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 doi:10.1111/j.1440-1746.2011.06851.x

GASTROENTEROLOGY jgh_6851 248..255

Cryptogenic pyogenic liver abscess as the herald of colon

cancer
Soung Won Jeong,* Jae Young Jang,* Tae Hee Lee,* Hyun Gun Kim,* Sung Wook Hong,*
Seung Hoon Park,* Sang Gyune Kim,* Young Koog Cheon,* Young Seok Kim,* Young Deok Cho,*
Jin-Oh Kim,* Boo Sung Kim,* Eun Jung Lee and Tae Hyong Kim
*Institute for Digestive Research and Digestive Disease Center, and Department of Internal Medicine, Soonchunhyang University Hospital,
Seoul, Korea

Key words Abstract

colon cancer, colonoscopy, diabetes mellitus,
Klebsiella pneumoniae, pyogenic liver
abscess.
Accepted for publication 28 June 2011.
Correspondence
Associate Professor Jae Young Jang, Institute
for Digestive Research and Digestive Disease
Center, Division of Gastroenterology,
Department of Internal Medicine,
Soonchunhyang University Hospital, Yong San
Gu, Han Nam Dong, Daesakwan Gil 22,
Seoul, Korea. Email: jyjang@hosp.sch.ac.kr
Background and Aim: Colonic mucosal defects might be a route for bacterial invasion
into the portal system, with subsequent hematogenous spread to the liver. We retrospec-
tively investigated the results of colonoscopy and the clinical characteristics of patients
with pyogenic liver abscess of colonic origin.
Methods: A total of 230 consecutive patients with pyogenic liver abscess were reviewed
between 2003 and 2010. The 230 patients were categorized into three groups (pancreato-
biliary [n = 135], cryptogenic [n = 81], and others [n = 14]). Of the 81 cryptogenic patients,
37 (45.7%) underwent colonoscopy. Colonic lesions with mucosal defects were considered
colonic causes of abscess.
Results: In the 37 colonoscopic investigations, colon cancer was found in six patients
(16.2%), laterally-spreading tumor (LST) in two patients (5.4%), multiple colon ulcers in
one patient (2.7%), colon polyps in 17 patients (45.9%), and diverticula in four patients
(10.8%). Nine (11%) of 81 cryptogenic abscesses were therefore reclassified as being of
colonic origin (colon cancer = 6, LST = 2, ulcer = 1). Three cases were stage III colon
cancer, and the others were stage I. Two LST were high-grade dysplasia. The percentage of
patients with Klebsiella pneumoniae (K. pneumoniae) and diabetes mellitus (DM) of
colonic origin was 66.7%, which was significantly higher than the 8.6% for other causes
(P < 0.001).
Conclusions: Of the 37 patients with cryptogenic pyogenic liver abscess who underwent
colonoscopy, nine (24.3%) were diagnosed with a colonic cause. Colonoscopy should be
considered for the detection of hidden colonic malignant lesions in patients with crypto-
genic pyogenic liver abscess, especially for patients with K. pneumoniae and DM.

with asymptomatic diverticulitis,3,4 inflammatory bowel disease,57

Introduction
The liver is the organ most vulnerable to the development of
abscesses. Abcesses might arise from the hematogenous spread of
bacteria or from contiguous sites of infection within the peritoneal
cavity. Pyogenic liver abscess is usually related to hepatobiliary
tract disease or intra-abdominal infections, including cholecystitis,
suppurative cholangitis, suppurative pylephlebitis, appendicitis,
diverticulitis, and peritonitis.1,2 In the past, appendicitis with
rupture and subsequent spread of infection was the most common
source for a liver abscess. Currently, associated disease of the
biliary tract is most common.
Recently, there have been many case reports of pyogenic liver
abscess associated with various colonic diseases. The association
tubulovillous adenoma,8,9 colon cancer,1019 and even colon
polypectomy20 have been reported. It has been believed that
mucosal defects present within colonic lesions or a compromised
mucosal barrier separating enteric bacteria from the circulation
allows a route for bacteria invasion into the portal system, with
subsequent hematogenous spread to the liver. Moreover, if the
colonic origin is colon cancer, prompt detection and treatment will
be essential. However, there have been few data about colono-
scopic investigation in patients with cryptogenic pyogenic liver
abscess, and there is no colonoscopic recommendation or consen-
sus for these patients. Therefore, we retrospectively investigated
the results of colonoscopy and the clinical characteristics of
patients with cryptogenic pyogenic liver abscess.

