Ocular Manifestations and Complications of Pyogenic Liver Abscess

In anecdotal reports, septic metastatic lesions from a pyogenic liver abscess can result in endogenous endophthalmitis, an infection of intraocular contents. Recent reports suggest that this devastating complication is increasing in frequency. The initial presentation may be nonspecific and easily misdiagnosed by the surgical team. When the infecting organism is virulent, it tends to be rapidly progressive and often leads to permanent visual deterioration or blindness despite medical intervention. We conducted a study to determine the incidence of endophthalmitis associated with pyogenic liver abscess, to identify its associations, and to determine the outcome of treatment. A retrospective review of 289 patients with a clinical diagnosis of pyogenic liver abscess admitted between January 1995 and March 2001 revealed 10 patients (3.5%) with the complication of endogenous endophthalmitis. Among them, seven had a previous history of diabetes mellitus. The offending organism was Klebsiella pneumoniae in all cases. There was no mortality in this series. Final visual outcomes of our patients were as follows: Five had no light perception (two had undergone evisceration), one had light perception only, and four were able to visualize hand motion only. There is a trend toward a worse outcome when ocular symptoms are not diagnosed and treated within 24 hours of onset. Of the five patients who lost their eyesight completely, three were initially misdiagnosed, and referral to the ophthalmologist was delayed. Surgeons must be alert to the complication of endogenous endophthalmitis. Ocular symptoms in patients treated for pyogenic liver abscess must be referred early for an ophthalmologic consult. Increased awareness and a high index of suspicion are required for salvage of visual function.     

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.     

Strategies in the management of pyogenic psoas abscesses.

The presentation and management of eight patients with pyogenic psoas abscesses treated at the National Naval Medical Center, Bethesda, Maryland, between January 1986 and July 1989 are presented. The psoas abscesses were secondary to underlying gastrointestinal disease in six patients and sacral osteomyelitis in one patient. In one patient, the etiology of the abscess could not be determined. The average duration of symptoms in these patients was 16 days. Computed tomography was useful in identifying the abscess, defining its complexity, and planning therapy in all eight patients. Seven patients had complex, multiloculated abscesses, and one patient had a simple abscess. Extraperitoneal drainage was used in all patients. The patients with multiloculated abscesses had open surgical drainage, while the patient with the simple abscess had percutaneous catheter drainage. Most patients with a gastrointestinal etiology for their abscess underwent staged resection 3 to 6 weeks after the drainage procedure. There were no deaths, recurrent abscesses, or fistulae in these patients. Two patients developed thromboembolic complications postoperatively. Extraperitoneal drainage with staged resection of underlying gastrointestinal pathology is a safe and effective way of treating patients with psoas abscesses.     

细菌性肝脓肿的放射介入和双介入治疗

目的: 探讨放射介入和双介入治疗细菌性肝脓肿的临床疗效. 方法: 回顾分析51例细菌性肝脓肿病人(其中12例行放射介入或双介入治疗)的临床资料. 结果: 介入组12例病人无1例需中转手术引流,均痊愈出院;对照组39例中,有2例因脓肿导管引流不畅需行手术引流,39例中死亡3例,均死于多脏器功能衰竭,病死率为7.7%(3/39),两组差异无显著性(P>0.05);两组病人的退热时间差异无显著性(P>0.05),但介入组脓肿消退时间显著短于对照组(P<0.01). 结论: 放射介入治疗联合经皮肝脓肿穿刺引流,即双介入治疗细菌性肝脓肿具有良好的疗效.     

