Hepatic abscess: Diagnosis and management

Abstract

Microbial contamination of the liver parenchyma leading to hepatic abscess (HA) can occur via the bile ducts or vessels (arterial or portal) or directly, by contiguity. Infection is usually bacterial, sometimes parasitic, or very rarely fungal. In the Western world, bacterial (pyogenic) HA is most prevalent; the mortality is high approaching 15%, due mostly to patient debilitation and persistence of the underlying cause. In South-East Asia and Africa, amebic infection is the most frequent cause. The etiologies of HA are multiple including lithiasic biliary disease (cholecystitis, cholangitis), intra-abdominal collections (appendicitis, sigmoid diverticulitis, Crohn's disease), and bile duct ischemia secondary to pancreatoduodenectomy, liver transplantation, interventional techniques (radio-frequency ablation, intra-arterial chemo-embolization), and/or liver trauma. More rarely, HA occurs in the wake of septicemia either on healthy or preexisting liver diseases (biliary cysts, hydatid cyst, cystic or necrotic metastases). The incidence of HA secondary to Klebsiella pneumoniae is increasing and can give rise to other distant septic metastases. The diagnosis of HA depends mainly on imaging (sonography and/or CT scan), with confirmation by needle aspiration for bacteriology studies. The therapeutic strategy consists of bactericidal antibiotics, adapted to the germs, sometimes in combination with percutaneous or surgical drainage, and control of the primary source. The presence of bile in the aspirate or drainage fluid attests to communication with the biliary tree and calls for biliary MRI looking for obstruction. When faced with HA, the attending physician should seek advice from a multi-specialty team including an interventional radiologist, a hepatobiliary surgeon and an infectious disease specialist. This should help to determine the origin and mechanisms responsible for the abscess, and to then propose the best appropriate treatment. The presence of chronic enteric biliary contamination (i.e., sphincterotomy, bilio-enterostomy) should be determined before performing radio-frequency ablation and/or chemo-embolization; substantial stenosis of the celiac trunk should be detected before performing pancreatoduodenectomy to help avoid iatrogenic HA.

Pyogenic liver abscess: current status and predictive factors for recurrence and mortality of first episodes

“…Coincident to the literature, our overall mortality in patients that were subjected to PD was 2.5% (3 patients out of 118). 23,24 We did not performed needle aspiration in our series in any case. A recent study published by Yu et al, compared repeated needle aspiration versus catheter aspiration in 64 patients with PLA larger than 3 cm in diameter.…”

Massive haemolysis, gas-forming liver abscess and sepsis due toClostridium perfringensbacteraemia

“…Although epigastric pain and fever are common features, they are non-specific. Pyogenic liver abscesses are often polymicrobial, and E. coli and Klebsiella pneumoniae are the two most frequently isolated pathogens 6. Mortality is ∼15%, but it depends on the underlying cause and the pre-existing hepatic disease 7.…”

Pyogenic Liver Abscess after Bile Duct Exploration Drained with Endoscopic Techniques

“…Most of them contributed to ischemia cholangitis and/ or biliary stricture [11]. Herein, T-tube drainage decreases suddenly from approximately 200 ml to 15 ml and subsequently the food residue refluxes into CBD.…”