248 Journal of Gastroenterology and Hepatology 27 (2012) 248255

2011 Journal of Gastroenterology and Hepatology Foundation and Blackwell Publishing Asia Pty Ltd
SW Jeong et al.
Methods
Patients
Between May 2003 and May 2010, the records of 230 patients
diagnosed with pyogenic liver abscess at the Soonchunhyang Uni-
versity Seoul Hospital in South Korea were reviewed. The cause of
pyogenic liver abscess was ascribed to the precipitating disease
that was most likely to account for the abscess. Computed tomog-
raphy (CT) scan and routine laboratory tests were performed on all
abscess patients. Biliary tract disease was documented by ultra-
sound, CT with contrast, magnetic resonance cholangiopancre-
atography, or endoscopic retrograde cholangiopancreatography.
When no primary cause of infection is found, the cause of abscess
was considered as cryptogenic by the physician in charge. Asso-
ciated conditions believed to contribute to abscess formation, such
as diabetes mellitus (DM) or immunocompromise, were recorded.
This study was approved by the institutional review boards of the
Soonchunhyang University Hospital, Seoul, Korea.
Diagnosis
Pyogenic liver abscess was diagnosed if the abscess was confirmed
by imaging as well as by either documentation of an organism
from the abscess site or resolution of symptoms and signs after
antibiotic treatment. Patients with amebic infection with Entam-
oeba histolytica in pus or in the abscess wall, and patients found to
be ameba antibody immunoglobulin G positive by ELISA were
excluded.
Colonoscopic investigation
The results of the colonoscopic investigation were reviewed from
the medical records between 2003 and 2010. Colonoscopy was
performed based on the patients gastrointestinal symptoms or a
search of an occult colonic etiology, unless the patients refused or
could not tolerate a colonoscopy. Routine colonoscopic investiga-
tions were performed after the resolution of pyogenic liver
abscess, generally within 6 weeks of diagnosis.
Colonic lesions were categorized according to the colono-
scopic findings and histology. To identify a colonic cause of
cryptogenic pyogenic liver abscess, colonic lesions that had
mucosal defects were investigated. When mucosal defects or
diverticulitis was noted in the colonoscopic findings, they were
determined to be the cause of pyogenic liver abscess. However,
colonic lesions that did not have mucosal defects, or diverticula
without diverticulitis, were excluded as the cause of liver
abscess. The location of colonic lesions and the characteristics of
the liver abscesses were also evaluated when colonic lesions
were identified as the cause of the liver abscess. Colon cancer
was diagnosed with histology and assessed with stage. To iden-
tify liver metastasis in colon cancer patients after abscess reso-
lution, patients were monitored by abdominal enhanced CT scan
after the treatment of colon cancer.
Pathogens
The microbiological results of blood and abscess cavity cultures
were assessed. All samples for the cultures were taken before the
Journal of Gastroenterology and Hepatology 27 (2012) 248255
2011 Journal of Gastroenterology and Hepatology Foundation and Blackwell Publishing Asia Pty Ltd
Colon cancer in cryptogenic liver abscess
start of antibiotic therapy. The abscess contents were aspirated
under abdominal ultraosonography guidance for diagnosis and
microorganism culture. Cultures were isolated for aerobic and
anaerobic organisms. Organisms found from the abscess or in
blood were assumed to be the etiologic organisms.
Association with DM
The presence of DM was evaluated in each patient, and was
defined by the 1997 criteria:21 history of DM, or symptoms of
DM and casual blood glucose concentrations 200 mg/dL, or
fasting plasma glucose 126 mg/dL, or 2 h plasma glucose
200 mg/dL during an oral glucose tolerance test.
Statistical analysis
Fishers exact test was used to assess the association between
etiology of abscess and the presence or absence of Klebsiella
pneumoniae (K. pneumoniae) and DM. Data are presented as the
mean standard deviation. A P-value < 0.05 was considered sta-
tistically significant. All statistical analyses were performed using
the SPSS software package (version 17.0; SPSS, Chicago, IL,
USA).
Results
Patients
The mean age of the 230 patients was 60.7 12.8 years. Of these,
120 (52.2%) were men, and 110 (47.8%) were women. The 230
patients with pyogenic liver abscess were classified according to
the cause of abscess: pancreatobiliary disease (n = 135), cryptoge-
nic (n = 81), and others (n = 14; metastatic liver cancer, 7; appen-
dicitis, 5; prostate abscess, 1; postoperation colon cancer, 1). Of
the 81 cryptogenic patients, one patient with HIV infection and
one post-kidney transplantation patient were included.
Colonoscopic investigation
Colonoscopic investigation was performed in 37 (45.7%) of 81
patients whose abscesses were of cryptogenic origin. Of these 37
patients, 15 underwent colonoscopy for symptoms including
altered bowel habits, hematochezia, and anemia, whereas 22
patients underwent colonoscopy purely to find the cause of the
abscess. The median time to colonoscopy after the diagnosis of
abscess was 21 days (range: 1183). Colon cancer was noted in
six patients (16.2%), laterally-spreading tumor (LST) with high-
grade dysplasia was noted in two (5.4%), multiple colon ulcers
was noted in one (2.7%), colon polyps were noted in 17 (45.9%),
and diverticula were noted in four patients (10.8%). Of these,
two patients had colon polyps and diverticula together. Nine
patients (24.3%) showed normal colonoscopic findings. Both
mucosal defects and friability were noted in six patients with
colon cancer, two patients with LST, and one patient with mul-
tiple colonic ulcers. Seventeen cases of colon epithelial lesions
(small polyps without mucosal defects and four cases of diver-
ticula without diverticulitis) were not considered causative eti-
ologies of abscess. Figure 1 shows the outcome of colonoscopic
investigation. Twenty-eight patients who underwent colonoscopy,
249
Colon cancer in cryptogenic liver abscess SW Jeong et al.

