2003 pyogenic liver abscess

CASE REPORT Journal of the Indonesian Medical Association

Jima (4)1: April 2003: 455-464. 455

Pyogenic Liver Abscess

Sugitha IGAN,* Aryasa IKN,* Sukerena IN,** Supari IA***

*Department of Child Health, **Department of Pediatrics Surgery, ***Department of Radiology

Medical Faculty of Udayana University, Sanglah Hospital, Denpasar, Bali

Abstract: Pyogenic liver abscess is one of the common liver abscesses. Worldwide, pyogenic liver abscess is much

less common than amoebic abscess, but in Western communities, pyogenic liver abscess is more frequent. Pyogenic

liver abscesses are rare in children. A three year old Balinese boy was admitted to the Department of Child Health,

Sanglah Hospital on February 13, 2002 with main complaint of the right-upper abdominal distension with pain,

fever, and loss of appetite. Laboratory results were leucocytosis, anaemia, elevated erythrocyte sedimentation rate

(ESR), normal serum transaminase, normal serum bilirubin, albumin more than 2g/dl, and negative amoeba serology.

The abdominal X-ray revealed elevated right hemidiaphragm. Liver ultrasonography revealed elevated right

hemidiaphragm. Liver ultrasonography revealed a solid mass within the right liver parenchyme. The mass margin

was clear and hypoechoic area was observed around it. Pus gram stain showed gram-negative bacilli bacteria. The

culture pus revealed Enterobacter aerogenes. An open surgical drainage was performed, combined with broad-

spectrum antibiotic therapy. The single pyogenic liver abscess was in the right liver. After an uneventful post open

surgical drainage, the child was discharged in good condition. The prognosis was good.

Key words: pyogenic liver abscess

Abstrak: Abses piogenik hati adalah salah satu abses hati yang paling sering ditemui. Umumnya abses piogenik hati

lebih jarang ditemui disbanding abses amuba, tetapi di populasi Barat, abses piogenik lebih sering dijumpai. Abses

piogenik jarang dijumpai pada anak. Seorang anak laki-laki berusia 3 tahun dating ke Bagian Kesehatan Anak

Rumah Sakit Umum Sanglah pada tanggal 13 Februari 2002 dengan keluhan utama kembung pada bagian kanan

atas perut disertai dengan nyeri, demam, dan hilangnya nafsu makan. Hasil laboratorium menunjukkan leukositosis,

anemia, ESR meningkat, serum transaminase normal, serum bilirubin normal, albumin > 2g/dl, dan uji serologi

amuba negatif. Foto abdomen menunjukkan hemidiafragma kanan yang meninggi. USG hepar menunjukkan massa

padat di parenkim kanan hepar, berbatas tegas, dikelilingi daerah hypoechoic. Pewarnaan gram dari pus

memperlihatkan bakteri basillus gram negatif. Kultur pus menghasilkan Enterobacter aerogenes. Telah dilakukan

operasi drainase terbuka, digabungkan dengan terapi antibiotik spectrum luas. Pascaoperasi, pasien dipulangkan

dalam keadaan baik. Prognosis kasus ini baik.

Kata kunci: abses piogenik hepar


Jima (4)1: April 2003. 456

Introduction

Pyogenic liver abscess is one of the

common liver abscesses. Worldwide,

pyogenic liver abscess is much less

common than amoebic abscess, but in

Western communities, pyogenic liver

abscess is more frequent. Pyogenic liver

abscesses are rare in children.1-3

Pyogenic Liver Abscess (PLA)

continues to be a significant source of

morbidity in the pediatric population.4

Although early reports in Milwaukee

Children’s Hospital between 1957-1977

quoted an incidence of 3 in 100,000

hospital admissions,3,4 recent authors

have suggested an increasing rate of

PLA, conditionally attributed to

improved overall survival of immuno-

compromised patient.4 Continuous

improvement in diagnosis and treatment

has greatly decreased the mortality from

as high as 80% before 1965 to 16% to

48% in the 1970s,3,4 while a recent series

suggested 15%.4

The patients at risk include those

with impaired host defenses, chronic

granulomatous disease and leukemia are

commonly noted.4-6

Clinical manifestation of PLA in

children are nonspecific.3-6 Diagnosis of

PLA is generally made by way of a high

index of clinical suspicion in

conjunction with appropriate imaging

techniques.4

The purpose of this paper is to report

a rare case of pyogenic liver abscess due

to Enterobacter aerogenes in a three-

year old boy.

