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G LIVER

94

Liver abscess
David S. Raiford

Amebic versus pyogenic abscess, 2412

Epidemiology, 2412
Clinical manifestations, 2412

Amebic versus pyogenic abscess

This chapter describes the clinical presentation, imaging characteristics, laboratory findings, natural history, and response
to treatment of hepatic abscess. Although there is considerable overlap in these features between amebic and pyogenic
abscesses, the differences in epidemiology, associated conditions, treatment, and prognosis underscore the need for the
physician to distinguish these entities. Effective management
depends critically on prompt and correct definition of the
abscess type.

Epidemiology
There are important differences in the epidemiology of amebic abscess, as it presents in the United States, and pyogenic
abscess. Intestinal amebiasis is a necessary prelude to hepatic
amebic abscess so patients with amebic abscess typically have
emigrated from or traveled to areas where intestinal amebiasis is prevalent [1,2]. Ethnicity of the local patient population
is important. For example, in a large series from Los Angeles,
92% of 457 patients with amebic liver abscess had Hispanic
surnames, compared with 37% of the local patient population [3]. In contrast, ethnicity of patients with pyogenic
abscess did not differ from that of the general hospital population. Another difference identified between amebic and
pyogenic liver abscess in this series was a striking male predominance (84%) in those with amebic abscess, whereas
the gender distribution in those with pyogenic abscess was
about equal. The median age of patients with amebic abscess
(28 years) was significantly lower than that of those with
pyogenic abscess (44 years) [3].

Textbook of Gastroenterology, Fifth Edition Edited by Tadataka Yamada

2009 Blackwell Publishing. ISBN: 978-1-405-16911-0

2412

Diagnosis and differential diagnosis, 2413

Course and complications, 2414
Treatment, 2415

Since the classic review by Ochsner and colleagues [4] in

1938, and after the introduction of antibiotics in the 1940s,
the frequency of pyogenic liver abscess associated with intraabdominal infection has diminished [5,6]. Although pyelophlebitis (mostly due to appendicitis) accounted for 43% of
cases of pyogenic liver abscess in the first decades of the 20th
century [4], a series of patients from 1973 to 1993 indicated
that in only 7% of cases was pyogenic liver abscess believed
to be the result of portal bacteremia [7]. During the past few
decades, biliary obstruction, both benign and malignant, has
emerged as the most common etiology of pyogenic liver
abscess, accounting for 50%60% of cases in several recent
series [79]. This trend undoubtedly reflects improvements
in early diagnosis and management of extrabiliary abdominal
infections attributable to modern imaging modalities and use
of antibiotics. Over time the incidence of cryptogenic hepatic
abscess has remained stable at ~ 20% of cases [4,7,10].
Several series suggest that diabetes mellitus may predispose
to pyogenic liver abscess because 15%25% of cases occur in
patients with diabetes [3,7,8,11]. Finally, since the 1980s, it
has become apparent that recipients of liver transplant allografts have an elevated risk for pyogenic liver abscess [12].

Clinical manifestations
Fever and right upper quadrant pain are the principal symptoms of hepatic abscess, both amebic and pyogenic. Fever is
evident in virtually all patients. Although spiking fever and
chills favor pyogenic abscess, these may be seen with amebic
abscess. Pain is reported by 75%90% of patients, is usually
constant, is of variable intensity, and may exhibit pleuritic
features with radiation to the right shoulder if diaphragmatic
involvement is present [3,1315]. Most patients have symptoms for less than 2 weeks before seeking medical care.
Nonspecific symptoms, such as weakness, anorexia, nausea,
and weight loss, are common. About one-third of patients
with either type of liver abscess report diarrhea, and onefourth have a nonproductive cough.

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Liver abscess CHAPTER 94

On physical examination, sequential measurements of
body temperature should be made to detect fever. Hepatic
enlargement and tenderness are typical, but not invariably
present. Jaundice is rare in amebic abscess and, when present, should suggest biliary tract obstruction with pyogenic
infection or underlying chronic liver disease. Percussion dullness, diminished breath sounds, or other chest findings at the
right lung base are evident in 20%30% of patients and suggest involvement of the superior portion of the right hepatic
lobe. Occasionally signs of weight loss, dehydration, and anemia are evident [3,7,14,16].