Figure 1 Algorithm of pyogenic liver abscess after colonoscopic investigation. LST, laterally-spreading tumor.

Figure 2 Distribution of causes in all patients according to colonoscopy. Distribution of causes in all patients before (a) and after (b) adding the results
of the colonoscopy. Others; metastatic liver cancer, appendicitis, prostate abscess, colon cancer, post operation state.

and 44 who did not, were classified as having cryptogenic
abscess, leading to reclassification of the initial 81 patients as
follows: cryptogenic, 72 (88.9%), and colonic, 9 (11.1%; colon
cancer, 6, 7.4%; LST with high-grade dysplasia, 2, 2.5%; colon
ulcers, 1, 1.2%). Figure 2 shows the distribution of causes in
all 230 patients according to colonoscopy. It shows how
colonoscopy lowers the rate of cryptogenic etiology among all
patients with pyogenic abscess.
In summary, our cohort of 230 pyogenic liver abscesses was
classified as follows: pancreatobiliary (58.7%), cryptogenic origin
(31.3%), colonic (3.9%), metastatic liver cancer (3%), appendicitis
(2.2%), others (0.8%) (Table 1).

250 Journal of Gastroenterology and Hepatology 27 (2012) 248255

2011 Journal of Gastroenterology and Hepatology Foundation and Blackwell Publishing Asia Pty Ltd
SW Jeong et al. Colon cancer in cryptogenic liver abscess

Clinical characteristics of patients with T2N0M0). Pathologies for two patients with LST showed high-
abscesses of colonic origin grade dysplasia. Regarding the location, one was in the hepatic
flexure, and the other was in the transverse colon. Figure 3 shows
In nine cases with abscesses of colonic origin, there were six cases
LST and associated pyogenic liver abscess.
of colon cancer, two LST, and one case with multiple colonic
One patient, who was HIV positive, had multiple ulcers
ulcers. Among the six colon cancers, three were adenocarcinoma
throughout the entire colon. The median time to colonoscopy after
of the well-differentiated type, and three were of the moderately-
diagnosis of abscess was 23 days (range: 1153), the mean size of
differentiated type. With respect to the location of colon cancers,
liver abscesses was 6.1 4.2 cm, and the treatment for the liver
two were from the ascending colon, two were from the descending
abscesses in all the patients with colonic pathologies was percu-
colon, one was from the sigmoid colon, and one was from the
taneous catheter drainage and intravenous antibiotics therapy. All
hepatic flexure. Three patients were stage III (T3N1M0, T3N1M0,
patients recovered from liver abscess after treatment.
T2N1M0), and three patients were stage I (T1N0M0, T1N0M0,
The characteristics of all colonic lesions are shown in Table 2.
Of the six patients with colon cancers, three patients with stage
Table 1 Possible causes of pyogenic liver abscess III cancer had surgery with adjuvant chemotherapy. Of the other
three patients with stage I cancer, one patient with T2 had surgery
Cause Patients and adjuvant chemotherapy, one patient with a large T1 tumor had
n % surgery, and the other patient with a T1 tumor had endoscopic
mucosal resection (EMR). Two LST were removed completely by
Pancreatobiliary 135 58.7 EMR. The mean follow-up period was 38.7 32.3 months. There
Biliary stone 56 24.3
was no tumor recurrence or hepatic metastasis in these patients
Cholangiocarcinoma 51 22.2
during follow up.
Choledochoduodenostomy 10 4.3
Metastatic bile duct cancer 9 3.9
Pancreatic cancer 3 1.3
Pathogens
Benign bile duct stricture 3 1.3
Gallbladder empyema 2 0.9 Bacterial cultures from abscess pus or blood were performed in
Bile duct fistula 1 0.4 230 patients, with a positive culture rate of 64.8% (149/230).
Cryptogenic 72 31.3 Cultures were sterile in 81 (35.2%) patients, and multiple organ-
Colonic 9 3.9 isms were found in 12.1% (18/149) of positive cultures. Sixteen
Colon cancer 6 2.6 species of bacteria were cultured. K. pneumoniae was the most
LST with high-grade dysplasia 2 0.9 frequently isolated aerobe (42.9%, 73/170) (Fig. 4). For pancre-
Colon ulcer 1 0.4 atobiliary abscess patients (n = 135), the positive culture rate was
Metastatic liver cancer 7 3.0 66.7% (90/135). Multiorganisms were cultured from 15 patients.
Appendicitis 5 2.2 K. pneumoniae was the most frequently isolated aerobe (23%,
Prostate abscess 1 0.4
31/135), and Escherichia coli was the second most common
Colon cancer, post operation state 1 0.4
(21.5%, 29/135). For cryptogenic abscess (n = 72) cultures, the
LST, lateral spreading tumor. positive culture rate was 59.7% (43/72). One patient has a positive