Case

KM, a three-year-old Balinese boy

was admitted to the Department of Child

Health, Sanglah Hospital on February

13, 2002 with main complaint of the

right-upper abdominal distension. The

complaints first appeared about two

weeks before admission. On the

admission the right-upper quadrant of

abdominal distension became more

severe, and there were abdominal pain

and redness on the right hipocondrium.

Since one and a half months before

admission, fever and abdominal pain had

appeared. Loss of appetite began since

two weeks before. Three days before

admission, he had vomiting. There were

no cough, jaundice, and abnormalities of

bowel habits nor urination noted.

Prenatal and labour history was

uneventful. No history of abdominal

surgery or trauma was found.


Jima (4)1: April 2003. 457

On physical examination, he was

alert with a pulse rate of 120/minute,

respiration rate 24/minute, and rectal

temperature was 380C. His body weight

was 13,5 kg (25th percentile).

Conjunctive was pale but no jaundice on

sclera. There was no enlargement of the

cervical, axial or inguinal lymph nodes.

The physical examination of the

chest revealed symmetrical thorax with

no retraction. There were no crackles nor

wheezing heard. The heart sound was

within normal limit. On palpation there

was enlargement of the right-upper

quadrant of abdomen with hyperaemia

and pain. Hepatomegaly was also

revealed. The spleen was not palpable.

The bowel sound was normal on all

quadrants. On percussion, shifting

dullness was negative. The palms of the

hands and feet were pale, without

cyanosis.

Laboratory examination showed

white blood cell count 21,500/µL,

neutrophil 15,000//µL, haemoglobin

concentration 8.5 g/dl, haematocrite

25.2%, platelet count 586,000/µL,

erythrocyte sedimentation rate 150

mm/hr. Blood smear: erythrocyte

normochromic-normocyter. Liver

function test revealed: SGOT 26 IU/L,

SGPT 8 IU/L, total bilirubin 0.52 mg/dl,

direct bilirubin 0.16 mg/dl, alkaline

phosphatase 390 IU/L, total protein 6.65

g/dl, albumin 2,97 g/dl. Stool

examination showed on macroscopy:

blood negative; on microscopic: white

blood cell, erythrocyte and amoeba

negative.

The abdominal radiographs showed

elevated right hemidiaphragm. There

were not revealed radiopaque stone,

calcification and mass with real border.

The ileus sign was not found.

The liver ultrasonography revealed

enlargement of the liver;

echoparenchyme was normal. There was

a solid mass within the liver

parenchyme. The margin of mass was

clear and hypoechoic area around it was

found. Size of the round mass was

approximately 67 X 66 mm. The gall

bladder was difficult to be evaluated.

The conclusion of liver ultrasonography

was hepatomegaly and intrahepatic mass

with the first differential diagnosis of

carcinoma hepatocellular and the second

differential diagnosis of liver abscess.

The history, physical examination,

abdominal X-ray, and liver

ultrasonography suggested working

diagnosis of pyogenic liver abscess with


Jima (4)1: April 2003. 458

differential diagnosis of amoebic liver

abscess and anaemia normochromic-

normocyter.

The patient was given intravenous

Amicillin 500 mg three times a day.

Intravenous metronidazole 200 mg

divided three times a day. He was

referred to The Paediatric Surgery

Department and was diagnosed as a liver

abscess with anaemia and so open

surgical drainage was planned.

Intravenous Cefotaxime 500 mg three

times a day was given.

Three days later open surgical

drainage was done. There was pus on the

right lobe of liver, 200 ml yellow pus

emerged 200 ml.

After the open surgical drainage,

haemoglobin concentration decreased

(6,6 g/dl), and then blood transfusion

was administered. Haemoglobin

concentration after transfusion increased

(9,5 g/dl). Pus gram stain revealed gram-

negative bacilli bacteria and leukocyte 1-

9/large field.

Five days after open surgical

drainage, the result of pus culture-

resistance emerged as Enterobacter

aerogenes that is sensitive to Ampicillin-

sulbactam (16), Aztreonam (30),

Cefotaxime (30), Ceftazidime (26),

Ceftriaxone (28), Cefuroxime (20),

Cephalexin (32), Chloramphenicol (30),

Erythromycin (26), Gentamycin (28),

Imipenem (22), Kanamycin (22).

