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Pyogenic liver abscess

  • Usually seen in elderly patients
  • Can be multiple or solitary
  • Arise as a result of biliary sepsis
  • Mortality is high as diagnosis is often delayed
  • Commonest organisms involved - E. coli, Klebsiella, Proteus and Bacteroides species

Multiple pyogenic liver abscesses

Picture provided by Dr Luis Pinheiro, Hospital S Teotonio, Viseu, Portugal

Aetiology

  • Portal pylophlebitis - appendicitis, diverticulitis or pelvic infections

  • Biliary disease - cholecystitis, ascending cholangitis or pancreatitis

  • Trauma - blunt or penetrating

  • Direct extension - empyema of the gall bladder, subphrenic or perinephric abscess

  • Septicaemia

  • Infected liver cysts or tumours

Clinical features

  • Patients are generally systemically unwell

  • Severe abdominal pain usually localised to right hypochondrium

  • Swinging pyrexia, rigors and weight loss

  • 25% present with jaundice

  • Examination shows an hypochondrial or epigastric mass

  • 30% have a pleural effusion

Investigation

  • Serology shows a raised WCC, increased ESR and deranged LFTs

  • Chest x-ray often shows a raised right hemidiaphragm and pleural effusion

  • Ultrasound will localised the abscess and will guide drainage

  • CT useful if diagnosis in doubt or if there are multiple abscess

Management

  • Patients should be started on appropriate antibiotics (cephalosporin and metronidazole)

  • Percutaneous drainage under ultrasound guidance is the initial treatment of choice

  • If biliary obstruction will need to consider decompression

  • Surgery may be required if

    • Failure of resolution with percutaneous drainage

    • Intraperitoneal rupture

  • Both situations are associated with a high mortality (>30%)

  • Laparoscopic drainage may succeed after failure of percutaneous route

Bibliography
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