Figure 3 Pyogenic liver abscess derived from huge laterally-spreading tumor. (a) Huge laterally-spreading tumor with mucosal defects and
easy-touch bleeding in colonoscopy, (b) Multiseptated pyogenic liver abscess in right lobe.

Journal of Gastroenterology and Hepatology 27 (2012) 248255 251

2011 Journal of Gastroenterology and Hepatology Foundation and Blackwell Publishing Asia Pty Ltd
Colon cancer in cryptogenic liver abscess SW Jeong et al.

Diabetes
mellitus
Stenotrophomonas

Yes
Yes
Yes

Yes

Yes
Yes
Yes
No

No
Serratia
Morganella

Sixteen species of bacteria cultured

Acinetobacter

Klebsiella pneumoniae
Klebsiella pneumoniae
Klebsiella pneumoniae

Klebsiella pneumoniae
Klebsiella pneumoniae
Klebsiella pneumoniae
Klebsiella pneumoniae
Anaerobes
Citrobacter
Streptococcus

No growth Pseudomonas

No growth
Pathogen

Enterobacter
Enterococcus
Staphylococcus
Escherichia
Klebsiella
Liver abscess

Both/multiple

Both/multiple
Both/multiple
Right/single

Right/single

Right/single
Right/single
Left/single

Left/single

Pathogens recovered per case (%)

Figure 4 Number of pathogens recovered per case in patients with

pyogenic liver abscesses.
Hepatic flexure

Hepatic flexure
Entire colon
Descending

Transverse
Ascending
Ascending

culture for Escherichia and Enterococcus. K. pneumoniae was the

Location

Sigmoid
Sigmoid

most frequently isolated aerobe (41.7%, 30/72). For abscess due to

colonic origin (n = 9), the positive culture rate was 77.8% (7/9).
No patient had a culture for more than one organism. K. pneumo-
niae was the most frequently isolated aerobe (77.8%, 7/9).
Size (cm)

Association with DM and K. pneumoniae

1.8
3.4
2.1
5.0
4.0
2.3
2.9
2.5
2.1

The overall percentage of DM was 23% (53/230). The DM per-

centage was 20% (27/135) in the pancreatobiliary-origin category,
High grade dysplasia
High grade dysplasia

22.2% (16/72) in the cryptogenic-origin category, 77.8% (7/9) in

the colonic-origin category, 28.6% (2/7) in the metastatic liver
cancer category, and 0% (0/5) in the appendicitis category.
T2N1M0(III)
T3N1M0(III)
T3N1M0(III)
T1N0M0(I)
T2N0M0(I)

T1N0M0(I)

In patients with DM, the percentage of K. pneumoniae was

Stage

None

47.2% (25/53), and in patients without DM, the percentage of

K. pneumoniae was 27.1% (48/177) (P = 0.006).
The percentage of patients with both K. pneumoniae and DM in
colonic-origin abscesses was 66.7% (6/9), and those in the groups
Moderately differentiated
Moderately differentiated
Moderately differentiated

with cryptogenic and all other causes were 12.5% (9/72) and 8.6%
(19/221), respectively (P < 0.001 for both) (Fig. 5).
Acute inflammation
Well differentiated