Diagnosis and differential diagnosis

Imaging modalities
The clinical constellation of fever, right upper quadrant discomfort, and hepatic enlargement with tenderness should
prompt an imaging study early in the diagnostic assessment.
Depending on the age of the patient and level of clinical suspicion for cholelithiasis or biliary obstruction, either ultrasonography or computed tomography (CT) will be performed.
These techniques facilitate discrimination of liver abscess

Figure 94.1 Sonogram of the right hepatic lobe showing multiple

hypoechoic pyogenic abscesses. This image is from a 54-year-old man who
developed multiple hepatic abscesses associated with sigmoid diverticulitis.
Blood cultures obtained before antibiotic administration yielded Bacteroides
thetaiotaomicron. Gram stain of abscess material obtained after
antimicrobial therapy was initiated showed gram-positive cocci, gramnegative rods, and gram-positive rods. He was treated initially by
percutaneous drainage and intravenous ceftriaxone and metronidazole.
After clinical improvement, he was discharged home and completed
uneventfully a several week course of oral ciprofloxacin and metronidazole.

from cholecystitis, bile duct obstruction, or pancreatitis.

Radionuclide liverspleen scanning after administration of a
technetium 99msulfur colloid has been supplanted by ultrasonography and CT because the latter two are more sensitive
for small lesions (less than 3 cm) and offer better precision in
localizing lesions that may require percutaneous aspiration
or drainage. Of note, lesions near the dome of the right hepatic
lobe may be difficult to see by ultrasonography. Typically, on
ultrasound abscesses appear as hypoechoic lesions, sometimes with internal echoes [17,18] (Fig. 94.1). CT scanning
identifies abscesses as low-density lesions (Fig. 94.2), often
with peripheral enhancement after intravenous administration of contrast, and may provide better definition of
extrahepatic pathology associated with pyogenic abscess
(e.g., appendiceal or diverticular abscess) [19]. Although both
modalities are sensitive for detecting abscesses and biliary
obstruction, neither can distinguish reliably between amebic
and pyogenic abscesses [2022]. Although less widely used,
magnetic resonance imaging (MRI) also has high sensitivity for detection of hepatic abscess. Characteristically, liver
abscesses are hypointense on T1-weighted images and hyperintense on T2-weighted images, and wall enhancement
soon after gadolinium infusion is typical [23]. Both CT and
MRI provide multiplanar imaging so these modalities may
be particularly valuable when ultrasound findings are ambiguous or when coronal or sagittal images will help guide

Figure 94.2 Computed tomography image showing numerous lowdensity lesions in both hepatic lobes in a 65-year-old man with colon
carcinoma. Streptococcus (g-hemolytic) was cultured from fluid obtained
by abscess aspiration. His liver lesions were treated by aspiration without
drain placement and by administration of levofloxacin and metronidazole.
He improved and subsequently tolerated resection of his colonic lesion.

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management of a lesion in the superior portion of a hepatic

lobe [24]. Most abscesses, both amebic and pyogenic, occur
in the right hepatic lobe. The presence of multiple abscesses
strongly suggests pyogenic infection, as does identification
of concomitant biliary tract obstruction. Chest radiographs
in patients with an abscess adjacent to the diaphragm may
show elevation of the right diaphragm, subpulmonic effusion, and right lower lobe atelectasis or infiltrate. It is well to
remember that hepatic tumors may present with necrosis
and secondary infection [25], mimicking a primary abscess.

Laboratory testing
Commonly employed blood tests are of limited utility in
reaching a specific diagnosis of hepatic abscess. This being
said, certain abnormalities are typically present. Leukocytosis
(more than 10 000/mm3) is present in more than 90% of
patients. Mild anemia is common, with hemoglobin levels
of less than 12 g/dL seen in two-thirds of patients. Mild to
moderate elevation of serum alkaline phosphatase activity
is typical but of little discriminating value in the absence of
information from imaging studies [3,7,26].
Detection of antiamebic antibodies is of primary importance in diagnosis of amebic liver abscess. Although serological tests may rarely be negative very early in infection, more
than 90% of patients with hepatic abscess develop antibodies
to Entamoeba histolytica in high titer. A positive serological
response to E. histolytica indicates tissue invasion by the parasite and not simply intestinal colonization. Both indirect
hemagglutination and enzyme-linked immunosorbent assays
are available [2,27]. Importantly, seropositivity does not distinguish current from prior disease. Persistence of antiamebic
antibodies after resolution of amebic abscess (usually in
diminishing titer) may lead to confusion in the differential
diagnosis of a subsequent liver lesion, especially in areas in
which infection is endemic [1,2,2830].
A key element in diagnosis and treatment of pyogenic liver
abscess is identification of the organisms in the abscess. Blood
cultures are positive for bacteria in about 50% of patients so
at least two separate specimens of blood should be taken for
culture before administration of antibiotic agents. Most pyogenic abscesses are caused by enteric gram-negative aerobic
rods, streptococci, and anaerobes. Although blood cultures
typically identify a single organism, cultures from abscess
aspiration are frequently polymicrobial [3,32,33]. Needle
aspiration of an abscess is the best and most direct method to
distinguish amebic from pyogenic abscess. Material from
an amebic abscess is brown-red in color and typically is not
particularly malodorous. A pyogenic abscess yields material
that is creamy, tan-green in color, and often putrid, reflecting
anaerobic infection. Gram stains of amebic abscess contents
show neutrophils but no bacteria, unless secondary infection
is present. Smears of pyogenic abscess contents usually identify at least one bacterial form. Meticulous handling of aspirated material to avoid exposure to air enhances the recovery