Cytology of pus showed acellular

specimen with amorph only. The

malignant cell was not found.

The amoeba serology was negative.

On serial stool examination, amoeba was

found negative.

Then diagnosis pyogenic liver

abscess was made. Medicament therapy

was given for 7 days with intravenous

cefotaxime followed by oral sefradine

for 7 days. Metronidazole was stopped.

The following day after the abscess

drainage, the result of laboratory

examination returned to normal. White

blood cell count 15,300/µL,

haemoglobin concentration 9.62 g/dl,

haematocrite 27.7%, platelet count

726,000/µL, erythrocyte sedimentation

rate 58 mm/hr. Liver function test

revealed: SGOT 36 IU/L, SGPT 16

IU/L, total bilirubin 0.32 mg/dl, direct

bilirubin 0.04 mg/dl, alkaline

phosphatase 173 IU/L.

After an uneventful post abscess

drainage recovery, the child was

discharged from hospital in good

condition.


Jima (4)1: April 2003. 459

Discussion

Pyogenic liver abscess is a disease of

middle-aged and older people7 both

sexes are affected about equally.7

Geographic variation in disease

frequency are not obvious, and there is

no racial susceptibility.7 Our patient is a

rare case, because he was three years

old.

Clinical manifestations of PLA in

Children commonly include malaise,

anorexia, nausea, vomiting, and loss of

weight.3,7 Fever, abdominal pain, right-

upper quadrant tenderness, and

hepatomegaly are common sign.4,6

Jaundice is uncommon.6 In our case, the

patient had similar symptom and sign

including anorexia, vomit, fever,

abdominal pain, right-upper quadrant

distension, and hepatomegaly. Jaundice

was not present.

Routine laboratory study, like

clinical presentation, is not specific for

liver abscess and generally reflects any

underlying disease of the patient.3,5,8

White blood count is generally elevated

with an increased proportion of

polymorphonuclear neutrofil.1,5

Although there is no comparable

paediatric figure available, anaemia is

found in 50% and elevated

sedimentation rate in 90% of adult

patients.3,6 Liver function test revealed

elevated bilirubin and alkaline

phosphatase in the presence of biliary

obstruction.1,3,5,7 Transaminases are

usually mildly elevated3,5,7 and may be

in normal range.3 Albumin levels reflect

disease severity, and levels below 2 g/dl

carry a poor prognosis.7 In our case,

Laboratory examination showed white

blood cell count was elevated with

neutrophilia, haemoglobin concentration

less than normal, erythrocyte

sedimentation rate was high. Liver

function test revealed serum

transaminases were normal, bilirubin

was normal, alkaline phosphatase was

high, albumin was no less than 2 g/dl.

Chest radiographs were found to be

abnormal in more than 50% of adults

with liver abscess, with findings

including right-side atelectasis,

infiltrates, pleural effusion, and elevation

of the right hemidiaphragm5,6,7 If

infection is with gas-forming organisms,

air-fluid level may be seen below the

diaphragm on chest or abdominal film.5,7

In our patient, the abdominal

radiographs showed elevated right

hemidiaphragm, but pleural effusion was

not found. We could not see air-fluid


Jima (4)1: April 2003. 460

level because we did not do postero-

anterior chest radiographs.

Ultrasonography showed pyogenic

liver abscess as round, ovoid, or elliptic

lesions within the liver parenchyme,

most often not contiguous with the liver

capsule. The margin of each lesion is

irregular and echo-poor. Abscesses are

mostly hypoechoic compared with

normal liver parenchyme, which

contained a variable number of internal

echoes. A hyperechoic appearance is

occasionally seen, particularly when gas-

forming organisms are present.7

Pyogenic liver abscess is usually found

in the right hepatic lobe,7,9 and mostly

solitary liver abscess(77,8%).10 In our

case, the liver ultrasonography revealed

the enlagement of the liver;

echoparenchyme was normal. There was

a solid mass within the right liver

parenchyme. The margin of mass was

clear and hypoechoic area around it was

found. Size of the round mass was

approximately 67 X 66 mm. The gall

bladder was difficult to evaluate. The

conclusion of liver ultrasonography was

hepatomegaly with mass intrahepatic.

The first differential diagnosis of

carcinoma hepatocellular and the second

differential diagnosis of liver abscess

were established.