Well differentiated
Well differentiated
Tubular adenoma
Tubular adenoma

Overall mortality
Histology

The hospital mortality for all 230 patients was 4.3% (10/230). Ten
patients died of sepsis and underlying disease. Nine of 10 patients
Characteristics of colonic lesions

had underlying cancer. Five patients had cholangiocarcinoma, two

patients had advanced gastric cancer, and one patient had pancre-
Diagnosis

atic cancer. One patient without underlying cancer died of septic

Cancer
Cancer
Cancer
Cancer
Cancer
Cancer

Ulcers

shock and femoral artery thrombosis. There was no death from

LST, laterally spreading tumor.
LST
LST

abscess without an accompanying underlying disease.

Discussion
(years)
Age

61
66
46
44
46
48
63
70
44

The aim of the present study was to examine the results of colonos-
copy and clinical characteristics of colonic origin in cryptogenic
pyogenic liver abscess. In this study, a colonoscopic investigation
Table 2

Female

Female
Female

Female

in patients with cryptogenic pyogenic liver abscess revealed a high

Male
Male

Male

Male

Male
Sex

percentage of advanced colonic lesions. Moreover, in the 45.7% of

252 Journal of Gastroenterology and Hepatology 27 (2012) 248255

2011 Journal of Gastroenterology and Hepatology Foundation and Blackwell Publishing Asia Pty Ltd
SW Jeong et al.
P<0.001
P<0.001
100%
33.3
80%
No. patients (%)
60%
87.5 91.4
40%
66.7
20%
12.5 8.6
0%
Colonic cause Cryptogenic Other causes
Figure 5 Percentage of patients with both Klebsiella pneumoniae and
diabetes mellitus (DM) in colonic, cryptogenic and other causes. , Both
Klebsiella pneumoniae and DM; , others.
patients who underwent colonoscopy, the percentage of colonic
tumors was 21.6% (8 patients; 6 patients with colon cancer, and 2
patients with LST with high-grade dysplasia). The percentage of
patients with DM and K. pneumoniae of colonic origin was sig-
nificantly higher than that of patients with K. pneumoniae and DM
with other causes.
A considerable portion of pyogenic liver abscess had a crypto-
genic origin. Therefore, colonoscopy should be recommended in
case of cryptogenic abscess to rule out a colonic origin, which
might be colon cancer, large adenoma, colon ulcers, diverticulitis,
or inflammatory bowel disease.
Colonoscopies have been actively performed since 1990, and in
many cases, colon cancer or large adenomas associated with pyo-
genic liver abscess have been reported. However, concrete data or
guidelines for colonoscopic investigations in cryptogenic pyo-
genic liver abscess have not yet been elucidated. Recently, Lai
et al. reported that cryptogenic pyogenic liver abscess might signal
colorectal cancer. In their population-based, 5-year follow-up
study, the hazard of colorectal cancer was 3.36 times greater for
patients with cryptogenic pyogenic liver abscess than for the com-
parison group.22
To our knowledge, the present study is the first to show concrete
colonoscopic results and microbiological data regarding colonic
causes of cryptogenic pyogenic liver abscess. In our study, the
overall percentage of DM was 22.6% (52/230). However, the rate
of DM in patients with liver abscess of colonic origin was 77.8%
(7/9), which was higher than in patients with liver abscess of other
or cryptogenic cause. Impaired polymorphonuclear neutrophil
(PMN) chemotaxis and phagocytosis in diabetic patients might
increase the risk of infectious episodes.23 Also, DM and impaired
glucose tolerance have been reported to be associated with an
increased incidence of colonic adenoma and cancer by hyperin-
sulinemia promoting colorectal carcinogenesis.2426 The associa-
tion with infection and colon cancer in DM might be the
predisposing factor for pyogenic liver abscess with colon cancer.
However, the reason all colon cancer patients with metastatic
liver cancer do not have evidence of liver abscesses might be the
Journal of Gastroenterology and Hepatology 27 (2012) 248255
2011 Journal of Gastroenterology and Hepatology Foundation and Blackwell Publishing Asia Pty Ltd