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and identification of anaerobic species. Reliable and complete identification of infectious agents ensures proper selection of an antibiotic treatment regimen [33].

Course and complications

Amebic abscess
Without treatment, amebic liver abscess tends to enlarge and
ultimately extend through the diaphragm or rupture into the
peritoneal cavity. Pleuropulmonary involvement is the most
common complication [13,3436]. On extension through
the diaphragm, amebic empyema or lung involvement with
development of hepatobronchial fistula may occur. Rupture
into the right pleural cavity is less frequent than into the
lung, probably because of fusion of the diaphragmatic and
visceral pleura induced by inflammation. Erosion into a
bronchus may be followed by expectoration of amebic pus
and by amelioration of symptoms. This mechanism of abscess
drainage affords an opportunity for spontaneous resolution.
Less frequently seen is rupture into the pericardium, typically a complication of amebic abscess within the left hepatic
lobe. This may be accompanied by retrosternal pain, a pericardial friction rub, and findings of cardiac tamponade, such
as jugular vein distention with pulsus paradoxus. Historically, rupture into the pericardium has carried a high mortality [13,34].
When an amebic abscess ruptures abruptly into the
peritoneum, diffuse abdominal pain and signs of peritonitis
occur. Less frequently encountered is a contained abscess
adjacent to the site of hepatic rupture. In neither instance is
surgery required because cure typically results from antimicrobial therapy alone [13,35]. Other rare intraabdominal
complications include rupture into bowel and hemobilia
through formation of an arteriobiliary fistula.

Pyogenic abscess
The mortality rate associated with untreated pyogenic liver
abscess approaches 100% [4,8,10]. As with amebic abscess,
complications of pyogenic liver abscess include rupture and
extension into the surrounding tissues, with pleuropulmonary
involvement most common. In contrast to amebic peritonitis, should rupture into the peritoneum occur from a pyogenic liver abscess, mortality is very high without surgical
management. Abscess-associated thrombosis within the
portal vein (Fig. 94.3) or a hepatic vein is associated with
anaerobic infections [5,6] and may lead to residual portal
hypertension or the BuddChiari syndrome after otherwise
successful treatment of the abscess. Patients with large or
multiple pyogenic abscesses are at increased risk for developing infections at remote body sites as a result of bacteremia.
Patients with polymicrobial abscesses have a higher mortality
rate than do those with monomicrobial infections. In one
series, all 14 patients who had two or more organisms isolated

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Liver abscess CHAPTER 94

likely, at least two sets of blood cultures should be obtained
before administration of antimicrobial agents.

Amebic abscess

Figure 94.3 Computed tomography image showing filling defects within

the intrahepatic portal vein, scattered hepatic hypodense lesions, and
free fluid within the abdominal cavity. These findings are compatible with
septic pyelothrombophlebitis. This image is from a 44-year-old man who
presented with sigmoid diverticulitis and pericolonic abscess. He was treated
by segmental colectomy and his liver abscesses resolved without aspiration
after prolonged antibiotic therapy. He was treated postoperatively with
heparin, then coumadin. After 3 months of anticoagulation therapy,
his portal vein thrombus resolved and there were no residual imaging
abnormalities.

from blood cultures died [8]. Mortality appears to be higher

in patients with pyogenic abscesses of biliary origin, probably
because these patients tend to have multiple abscesses. Even
with prompt diagnosis and treatment, the mortality rate from
pyogenic liver abscess remains high, ranging from 10% to
30% [3,8].

