liver abscess.docx
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Liver Abscess
Gastroenterology> Liver Abscess
Key points
A liver abscess is a pus-filled cavity within the liver, usually caused by a biliary tractsource; occasionally, multiple cavities are seen
Origin may be pyogenic, amebic, or (rarely, and usually in severelyimmunocompromised patients) fungal
Clinical presentation is with fever and abdominal pain but is frequently nonspecific,without localized right upper quadrant symptoms
Computed tomography (CT), both with and without intravenous and oral contrast, andultrasound are the imaging studies of choice
Treatment involves antimicrobial therapy with or without percutaneous or surgicaldrainage Liver abscess is almost uniformly fatal if left untreated. Timely treatment reduces
mortality to 5% to 30%
Background
Description
The most common source of liver abscess is the biliary tree in patients withcholecystitis, choledocholithiasis, or cholangitis
Less common sources include other intra-abdominal processes, such as appendicitisor diverticulitis, and hematogenous spread from sources such as an infected heart
valve or the oral cavity
Amebic liver abscess should be considered in endemic areas or patients who havebeen to the tropics
Fungal microabscesses are seen primarily in patients with compromised immunesystems
Rarely, liver abscess may be due to trauma, secondary infection from an amebicabscess or a necrotic malignant hepatic tumor, or direct extension from local
structures
Common pathogens include Streptococcus spp.,Escherichia coli,Klebsiella, andBacteroides spp. Polymicrobial infections occur in 15% to 20% of patients;
approximately the same percentage have multiple abscesses
Amebic liver abscess follows vascular spread ofEntamoeba histolytica from thecolon in patients with the intestinal infection amebiasis. Amebic abscesses may be
very large; they contain aspirate with 'anchovy-sauce' color and consistency
Liver abscess in a child suggests immunocompromise A single abscess is the most common presentation; spread to the liver via the vascular
route is associated with multiple abscesses
The right hepatic lobe is affected more than twice as frequently as the left, due tovascular anatomy
Aspiration of abscess fluid and subsequent culture guide antibiotic choice
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Failure to culture pathogenic organism(s) may be due to prior antibiotic treatment orinadequate anaerobic culture
Treatment includes antibiotics and often either percutaneous or surgicaldrainage/debridement, depending on the size, number, and complexity of the
abscess(es)
Epidemiology
Incidence and prevalence
Incidence:
Approximately 3.6 per 100,000 in the U.S., based on the Nationwide Inpatient Sampledatabase from 1994 to 2005
Reported incidence ranges from 1.1 and 2.3 per 100,000 in Denmark and Canada,respectively, to 17.6 per 100,000 in Taiwan
Amebic abscesses are significantly more common in countries with endemicamebiasis and poor healthcare
Prevalence:
Prevalence rates from autopsy data: 300 to 1,500 per 100,000 of populationDemographics
Age:
A slight peak in incidence is seen in neonates, when liver abscess may be associatedwith umbilical vein catheterization and sepsis
A gradual increase is seen beyond age 60 years, due to the average age of patientswith biliary disease
Liver abscess in children and adolescents suggests underlying immunocompromise ortrauma
Gender:
Pyogenic liver abscess shows no gender difference Amebic abscess is 10 times more common in men than in women
Race:
No racial differences other than those related to the geographic distribution ofpopulations with endemic amebiasis
Geography:
Incidence of amebic abscess is higher in areas of endemic amebiasis, such as Mexico,India, East and South Africa, and parts of Central and South America
Pyogenic liver abscess shows no geographic influence
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Socioeconomic status:
Malnutrition, immunocompromise, and excess alcohol intake (which is believed toimpair immunologic response) predispose to amebic liver abscess in those exposed to
Entamoeba histolytica
Causes and risk factors
Causes
Common causes:
Biliary tract infection (30%-60%): secondary to biliary obstructive and inflammatoryconditions (eg,cholecystitis,choledocholithiasis, andcholangitis, especially in
patients with biliary tract malignancies with biliary stents)
Infection from gastrointestinal or pelvic organs drained via the portal circulation(24%): examples includeappendicitis, diverticulitis, and perforated bowel
Unknown (20%) Hematogenous spread secondary to bacteremia (15%):infective endocarditis,
pyelonephritis, untreated oral infections, any cause of immunocompromise in children
(eg, leukemia)
Pathogens causing infection:
Most common bacterial causes:Escherichia coli,Klebsiella spp.,Proteus,Enterococcus, Staphylococcus aureus, and Streptococcus faecalis. Streptococcus
milleri and anaerobes such asBacteroides spp. are increasingly common ConsiderEntamoeba histolytica if the patient has recently traveled to the tropics or is
from an endemic area or HIV-positive
Candida albicans is the likely pathogen in patients with compromised immunesystems
Amebic liver abscess is significantly more common in men than womenRare causes:
Secondary infection from amebic liver abscess, primary and secondary malignanthepatic tumors
Direct spread of infection from local organs (empyema of the gallbladder, perinephricabscess)
Fistula between the liver and infected intra-abdominal organs, such as the hepaticflexure of the colon
Penetrating or blunt trauma to the liver Fungal pathogens in patients with compromised immune systems
Contributory or predisposing factors
Inflammatory bowel disease, particularlyCrohn disease, due to loss of integrity of themucosal barrier
Liver cirrhosis Hepatic transplant
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Hepatic artery embolization (usually in patients with a symptomatic but unresectablehepatocellular carcinoma)
Institutionalization Immunocompromise Older age (particularly associated with biliarysepsis) Malnutrition, malignancy, pregnancy, steroid use, and excessive alcohol intake
predispose to liver abscess formation
Associated disorders
Infectious and inflammatory disorders:
Abscesses caused by Streptococcus milleri may be seen in patients withCrohn disease Candidiasis:Candida albicans infection of the liver may occur in patients with
compromised immune systems
Tuberculosis Pyrexia of unknown origin Abscesses caused byKlebsiella spp. may be associated withendophthalmitis Abscesses caused by Staphylococcus aureus may be associated withinfective
endocarditisand other distant sources of infection
Empyema,peritonitis, andsepsissecondary to abscess rupture Hemorrhoidal abscess Pleural effusion Liver cirrhosis Peptic ulcer Hepatitis
Malaria
Metabolic disorders:
Alcoholism Diabetes (type 1ortype 2)
Immune deficiencies:
Neutrophil deficiencies (leukemia, chronic granulomatous disease) Severe immunocompromise in children Any cause of significant immunocompromise, for example,HIV/AIDS
Screening
Not applicable.
Primary prevention
Summary approach
Prompt treatment of biliary, gastrointestinal, pelvic, and systemic infections that mayspread to the liver is the best means of primary prevention of pyogenic abscess
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