CT scanning is highly sensitive for

diagnosis of intraabdominal abscess

including liver abscess.5,7 In liver the

lesion appeared as areas of decreased

attenuation. An advantage of CT

scanning over ultrasonography is that the

quality of the scan is not affected by

bowel gas or foreign objects such as

tubes and dressings.7 In our case, CT

scanning was not done.

Blood cultures should be taken

before the initiation of therapy. Although

many authors quote 50% as the expected

rate of positive culture, in some reports,

the success rate has been almost 100%.7

Paediatric patients with multiple

abscesses are even more likely to have

positive blood cultures than those with

single abscesses.3 If aspiration is

performed, pus, not swabs, should be

submitted to the laboratory, as promptly

as possible. Aspirate pus is variably

coloured, usually not dark brown or red-

brown as is amoebic abscess content,

and frequently is foul smelling.7 Gram

stain usually shows organisms unless

there has been substantial preceding

antibiotic treatment. The submitted

material should be cultured for aerobic,


Jima (4)1: April 2003. 461

anaerobic, and microaerophilic

organisms.7

In our case, pus aspiration was not

performed. We took the pus from open

surgical drainage of abscess. The colour

of pus was yellow with foul smelling.

The result of the pus gram stain was

gram-negative bacilli bacteria and

leukocyte 1-9/large field. Blood culture

was not done.

The presence of a liver abscess may

be suggested by the patient’s history,

physical examination, results of

laboratory test and is confirmed by

imaging techniques.7 In most cases, a

confident diagnosis is reached

combining epidemiological, clinical, and

radiological features with the results of

blood cultures and amoebic serology.7

Negative amoebic serology virtually

excludes the diagnosis of hepatic

amoebiasis, despite rare cases in which

serologic test becomes positive after the

patient’s initial presentation.7 In our

patient, before the open surgical

drainage, diagnosis of single liver

abscess on the right liver was

established.

Differential diagnosis of pyogenic

liver abscess were amoeba liver abscess,

subphrenic abscess, malignancy of the

liver, or acute cholecystitis.1

In our patient, Cefotaxime and

Metronidazole was given combined with

open surgical drainage. The result of

pus-culture Enterobacter aerogenes,

indicated while amoebic serology was

negative, and the diagnosis of pyogenic

liver abscess was established. After that

Metronidazole was stopped, the patient,

was also given transfusions of blood

after open surgical drainage. On the

literature, the traditional treatment for

pyogenic liver abscess has been open

surgical drainage combined with broad-

spectrum antibiotics. In recent time,

percutaneous drainage has been applied

to hepatic abscesses because it has more

safety more safe and effective

procedure.7,11-13 Small abscess of less

than 3-4 cm may be resolved with

prolonged antibiotic therapy.5

Pyogenic liver abscess may arise

from (1) the portal circulation in patient

with pyleplebitis or intra-abdominal

sepsis (appedicitis, inflammatory bowel

disease); (2) generalized sepsis; (3)

cholangitis associated with biliary tract

obstruction, such as gallstones, in

inflammatory bowel disease, after a

Kasai procedure, and with choledochal


Jima (4)1: April 2003. 462

bowel cyst; (4) Systemic spread from an

intra-abdominal infection or contiguous

spread (which usually produces large

abscess); and (5) cryptogenic biliary

tract infection.3,6 Small abscesses

(microabscesses) are most commonly

secondary to bacteremia, or candidemia.6

In our case, PLA was large abscess that

may arise from systemic spread from an

intra-abdominal.

Most pyogenic liver abscesses are

secondary to infection originating in the

abdomen.14 E. coli remains the single

bacterium most frequently isolated in

most reported series.7 Other important

aerobic organisms are various gram-

negative bacilli, including species of

Klebsiella, Proteus, and Pseudomonas,

and gram-positive enteric organisms,

such as Streptococcus faecalis and

Streptococcus faecum. The latter two

agents are referred to as enterococci.5,7

The importance of anaerobic and

microaerophilic organisms in liver

abscess are a recent recognition. As

many as one third to one half of patients

may be infected with such organisms.

Anaerobic organism incriminated

include Bacteroides sp, Fusobacterium

sp, anaerobic streptococci

(Peptostreptococcus and Peptococcus

spp), and rarely, Clostridium sp.

Microaerophilic streptococci are

considered by some authors as the most

common of all organisms that cause liver

abscess. Streptococcus milleri is the

most important member of the group.7

Unusual organisms documented as

causing liver abscess on occasion

includes species of Salmonella,

Haemophilus, and Yersinia.

