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The Journal of Emergency Medicine, Vol. 28, No. 3, pp. 337–339, 2005Copyright © 2005 Elsevier Inc.

Printed in the USA. All rights reserved0736-4679/05 $–see front matter

doi:10.1016/j.jemermed.2004.08.024

Visual Diagnosisin Emergency Medicine

HEPATIC ABSCESS

Rachel Pearl, MD, Diana Pancu, MD, and Eric Legome, MD

Department of Emergency Medicine, Bellevue Hospital/New York University, New York, New York

Reprint Address: Rachel C. Pearl, MD, Emergency Medical Services, 1st Avenue and 27th Street, New York, NY 10016

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CASE REPORT

44-year-old previously healthy man presented to themergency Department (ED) with a chief complaint of

ever, chills, and right upper quadrant abdominal pain forweeks. The patient was treated with oral levofloxacin

or unclear reasons at the onset of his complaints 2 weeksrior without improvement. Past medical and surgicalistory was unremarkable. Review of systems was neg-tive for cough, hematuria, urinary symptoms, nausea,omiting or change in stool habits. Social history re-ealed that the patient had moved to the United Statesrom Taiwan several years prior and had not traveledince that time. He denied risk factors for human immu-odeficiency virus or hepatitis.

Vital signs revealed temperature 39.5°C (103.3°F),lood pressure 109/66 mm Hg, heart rate 129 beats/min,nd respiratory rate 18 breaths/min. Physical examinationevealed a well-developed 44-year-old man in moderateistress secondary to abdominal discomfort. Pertinent phys-cal findings included: anicteric sclerae, cardiopulmonaryxamination notable only for tachycardia, and abdominalxamination significant for a palpable liver 2 cm below theight costal margin with right upper quadrant tenderness.here was no guarding or rebound. Bowel sounds wereormal and there was no splenomegaly.

Laboratory studies yielded the following abnormalesults: hematocrit, 32.5 g/dL; white blood cell count,0,800; platelet count, 609,000; sodium, 133 mEq/dL;nd alkaline phosphatase, 158 U/L. The other laboratoryesults, including remaining chemistry, other liver and

ECEIVED: 31 December 2003;

CCEPTED: 12 August 2004

337

ancreatic enzymes, were within normal limits. Urinal-sis was negative. Chest radiograph revealed elevation ofhe right hemidiaphragm with blunting of the right costo-hrenic angle.

Bedside abdominal ultrasonography was performed inhe ED (Figure 1), revealing a septated mass within theiver, as well as diffuse gallbladder wall thickening with-ut the presence of gallstones. Given the appearance onedside abdominal ultrasound, therapy was institutedith intravenous levofloxacin and metronidazole for the

mpiric treatment of hepatic abscess. Abdominal com-uted tomography (CT) scan (Figure 2), obtained severalours later, confirmed the presence of a hepatic abscessn the right hepatic lobe. The patient was admitted to theedical service where he underwent ultrasound and flu-

roscopic-guided needle aspiration, yielding 400 cc ofurulent yellow fluid. A pigtail catheter was inserted forontinued drainage. Culture of the fluid subsequentlyrew klebsiella pneumoniae. The patient was dischargedfter a 12-day course of intravenous antibiotics. A fol-ow-up abdominal CT scan at 2 weeks showed resolutionf the abscess.

DISCUSSION

he incidence of pyogenic liver abscess ranges from0–20 cases per 100,000 hospital admissions. The mostommon location for abscess formation is the right he-atic lobe (75%) followed by the left hepatic lobe (20%)

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338 R. Pearl et al.

nd the caudate lobe (5%). The disease is most prevalentn individuals aged 50–60 years (1).

In the pre-antibiotic era, untreated appendicitis washought to be the most common cause of abscessormation. Obstructive biliary disease now seems toccount for the majority of identifiable causes. Infec-ion via the portal route, as with diverticulitis, pyelo-

igure 1. Right upper quadrant ultrasound demonstrated a l

igure 2. Contrast abdominal CT scan confirmed the presence of

hlebitis, appendicitis, and proctitis is also common.ther proposed routes of hepatic microbial invasion

nclude direct extension from a contiguous location,enetrating trauma, and hepatic arterial microembolichenomenon with severe sepsis. Cryptogenic ab-cesses account for nearly half of all cases and occurore commonly in patients with systemic illness such

eptated hypoechic mass (arrows).

a located hepatic abscess (arrows).

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Hepatic Abscess 339

s diabetes mellitus, cardiopulmonary disease, malig-ancy and cirrhosis.

The microbiology of pyogenic abscess depends on thenitial source of infection, but most infections are thoughto be polymicrobial. Escherichia coli and klebsiellaneumoniae are by far the most common isolates, butnterococcus, viridans streptococcus, bacteroides andtaphylococcus aureus also have been identified. There isesearch to suggest a higher frequency of klebsiellaneumoniae in patients of Taiwanese origin (2).

Fever, jaundice and right upper quadrant pain repre-ent the classic “triad” in patients with hepatic abscess.alaise, vomiting, anorexia, fatigue and weight loss are

lso seen, but none of these complaints is either sensitiver specific for the diagnosis. Abnormalities on physicalxamination may include hepatomegaly, jaundice, andight upper quadrant tenderness. Leukocytosis and ele-ation of alkaline phosphatase are common laboratorybnormalities. Other abnormal markers of liver functionnd hepatocellular damage are less common. Radio-raphic imaging studies are essential in diagnosis, and

oth ultrasonography and CT scan have demonstrated

ood accuracy. Sonography is limited, particularly whenbscesses are small, isoechoic and solitary, but still has aensitivity of around 79% (3), suggesting a valuable roleor emergency bedside ultrasonography for early diag-osis and rapid treatment. CT scan has a sensitivity of8% but may not be obtainable in patients with allergieso intravenous contrast. The treatment of choice for pyo-enic abscess is radiography-guided needle aspirationnd drainage in conjunction with intravenous antibiotics.n this patient we were able to identify multiple ab-cesses and institute early empiric therapy based on theesults of our bedside study in conjunction with historicalnd physical factors.

REFERENCES

. Johannsen EC, Sifri CD, Madoff LC. Pyogenic liver abscesses.Infect Dis Clin North Am 2000;14:547–63.

. Chang SC, Fang CT, Hsueh PR, Chen YC, Luh KT. Klebsiellapneumoniae isolates causing liver abscess in Taiwan. Diagn Micro-biol Infect Dis 2000;37:279–84.

. Hernandez JL, Ramos C. Pyogenic hepatic abscess: clues for diag-nosis in the emergency room. Clin Microbiol Infect 2001;7:

567–70.