Liver abscesses

Clinical suspicion of a liver abscess mandates an investigation of the liver for evidence of a liver abscess by radionuclide, ultrasound, or CT scan. Amebic abscesses have a lower mortality rate than pyogenic abscesses. Amebic and pyogenic abscesses can be distinguished on the basis of epidemiologic, clinical, and laboratory studies. The definitive studies for identifying amebic liver abscesses are hemagglutinin or gel diffusion studies. Amebic abscess of the liver may be complicated by extension to the lung, with pulmonary complications. Patients suspected to have amebic abscesses require metronidazole. Emetine or chloroquine may be added if there is no response or if the abscess recurs. Unless there is a failure of the amebic abscess to resolve or secondary infection occurs, there is seldom a need to aspirate or drain these abscesses. Pyogenic abscesses should be treated with broad-spectrum antibiotics to cover gram-negative aerobes and anaerobic organisms. All pyogenic abscesses larger than 1.5 cm in diameter should be aspirated, and the aspirate should be Gram stained and cultured. Percutaneous or surgical drainage should then be performed. Operative intervention is required in those patients with intra-abdominal pyogenic infections that are seeding the liver abscess. The marked reduction in the mortality rate of pyogenic liver abscess witnessed in this decade is multifaceted and attributable in part to earlier diagnosis, permitting definitive treatment in a timely fashion, as well as to improved intensive unit care, antibiotic management, and operative technique.     

Gas-containing pyogenic liver abscess —A case report and review of the literature—

The incidence of gas-containing pyogenic liver abscess is exceedingly rare. We report herein, a case of a 36 year-old Japanese woman with a gas-containing pyogenic liver abscess associated with diabetes mellitus and cholelithiasis. An abdominal plain X-ray film, which showed a fine air-fluid level in the liver at an up-right position, enabled us to easily diagnosed a gas-containing liver abscess. Echo-guide percutaneous drain-age revealed the organism to beEscherichia coli, however, although this treatment has recently been employed often in the treatment of pyogenic liver abscesses, especially single abscesses, it did not prove effective in this case. We finally cured the gas-containing pyogenic liver abscess by operative drainage.     

Laparoscopic Drainage of Pyogenic Liver Abscess

Background and Objectives:

Pyogenic liver abscesses are mainly treated by percutaneous aspiration or drainage under antibiotic cover. If interventional radiology fails, surgical drainage becomes necessary. Recently, we performed laparoscopic liver abscess drainage successfully, and we aimed to focus on the topic in light of a systematic review of the literature.

Methods:

A 22-year-old man was admitted with a 4.5-cm multiloculated abscess in the left lobe of the liver. The abscess did not resolve with antibiotic-alone therapy. Percutaneous aspiration was unsuccessful due to viscous and multiloculated contents. Percutaneous catheter placement was not amenable. Laparoscopic abscess drainage was preferred over open abscess drainage. We used 3 trocars, operation time was 40 minutes, and blood loss was minimal. In the mean time, we searched PubMed using the key words [(liver OR hepatic) abscess*] AND [laparoscop* OR (minimal* AND invasiv*)].

Results:

Postoperative recovery of the patient was uneventful, and the patient was asymptomatic after 3 months of follow-up. In the literature search, we found 53 liver abscesses (51 pyogenic and 2 amebic) that were treated by laparoscopy. Mean success rate was 90.5% (range, 85% to 100%) and conversion rate was zero.

Conclusion:

Treatment of liver abscess is mainly percutaneous drainage. Laparoscopic drainage should be selected as an alternative before open drainage when other modalities have failed.     

Treatment of pyogenic hepatic abscesses. Surgical vs percutaneous drainage

A retrospective review of 39 patients with pyogenic hepatic abscess treated from 1977 through 1984 included 23 patients who were surgically treated and 16 who underwent percutaneous drainage. The average age in each group was similar (about 55 years). The most common cause of abscesses in each group was biliary tract disease. Abscesses caused by portal seeding and local extension were more common in the surgical group, 14 of whom required additional surgical procedures at the time of surgical drainage. Of the 16 patients in the percutaneously drained group, seven were seen during the immediate postoperative period. Most of the abscesses occurred in the right lobe of the liver, but single abscesses in the left lobe (30%) and multiple abscesses (57%) were more common in the surgical group. Klebsiella enterobacter and group D streptococcus were most common in the surgically and percutaneously drained groups, respectively. All patients received antibiotics, with a mean length of treatment of 14 days. Mean time to defervescence was about four days in both groups, with a longer hospital stay for the percutaneously drained group (26 vs 46 days). Morbidity was high in both groups (surgical, 48%; percutaneous, 69%). Three of the percutaneously treated patients required surgical drainage because of highly viscous abscess contents. Mortality was 17% in the surgical group and 13% in the percutaneously drained group. Percutaneous drainage with computed tomography probably should be the initial drainage procedure in patients with pyogenic hepatic abscesses in whom no concomitant surgical procedure is planned. Regardless of treatment, the morbidity and mortality remain high.     

