abscess is a rare entity and it is not easy to diagnose this condition based on the symptoms and chest radiography.Patient concerns:An 81-year-old man presented with productive cough and dyspnea.Diagnosis:Chest radiography indicated increased opacities in the right lower lung field with an air-fluid level suggestive of pneumonia complicated by a lung abscess. Chest and abdominal computed tomography revealed an abscess in the right lower lung field that bordered an abscess at segment 7 of the liver. Tubography confirmed a fistula between the liver and lung abscesses.Interventions:Due to communication between 2 abscesses, transhepatic approach was done instead of transpleural approach to avoid complications.Outcomes:A liver abscess complicated by a lung abscess was resolved following percutaneous transhepatic drainage of the liver abscess and antibiotic administration.Lessons:Though uncommon, the lack of suspicion of sub-diaphragmatic liver abscess often lead to a delay in diagnosis and proper treatment. Our case implies the importance of computed tomography in early diagnosis of liver abscess in case of lung abscess in the right lower lung field.     

An experimental model for pyogenic liver abscess

We have developed a reproducible small-animal model for pyogenic liver abscess, suitable for investigating diagnostic and therapeutic modalities. Male New Zealand white rabbits weighing 2-3 kg were anaesthetized and the liver exposed. Gentle pressure was applied with forceps to the right hepatic lobe. A suspension of 10(5) colony forming units (cfu) Escherichia coli plus Fusobacterium necrophorum (10(6) cfu) plus Bacteroides fragilis (10(6) cfu) was immediately injected into a mesenteric vein. Two weeks later a palpable mass (mean diameter 4 cm) had developed. Thick pus could be aspirated percutaneously. Necropsy revealed a single, but often multiloculated, abscess at the site of the previous trauma. Injection of E. coli alone did not produce any abscesses and B. fragilis alone only small abscesses, with low and variable frequency. Inoculation with F. necrophorum alone produced large abscesses, and a dose-response relationship was established. This is a simple and reliable small-animal model useful in studies of imaging techniques, antibiotic regimens and invasive treatments for pyogenic liver abscess.     

Liver abscess due to clostridium septicum. A case report and review of the literature

The onset of liver abscess due to Clostridium septicum -an anaerobic gram-positive bacillus- is a rare condition, generally arising in cancer patients. The radiological picture is that of gas-containing pyogenic abscess, that predominates within preexisting liver metastases. We report a case of a 50-year-old patient with metastatic colon cancer who was referred with multiple Clostridium septicum liver abscesses. The patient underwent parenteral antibiotherapy as well as transcutaneous drainage of the largest liver abscess. However the outcome was unfavorable in a clinical picture of liver failure that was likely due to disease progression rather than sepsis. Clostridium septicum liver abscess is a life-threatening condition that occurs in fragile patients, mostly with metastatic cancers. A review of the reported cases is presented and treatment options are discussed.     

Video-assisted hepatic abscess debridement

BackgroundPyogenic liver abscesses are currently treated by either percutaneous computer tomography (CT)-guided drainage or by laparoscopic and a conventional liver resection when conservative treatment fails but may be associated with substantial morbidity and mortality.MethodsA minimally invasive technique involving debridement of right liver abscesses was employed using a minimally invasive video-assisted hepatic abscess debridement (VAHD) after unsuccessful percutaneous CT-guided drainage. Clinical data, complication rates and outcomes of patients were recorded retrospectively.ResultsBetween 2011 and 2014, VAHD was performed on 10 patients at two centres with no observed recurrence of a liver abscess. The median age of the patients was 57 years (range 42–78) with a median pre-operative size of a liver abscess of 78 mm (range 40–115). The median operation time was 47 min (range 23–75), and the median postoperative hospital stay was 9 days (range 7–69). One patient developed a subcutaneous abscess that required further surgery. No patient died, and there were no major complications related to the VAHD.ConclusionsVideo-assisted hepatic abscess debridement is a feasible technique that shows promising results for the treatment of a recurrent right liver abscess.     

Pyogenic liver abscess as a complication of Crohn's disease

Pyogenic liver abscess in patients with Crohn's disease is not common, but the mortality has been reported to be high if diagnosis and treatment is delayed. Intra-abdominal abscesses, fistulous disease, and steroid therapy have all been reported to be important predisposing factors in the pathogenesis of this entity. We present a patient with Crohn's disease in whom multiple abscesses were encountered in the right lobe of the liver. The diagnosis of liver abscess was established by abdominal computed tomography and the patient was treated by percutaneous catheter drainage. Awareness of this rare complication is important because diagnosis is difficult to make and a high index of suspicion is required. Once suspected, aggressive diagnostic workup and treatment is indicated. Most patients with liver abscess can be successfully managed by percutaneous catheter drainage combined with antibiotic therapy if it is diagnosed before extensive necrosis has occurred.     