If the patient is a young man who has emigrated from or

traveled to an area where amebiasis is endemic, who has a
single lesion on an imaging study, and who does not appear
toxemic, then amebic abscess is the more likely diagnosis.
Stool specimens should be examined for amebic cysts and
trophozoites and serum should be tested for E. histolytica antibodies. Treatment in adult patients should then be initiated
with metronidazole, 750 mg given orally three times daily
for 10 days [1,2,33]. An alternative regimen is chloroquine
phosphate, 1000 mg (600 mg chloroquine base) given orally
daily for 2 days, and then 500 mg (300 mg chloroquine base)
given orally daily for 23 weeks [1,2,37]. Clinical improvement is expected within 3 days. After treatment with either
of these tissue amebicides, therapy with a lumenal amebicide
is appropriate to eradicate amebas within the bowel because
these may cause relapsing or persisting infection. Iodoquinol,
650 mg given orally three times daily for 20 days, is the drug
of choice for this purpose [37]; paromomycin is a satisfactory
alternative [2,33]. Aspiration of the abscess is indicated if
there is no clinical improvement within several days, if the
diagnosis is in doubt, or if the abscess is large or located such
that rupture is believed likely. Amebic pleural effusions are
treated by aspiration and one of the amebicidal regimens.
Amebic pericarditis is treated by pericardiocentesis and by
aspiration of the (usually left lobe) hepatic abscess in addition
to amebicidal antibiotics. Surgery is not indicated for uncomplicated amebic liver abscess but may be appropriate in some
instances for rupture or, rarely, for failure of medical therapy
alone [38]. Ultrasound-guided percutaneous drainage is
effective and should obviate the need for surgical management in most cases [39]. In uncomplicated amebic liver
abscess, the prognosis is good, with a mortality rate of about
1% [13]. Extension into the chest or pericardium increases
mortality significantly, to 6% or 25%30%, respectively
[13,35].

Pyogenic abscess

Treatment
Liver abscess should be considered in any patient with fever,
leukocytosis, pain in the right upper quadrant, and tenderness over the liver or right lower chest wall. Depending on
the age of the patient and the nature of the discomfort and
associated symptoms elicited by history, either ultrasonography or CT should be obtained. Either modality will detect
reliably one or more hepatic lesions, with imaging characteristics suggesting abscess. Should jaundice or evidence
for biliary obstruction be discovered, consideration of cholangiography and biliary decompression is appropriate. Regardless of whether amebic or pyogenic abscess is believed more

If the patient is older, lacks a history suggesting risk for amebiasis, or has multiple lesions or bile duct obstruction on an
imaging study, pyogenic abscess is more likely. After blood
cultures have been obtained, treatment with a broad-spectrum
antibiotic regimen is appropriate. The mixed nature of many
pyogenic infections dictates that the initial empiric regimen
should provide effective coverage against aerobic enteric
bacilli, microaerophilic streptococci, and enteric anaerobes.
Suitable regimens include ampicillinsulbactam, piperacillin
tazobactam, cefoxitin, imipenem, or a third-generation cephalosporin plus metronidazole [33]. Previous instrumentation
or obstruction of a patients biliary tree and local patterns of
bacterial antibiotic resistance should prompt broader coverage

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or antibiotic selection to strengthen coverage against specific

pathogens such as Enterococcus and Pseudomonas species [7].
In most instances, diagnostic aspiration for bacterial culture
is appropriate. Ideally, this should occur before antibiotics are
administered, but treatment should not be delayed injudiciously if prompt aspiration is not feasible. Although many
choose to leave a drain in place after aspiration, several series
have indicated that aspiration without catheter drainage (in
concert with antibiotic therapy) is curative in most instances
[3,7,9,16,4047]. Antibiotic therapy alone should be employed only for those with multiple small abscesses not
amenable to aspiration and for those with a contraindication
to aspiration and drainage (e.g., coagulopathy) [48]. Surgical
drainage, either open or laparoscopic [49], is appropriate for
patients who fail to improve with percutaneous drainage and
antibiotic therapy and for those who have an extrahepatic or
biliary source of hepatic abscess in need of surgical treatment.
It is important to note that resolution of abscess cavities (as
determined by sequential imaging studies) typically lags
behind clinical improvement in effectively treated patients.
Thus, clinical judgment and not simply persistence of an
abscess cavity should guide decision-making regarding the
need for recurrent aspiration or operative drainage. Surgical
intervention may ultimately be necessary in up to one-third
of patients with pyogenic abscess [50,51]. Although percutaneous drainage and current antibiotic regimens have
reduced mortality from pyogenic liver abscess significantly, it
remains high (20%40%) in patients with significant comorbidity, multiple abscesses, malignant biliary obstruction, and
inadequate drainage [7,8].

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