Management of pyogenic liver abscess in the era of computed tomography

The advent of high-resolution imaging has allowed earlier diagnosis of pyogenic liver abscess. Because radiologically guided percutaneous drainage (PCD) of liver abscesses is controversial, the authors studied 40 patients with liver abscess admitted to the Toronto Hospital between 1982 and 1987 to determine the role of PCD versus operative drainage (OD). The diagnosis of pyogenic liver abscess was made at autopsy (4 patients), at laparotomy (6) or by radiologically guided aspiration of pus (30). Ultrasonography and computed tomography were highly sensitive (85% and 96% respectively) in detecting liver abscess. Of the 36 patients treated for liver abscess all received antibiotics intravenously; 31 also underwent a drainage procedure. Treatment with antibiotics alone was associated with a success rate of 80% and a death rate of 20%. The success rate for those who had PCD was 75% with a death rate of 13%; 2 patients in this group of 16 subsequently required OD for cure. In the 15 patients initially treated with OD, success and death rates were 87% and 13% respectively. For solitary abscesses, success rates wer comparable for PCD and OD (86% and 90% respectively). For unilobar multiple abscesses the success rate was 100% for both PCD and OD, but for bilobar multiple abscesses the rates were only 40% and 67% respectively. Complication rates were similar for both methods of drainage. The authors conclude that pyogenic liver abscess can now be safely and efficaciously managed with a combination of antibiotics and PCD.     

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.     

Liver abscess: a clinicopathological analysis of 82 cases

Liver abscesses are a common pathology in India, but a strategy for effective treatment has not been established. Eighty-two patients with liver abscess were studied over a 4-year period. Clinical features, ultrasound findings, laboratory studies, and outcome of therapy were evaluated. Treatment options were antibiotics alone, needle aspiration, catheter drainage, or open surgical drainage; 51.2% of all abscesses were amebic, 23.2% were pyogenic, and 25.6% had unknown causes. A total of 75.6% of the abscesses were solitary, with 62.2% confined to the right lobe. Pyogenic abscesses were more likely to have anemia, leukocytosis, and deranged liver function. Amebic abscesses tended to have a larger volume. Patients undergoing catheter drainage showed a more rapid reduction in initial abscess volume, whereas resolution of the abscess cavity took longer with antibiotic therapy alone. Ultrasound-guided needle aspiration and catheter drainage are safe and effective in the management of liver abscess. Drug therapy alone may be useful only in select cases.     

Primary Psoas Abscess. Report of Three Cases

Abstract

Background: Primary psoas abscesses are a rare clinical entity with subtle and non specific symptoms, most commonly seen in patients predisposed to infections.

Early diagnosis and appropriate management are therefore challenging aspects for physicians. Patients and methods: We present three patients with primary pyogenic psoas abscess, treated at the Heraklion University Hospital, during a 5-year period. The two male and one female patient, aged 36–51 years were admitted with fever, abdominal pain and a palpable tender mass.

Results: The classical sign of limping was absent in all cases. Positive psoas symptoms were detected in only two patients. CT scan accurately confirmed the diagnosis in all cases. The patients were successfully treated with antibiotics and prolonged surgical drainage. Staphylococcus aureus was the causative microorganism in the first two and Bacteroides fragilis in the third patient. This is the first reported case resulting from this specific bacteria. None of our patients had any predisposing risk factor.

Conclusions: A high index of suspicion is mandatory to enable early recognition of this rare clinical disease. CT scan is the standard diagnostic tool to confirm diagnosis. Prolonged drainage and appropriate antibiotics are essential for the successful treatment of primary psoas abscesses.     

Pyogenic liver abscess complicating biliary stricture due to chronic pancreatitis

BACKGROUND: Chronic pancreatitis uncommonly causes common bile duct stricture, and common bile duct stricture rarely leads to pyogenic liver abscess. METHODS: We describe a 51-year-old man who developed a pyogenic liver abscess after the development of a common bile duct stricture due to chronic pancreatitis. RESULTS: The patient required open drainage of the liver abscess and decompressive choledochoduodenostomy. His infection was persistent and he required percutaneous and subsequent open drainage of a second hepatic abscess. The patient died of refractory sepsis and multi-organ failure. CONCLUSIONS: The relevant English literature concerning pyogenic liver abscesses, specifically in the setting of common bile duct stricture due to chronic pancreatitis, is reviewed and discussed.     