Clinical features and treatment of hepatic abscesses with biloma formation after transcatheter arterial chemoembolization

Background and study aimsA full understanding of the clinical manifestations and risk factors for hepatic abscesses with biloma formation after transcatheter arterial chemoembolization (TACE) is crucial for accurate diagnosis and effective therapeutic intervention.Patients and methods11,524 patients with hepatic tumors were treated with TACE. 84 patients were diagnosed with hepatic abscesses after TACE, and 35 progressed to hepatic bilomas and were treated with percutaneous transhepatic drainage (PTD) and/or percutaneous transhepatic cholangiography and drainage (PTCD). Clinical features, blood samples, bacterial cultures, and imaging data were collected, and incidence, risk factors, therapeutic effects, and prognostic indicators were analyzed.ResultsThe incidence of biloma in patients with liver abscesses was 41.7% with an average diagnosis time of 12.3 ± 3.2 days. 71.4% of patients complained of abdominal pain, and 63.7% had metastatic liver cancer. In the latter patients, clinical features included multiple abscess lesions with a poor blood supply to the tumor and large necrotic lesions. The original tumors were primarily in the digestive system (87.0%). The mean diameter of the largest lesions was 6.5 ± 2.3 cm. Before abscess formation, the Child-Pugh liver function classification was grade A in 14 cases and grade B in 21 cases. Escherichia coli was the most frequently seen infectious bacteria. Liver function was significantly compromised by the occurrence of hepatic abscesses. The mean survival time after diagnosis of liver abscesses in all patients was 11.5 ± 0.6 months. The causes of death included abscess (n = 9, 25.7%), tumor (n = 22, 62.9%), and other causes (n = 4, 11.4%). Risk factors included tumors, gastrointestinal surgery, and diabetes.ConclusionPTD and/or PTCD combined with active antibiotics are recommended as the first-line treatment and are effective therapeutic regimens for biloma formation after TACE.     

Pyogenic and amebic liver abscesses

Pyogenic and amebic liver abscesses are the two most common hepatic abscesses. Amebic abscesses are more common in areas where Entamoeba histolytica is endemic, whereas pyogenic abscesses are more common in developed countries. Pyogenic abscess severity is dependent on the bacterial source and the underlying condition of the patient. Amebic liver abscess is more prevalent in individuals with suppressed cell-mediated immunity, men, and younger people. The right lobe of the liver is the most likely site of infection in both types of hepatic abscess. Patients usually present with a combination of fever, right-upper-quadrant abdominal pain, and hepatomegaly. Jaundice is more common in the pyogenic abscess. The diagnosis is often delayed and is usually made through a combination of radiologic imaging and microbiologic, serologic, and percutaneous techniques. Treatment involves antibiotics along with percutaneous drainage or surgery.     

Endoscopic drainage of pyogenic liver abscesses with suspected biliary origin

OBJECTIVES: Pyogenic liver abscesses remain an important and life-threatening clinical problem but their causes and management have changed over the last two decades. The aim of this study was to assess the feasibility and the impact of an endoscopic approach in the management of liver abscesses with suspected biliary origin. METHODS: We reviewed the records of 16 patients suffering from pyogenic liver abscess, who underwent endoscopic retrograde cholangiopancreatography (ERCP) in the setting of biliary diseases between January 1995 and December 2004. Nine patients had an underlying neoplastic disease; 13 had a history of biliary endoscopic maneuvers. When the collections were communicating with the biliary tree, an endoscopic drainage of the abscess was performed either by sphincterotomy, dilation, insertion of a nasobiliary catheter, or stenting. In noncommunicating liver abscesses associated with bile duct abnormalities, biliary decompression was obtained by insertion or replacement of biliary stents. RESULTS: Fourteen patients had liver abscesses communicating with the biliary system and underwent an endoscopic drainage of the cavity. Ten of these patients had an exclusive endoscopic drainage of the abscess, while four cases required additional percutaneous drainage. The two noncommunicating abscesses were associated with previous insertion of biliary stents; these were cured percutaneously after endoscopic stent replacement. Among the 16 patients, 13 had a rapid resolution of symptoms (81%). CONCLUSION: This initial clinical experience suggests that ERCP can demonstrate communications between the biliary tract and liver abscesses, and that an internal drainage of the cavity is feasible and safe.