Actinomycosis, tuberculosis, and

melioidosis may also be associated with

liver abscess.5,7

Complications of PLA are rupture

into the peritoneum or biliary system,

septicaemic empyema, curiously

endophthalmitis,5 septicemias, metastatic

abscess, direct extension, hypotension

and shock, respiratory distress

syndrome, mental obtundation, and renal

failure. This complication was not found

in our patient.

Delay in diagnosis and treatment of

pyogenic liver abscess has a major effect

on outcome.7,15 Reports of successful

medical management, with or without

aspiration, describe case-fatality rate as

low as 10%. The prognosis is also

related to underlying disease.7 Mortality

seems greater in patients with multiple

abscesses.7 Our patient’s prognosis is


Jima (4)1: April 2003. 463

good, because the cause of liver abscess

is clear; single abscess, with albumin

more than 2 g/dl, and diagnosis and

treatment were performed early.

Summary

A case of pyogenic liver abscess in a

three-years-old Balinese boy has been

reported. The diagnosis of pyogenic liver

abscess was suspected by way of the

patient’s history, physical examination,

results of laboratory test, imaging

techniques and confirmed by pus-

culture. The single pyogenic liver

abscess was in the right liver. The

treatment of choice was open surgical

drainage combined with antibiotic

therapy. The prognosis of this patient

was good.

References

1. Kapoor OP. Amoebic liver abscess.

Available from http://www.bhj.org/

books/liver/s6c02.htm

2. Taylor LA, Ross AJ. Abdominal

masses. In: Walker WA. Pediatric

gastrointestinal disease

pathophysiology, diagnosis,

management. second edition.

Baltimore: Mosby, 1996;227-30.

3. Puck JM. Bacterial, parasitic, and

other infections of the liver. In:

Walker WA. Pediatric

gastrointestinal disease

pathophysiology, diagnosis,

management. second edition.

Baltimore: Mosby, 1996;1075-83.

4. Novak DA, Dolson DJ. Bacterial,

parasitic, and fungal infections of the

liver. In: Suchy FJ. Liver Disease in

Children. Baltimore: Mosby, 1994;

550-2.

5. Mowat AP. Liver disorder in

childhood. third edition. Oxford:

Butterworth-Heinemann, 1994;138-

50.

6. Balistreri WF. Liver Abscess. In:

Behrman RE, Kliegman RM, Arvin

AM, editors. Nelson Textbook of

Pediatrics 16th edition. Philadelphia:

WB Sounders, 2000;1141-2.

7. DeCock KM, Reynolds TB. Amebic

and pyogenic liver abscess. In: Schiff

l, Schiff ER. Disease of the liver

seventh edition. Philadelphia: JB

Lippincott Company, 1993;1320-37.

8. Kong Ms, Lin JN. Pyogenic liver

Abscess in children. J Formos Med

Assoc 1994; 93(1): 45-50.


Jima (4)1: April 2003. 464

9. Spiegel R, Miron D, Horovitz Y.

Pyogenic liver Abscess in children.

Harefuah 1997; 133(12): 613-5.

10. Kumar A, Srinivasan S, Sharma AK.

Pyogenic liver Abscess in children-

South Indian experiences. J Pediatr

Surg 1998; 33(3): 417-21.

11. D’Albuquerque LA, Ulflacker R,

Genzini T. Pyogenic liver abscess:

analysis of 36 cases treated by

percutaneous drainage: Rev Assoc

Med Bras 1993; 39(1): 12-6.

12. Lin CC, Huang SC, Tiou MM.

Pyogenic liver abscesses

complicated with abscess-duodenum

fistula in a child: report of one case.

Acta Paediatr Sin 1996; 37(1): 45-7.

13. Setto RK, Rockey. Pyogenic liver

Abscess Changes in etiology,

management and outcome. Medicine

1996; 75(2): 99-115.

14. Krige JEJ, Beckingham IJ. Liver

abscess and hydatid disease. BMJ

2001; 322: 537-40.

15. Corbella X, Vadillo M, Torras J.

Presentation, diagnosis and treatment

of pyogenic liver abscess: Analysis

of a series of 63 cases. Enferm Infec

Microbiol Clin 1995: 13(2): 80-4.

2003 pyogenic liver abscess

Documents