Colon cancer in cryptogenic liver abscess
strength of the immune barrier in the host, the difference in patho-
gens, and other as yet unknown complex factors that might regu-
late the invasion of bacteremia into the portal blood flow. In this
process, DM might weaken the immunologic system in affected
patients.
K. pneumoniae has been reported to be the most common patho-
gen in Asia2733 and emerging pathogen in Western countries.34 In
our study, K. pneumoniae was the most common pathogen. Kleb-
siella is a colonizer in the human gastrointestinal tract and is rarely
associated with disease in the normal host. However, abscesses
containing only Klebsiella are much more likely to be cryptoge-
nic,31,34 and still, a considerable percentage of pyogenic liver
abscess are deemed cryptogenic (4099%).3538 In the present
study, K. pneumoniae was found to be highly associated with the
cryptogenic categories, including DM, compared to all other
causes. Interestingly, the percentage of K. pneumoniae in
abscesses of colonic origin was higher than that of cryptogenic
origin and in all other causes. Colonic mucosal defects might be
the route of K. pneumoniae transmission. Also, the prevalence
rates of K. pneumoniae were higher in the DM group, and these
findings are consistent with previous studies.34,3942 These results
could be explained by the hypothesis of intimal vascular defects in
DM patients, which predispose to the hematogenous seeding of
Klebsiella,40 the serotype K1 of Klebsiella,41 and the chromosomal
heterogeneity of tissue-invasive Klebsiella strains.42
Finally, the percentage of colonic origin patients with both
K. pneumoniae and DM was significantly higher than the percent-
age among patients with cryptogenic and all other causes.
We hypothesized that three factors are related to pyogenic liver
abscess in colon tumor patients with DM: (i) mucosal disruption
and underlying blood vessel exposure due to colon tumor, (ii)
increased episodes of infectious disease in DM patients by
impaired PMN chemotaxis and phagocytosis; and (iii) the charac-
teristics of Klebsiella pathogen: DM affinity and chromosomal
heterogeneity of tissue invasiveness.
However, colonoscopic investigation is not generally performed
to search for the colonic origin. Lai et al.22 reported that only
19.3% of patients with cryptogenic pyogenic liver abscess under-
went endoscopic procedures or fecal testing analysis, and Rahim-
ian et al.43 reported that only 3.8% of all their pyogenic liver
abscess patients received colonoscopy.
We also performed colonoscopic investigation in only 45.7% of
cryptogenic pyogenic liver abscess patients. If we perform the
colonoscopy actively in deemed cryptogenic pyogenic liver
abscess to detect a hidden colonic cause, we might be able to more
accurately detect the colonic cause.
Although this study showed that the percentage of patients
with DM and K. pneumoniae in colonic origin was significantly
higher than that of patients with other causes, K. pneumoniae is
the most common pathogen in a pyogenic liver abscess, and DM
patients are more likely to have abscess, so high rates of DM and
K. pneumoniae are not unexpected in patients with pyogenic
abscess of colonic origin. We feel that all patients with crypto-
genic pyogenic liver abscess, regardless of the presence of DM or
K. pneumoniae, should undergo colonoscopy to rule out an occult
colonic etiology.
This study had several limitations. First, the data were collected
retrospectively from the medical records of a single tertiary care
center where all patients did not undergo colonoscopy. Second, the
253
Colon cancer in cryptogenic liver abscess
colonoscopic investigation was not performed in all cryptogenic
patients, and some cases of colonic origin might therefore have
remained inappropriately categorized as cryptogenic. Third, we
could not follow up all 44 patients who had cryptogenic pyogenic
liver abscess without colonoscopic investigation.
However, we believe that our study has advantages over previ-