PYOGENIC LIVER ABSCESS: A REVIEW OF 10 YEARS’ EXPERIENCE IN MANAGEMENT

Background : Over the past 15 years, diagnostic and interventional radiology techniques have allowed accurate localization of liver abscesses and image-guided percutaneous drainage. This review examines whether these technical advances improve clinical results and discusses the selection of treatment for patients with liver abscesses. Methods : Ninety-eight patients were treated for pyogenic liver abscess (PLA) at the Royal Prince Alfred Hospital, Sydney, between January 1987 and June 1997. The hospital records were examined and clinical presentation, laboratory, radiological and microbiological findings were recorded. Associations between these findings and failure of initial non-operative management were determined using odds ratios with 95% confidence intervals. Independent predictors were then determined by logistic regression. This analysis was repeated to determine factors associated with mortality. Results : Cholelithiasis and previous hepatobiliary surgery were the most frequently identifiable causes of PLA, each responsible in 15 patients. All 98 patients were treated with intravenous antibiotics and in 13 patients this was the only therapy. Of the remaining 85 patients, six proceeded straight to laparotomy and 79 had percutaneous drainage, of whom 15 required subsequent laparotomy. Factors predicting failure of initial non-operative management were unresolving jaundice, renal impairment secondary to clinical deterioration, multiloculation of the abscess, rupture on presentation and biliary communication. The overall hospital mortality rate was 8%. Conclusion : Pyogenic liver abscess remains a disease with significant mortality. Image-guided percutaneous drainage is appropriate treatment for single unilocular PLA. Surgical drainage is more likely to be required in patients who have abscess rupture, incomplete percutaneous drainage or who have uncorrected primary pathology.     

Pyogenic liver abscess: a review of 10 years' experience in management

BACKGROUND: Over the past 15 years, diagnostic and interventional radiology techniques have allowed accurate localization of liver abscesses and image-guided percutaneous drainage. This review examines whether these technical advances improve clinical results and discusses the selection of treatment for patients with liver abscesses. METHODS: Ninety-eight patients were treated for pyogenic liver abscess (PLA) at the Royal Prince Alfred Hospital, Sydney, between January 1987 and June 1997. The hospital records were examined and clinical presentation, laboratory, radiological and microbiological findings were recorded. Associations between these findings and failure of initial non-operative management were determined using odds ratios with 95% confidence intervals. Independent predictors were then determined by logistic regression. This analysis was repeated to determine factors associated with mortality. RESULTS: Cholelithiasis and previous hepatobiliary surgery were the most frequently identifiable causes of PLA, each responsible in 15 patients. All 98 patients were treated with intravenous antibiotics and in 13 patients this was the only therapy. Of the remaining 85 patients, six proceeded straight to laparotomy and 79 had percutaneous drainage, of whom 15 required subsequent laparotomy. Factors predicting failure of initial non-operative management were unresolving jaundice, renal impairment secondary to clinical deterioration, multiloculation of the abscess, rupture on presentation and biliary communication. The overall hospital mortality rate was 8%. CONCLUSION: Pyogenic liver abscess remains a disease with significant mortality. Image-guided percutaneous drainage is appropriate treatment for single unilocular PLA. Surgical drainage is more likely to be required in patients who have abscess rupture, incomplete percutaneous drainage or who have uncorrected primary pathology.     

Percutaneous management of pyogenic hepatic abscesses

Twelve patients (9 men, 3 women) with a mean age of 65 (54-78) years, with pyogenic hepatic abscesses were managed by percutaneous drainage between 1979 and 1987. Biliary origin was most common (4 patients), followed by hepatic abscesses as a late postoperative complication (seen in 3 patients) and hepatic abscesses occurring in association with acute appendicitis (2 patients). The origin was unknown in 3 patients. Diagnosis was reached by computed tomography or ultrasonography with a diagnostic delay of in mean 11 days. Seventeen abscesses were found among the 12 patients. The median abscess size (maximal diameter) was 7 (1-12) cm. Nine patients were treated with percutaneous drainage with an indwelling catheter within the abscess cavity for up to 3 weeks, while 3 patients were managed with percutaneous puncture and aspiration alone. The most commonly isolated organism from the drained hepatic abscess was E. coli. The course following percutaneous treatment was uneventful, without mortality and recurrence of the hepatic abscess during follow-up. One patient required surgical drainage of an additional hepatic abscess. Percutaneous drainage of hepatic abscesses, independent of origin, thus seems as a safe and reliable method, which should be considered as the treatment of choice if facilities and knowledge of percutaneous management are provided.     