ous studies. Our results had a high percentage of colonoscopic
investigations in cryptogenic-origin patients, and the results are
based on concrete microbiologic data.
In conclusion, active colonoscopic investigation might be war-
ranted in cryptogenic pyogenic liver abscess patients to detect
hidden colonic malignant lesions, especially in patients who have
both DM and K. pneumoniae.
References
1 Miedema BW, Dineen P. The diagnosis and treatment of pyogenic
liver abscesses. Ann. Surg. 1984; 200: 32835.
2 Branum GD, Tyson GS, Branum MA, Meyers WC. Hepatic abscess.
Changes in etiology, diagnosis, and management. Ann. Surg. 1990;
212: 65562.
3 Jovanovic P, Zerem E, Zildzic M. Management of liver abscess
formed after asymptomatic sigmoid diverticulitis. Med. Arh. 2007;
61: 11718.
4 Niemann H, Wintzer G. Formation of a liver abscess as the first
manifestation of concealed perforated sigmoid diverticulitis. Leber
Magen Darm 1995; 25: 357.
5 Wells CD, Balan V, Smilack JD. Pyogenic liver abscess after
colonoscopy in a patient with ulcerative colitis. Clin. Gastroenterol.
Hepatol. 2005; 3: xxiv.
6 Margalit M, Elinav H, Ilan Y, Shalit M. Liver abscess in
inflammatory bowel disease: report of two cases and review of the
literature. J. Gastroenterol. Hepatol. 2004; 19: 133842.
7 Song J, Swekla M, Colorado P, Reddy R, Hoffmann S, Fine S. Liver
abscess and diarrhea as initial manifestations of ulcerative colitis:
case report and review of the literature. Dig. Dis. Sci. 2003; 48:
41721.
8 Lai HC, Chan CY, Peng CY, Chen CB, Huang WH. Pyogenic liver
abscess associated with large colonic tubulovillous adenoma. World
J. Gastroenterol. 2006; 12: 9902.
9 Leiba A, Apter S, Avni I, Osherov A, Thaler M, Grossman E.
Pyogenic liver abscessan unusual presentation of colonic villous
adenoma. Harefuah 2003; 142: 3367.
10 Lonardo A, Grisendi A, Pulvirenti M et al. Right colon
adenocarcinoma presenting as Bacteroides fragilis liver abscesses. J.
Clin. Gastroenterol. 1992; 14: 3358.
11 Teitz S, Guidetti-Sharon A, Manor H, Halevy A. Pyogenic liver
abscess: warning indicator of silent colonic cancer. Report of a case
and review of the literature. Dis. Colon Rectum 1995; 38: 12203.
12 Tzur T, Liberman S, Felzenstein I, Cohen R, Rivkind AI, Almogy G.
Liver abscesses caused by Streptococcus milleri: an uncommon
presenting sign of silent colonic cancer. Isr. Med. Assoc. J. 2003; 5:
2067.
13 Matsushita M, Hajiro K, Okazaki K, Takakuwa H, Nishio A.
Endophthalmitis with brain, lung, and liver abscesses associated with
an occult colon cancer. Am. J. Gastroenterol. 2000; 95: 36645.
14 Lim WC, Lim CC. Silent colorectal carcinoma and pyogenic liver
abscess. J. Gastroenterol. Hepatol. 2004; 19: 9456.
15 Weng SW, Liu JW, Chen WJ, Wang PW. Recurrent Klebsiella
pneumoniae liver abscess in a diabetic patient followed by
Streptococcus bovis endocarditisoccult colon tumor plays an
important role. Jpn. J. Infect. Dis. 2005; 58: 702.
254
2011 Journal of Gastroenterology and Hepatology Foundation and Blackwell Publishing Asia Pty Ltd
SW Jeong et al.
16 Siegert CE, Overbosch D. Carcinoma of the colon presenting as
Streptococcus sanguis bacteremia. Am. J. Gastroenterol. 1995; 90:
15289.
17 Gamberini S, Anania G, Incasa E et al. Staphylococcus hemolyticus
liver abscess as an uncommon presentation of silent colonic cancer:
a case report. J. Am. Geriatr. Soc. 2006; 54: 161920.
18 Lee JK, Kum J, Ghosh P. Nonmetastatic cancer of the colon
associated with pyogenic liver abscess. Am. J. Gastroenterol. 2008;
103: 7989.
19 Hsu WH, Yu FJ, Chuang CH, Chen CF, Lee CT, Lu CY. Occult
colon cancer in a patient with diabetes and recurrent Klebsiella
pneumoniae liver abscess. Kaohsiung J. Med. Sci. 2009; 25:
98103.
20 Gross RG, Reiter B, Korsten MA. Pyogenic liver abscess
complicating colonoscopic polypectomy. Gastrointest. Endosc. 2008;
67: 7678.
21 The Expert Committee on the Diagnosis and Classification of
Diabetes Mellitus. Report of the expert committee on the diagnosis
and classification of diabetes mellitus. Diabetes Care 1997; 20:
118397.