Pyogenic liver abscess of a male patient with diabetes mellitus due to <Emphasis Type="Italic">Escherichia coli</Emphasis> with fever and chills as the only symptoms

Pyogenic liver abscesses (PLAs) are the most frequent visceral abscesses with predominance in men. They are extremely rare and their mechanism of formation is extended to infection of an anatomically contiguous organ or hematogenous seeding. Diabetes mellitus is a major predisposing factor and if so, the mortality rate is high. The most common clinical presentation forms are fever with chills, abdominal pain and hepatomegaly. In the present report we present the case of a 65-year-old Greek male patient with history significant for diabetes mellitus, who attended the emergency department complaining of fever and chills for five days. The final diagnosis was pyogenic liver abscess of the right lobe. Blood cultures were positive for Escherichia coli. The patient was treated with broad spectrum antibiotics and percutaneous drainage of the abscess. To our knowledge, this is the first pyogenic liver abscess in a diabetic patient due to E. coli reported in Western Greece.     

细菌性肝脓肿经皮穿刺与手术治疗疗效的比较

目的：比较细菌性肝脓肿经皮穿刺与手术治疗的疗效。方法：回顾分析首都医科大学宣武医院1989年1月—2008年12月收治的193例细菌性肝脓肿患者的临床资料,按治疗方法分为经皮穿刺组（96例）及手术治疗组（97例）,比较2组的治疗成功率、并发症率、死亡率及住院时间。结果：2组患者的性别,年龄,糖尿病有无,白蛋白水平,脓肿的部位、个数、大小、来源等差异均无统计学意义。经皮穿刺组患者治疗成功率、死亡率及平均住院时间分别为87.5%（84/96）、2.1%（2/96）、（20.8±12.4）d;手术组为94.8%（92/97）、2.1%（2/97）、（18.9±13.5）d,差异均无统计学意义（P=0.072,1.000,0.575）。经皮穿刺组并发症率较手术组低（2.1%vs9.3%,P=0.037）。结论：经皮穿刺治疗细菌性肝脓肿与手术同样有效,且并发症率较低,应成为肝脓肿治疗的首选。     

单发及多发细菌性肝脓肿临床资料的对比分析

摘要：目的:探讨单发及多发肝脓肿的临床特点及诊治方法。方法:回顾性分析近25年间收治的148例细菌性肝脓肿患者的临床资料，按单发及多发性肝脓肿分组，比较两组临床特征、治疗方法及预后。结果:胆源性在多发性肝脓肿组的比例明显高于单发组（P=0.018），平均年龄、就诊时间及住院天数多发性肝脓肿组也明显高于单发组(P=0.023,0.043，0.015)。多发性肝脓肿患者的碱性磷酸酶水平较高（P=0.021）， 血清白（清）蛋白水平较低（P=0.039）。单发肝脓肿最常见部位在肝右叶(P=0.002)，而多发性肝脓肿更易累及左右两叶(P<0.001)。大肠杆菌是两种肝脓肿最常见的致病菌。单纯抗生素治疗多用于多发脓肿的患者（P=0.022），经皮穿刺置管引流则多用于单发性肝脓肿（P=0.021）。多发性肝脓肿患者发生急性呼吸窘迫综合征（ARDS）的比例较高（P=0.03）。肝脓肿相关的病死率在多发性肝脓肿患者中明显为高（P=0.025）。结论:与单发性肝脓肿相比，多发性肝脓肿病例具有年龄较大、症状持续时间较长、常合并胆道疾病、脓肿多侵及肝脏两叶、容易发生ARDS和病死率较高的特点，治疗多采用手术和/或单纯抗生素治疗。