22 Lai HC, Lin HC. Cryptogenic pyogenic liver abscess as a sign of
colorectal cancer: a population-based 5-year follow-up study. Liver
Int. 2010; 30: 138793.
23 Delamaire M, Maugendre D, Moreno M, Le Goff MC, Allannic H,
Genetet B. Impaired leucocyte functions in diabetic patients. Diabet.
Med. 1997; 14: 2934.
24 Nilsen TI, Vatten LJ. Prospective study of colorectal cancer risk and
physical activity, diabetes, blood glucose and BMI: exploring the
hyperinsulinaemia hypothesis. Br. J. Cancer 2001; 84: 41722.
25 Giovannucci E, Michaud D. The role of obesity and related
metabolic disturbances in cancers of the colon, prostate, and
pancreas. Gastroenterology 2007; 132: 220825.
26 Larsson SC, Orsini N, Wolk A. Diabetes mellitus and risk of
colorectal cancer: a meta-analysis. J. Natl. Cancer Inst. 2005; 97:
167987.
27 Foo NP, Chen KT, Lin HJ, Guo HR. Characteristics of pyogenic
liver abscess patients with and without diabetes mellitus. Am. J.
Gastroenterol. 2010; 105: 32835.
28 Yu SC, Ho SS, Lau WY et al. Treatment of pyogenic liver abscess:
prospective randomized comparison of catheter drainage and needle
aspiration. Hepatology 2004; 39: 9328.
29 Yang CC, Yen CH, Ho MW, Wang JH. Comparison of pyogenic
liver abscess caused by non-Klebsiella pneumoniae and Klebsiella
pneumoniae. J. Microbiol. Immunol. Infect. 2004; 37: 17684.
30 Chou FF, Sheen-Chen SM, Chen YS, Lee TY. The comparison of
clinical course and results of treatment between gas-forming and
non-gas-forming pyogenic liver abscess. Arch. Surg. 1995; 130:
4015. discussion 6.
31 Yang CC, Chen CY, Lin XZ, Chang TT, Shin JS, Lin CY. Pyogenic
liver abscess in Taiwan: emphasis on gas-forming liver abscess in
diabetics. Am. J. Gastroenterol. 1993; 88: 191115.
32 Kuo CM, Kuo CH, Changchien CS. Liver abscess in patients with
cirrhosis of the liver: a 12-year experience. J. Gastroenterol. 2001;
36: 5526.
33 Cheng DL, Liu YC, Yen MY, Liu CY, Shi FW, Wang LS. Pyogenic
liver abscess: clinical manifestations and value of percutaneous
catheter drainage treatment. J. Formos. Med. Assoc. 1990; 89:
5716.
34 Lederman ER, Crum NF. Pyogenic liver abscess with a focus on
Klebsiella pneumoniae as a primary pathogen: an emerging disease
with unique clinical characteristics. Am. J. Gastroenterol. 2005; 100:
32231.
35 Seeto RK, Rockey DC. Pyogenic liver abscess. Changes in etiology,
management, and outcome. Medicine (Baltimore) 1996; 75: 99113.
Journal of Gastroenterology and Hepatology 27 (2012) 248255
 SW Jeong et al.
36 Okano H, Shiraki K, Inoue H et al. Clinicopathological analysis of
liver abscess in Japan. In.t J. Mol. Med. 2002; 10: 62730.
37 Wang JH, Liu YC, Lee SS et al. Primary liver abscess due to
Klebsiella pneumoniae in Taiwan. Clin. Infect. Dis. 1998; 26:
14348.
38 Lee KT, Wong SR, Sheen PC. Pyogenic liver abscess: an audit of
10 years experience and analysis of risk factors. Dig. Surg. 2001;
18: 45965. discussion 656.
39 Yang YS, Siu LK, Yeh KM et al. Recurrent Klebsiella pneumoniae
liver abscess: clinical and microbiological characteristics. J. Clin.
Microbiol. 2009; 47: 33369.
40 Cheng DL, Liu YC, Yen MY, Liu CY, Wang RS. Septic metastatic
lesions of pyogenic liver abscess. Their association with Klebsiella
Journal of Gastroenterology and Hepatology 27 (2012) 248255
2011 Journal of Gastroenterology and Hepatology Foundation and Blackwell Publishing Asia Pty Ltd
View publication stats
Colon cancer in cryptogenic liver abscess
pneumoniae bacteremia in diabetic patients. Arch. Intern. Med. 1991;
151: 15579.
41 Fung CP, Chang FY, Lee SC et al. A global emerging disease
of Klebsiella pneumoniae liver abscess: is serotype K1 an
important factor for complicated endophthalmitis? Gut 2002; 50:
4204.
42 Ma LC, Fang CT, Lee CZ, Shun CT, Wang JT. Genomic
heterogeneity in Klebsiella pneumoniae strains is associated with
primary pyogenic liver abscess and metastatic infection. J. Infect.
Dis. 2005; 192: 11728.
43 Rahimian J, Wilson T, Oram V, Holzman RS. Pyogenic liver
abscess: recent trends in etiology and mortality. Clin. Infect. Dis.
2004; 39: 16549.
255