POINT OF VIEW

Pyogenic Abscess of the Liver

Americo A. Abbruzzese, MD

Invasion of the liver by pus-forming orga- nisms, with subsequent formation of single or multiple pyogenic abscesses, is a rare sequel to any disease. First described in 1846 as a direct complication of appendicitis, the pyogenic liver abscess was further defined as a clinical entity by Fitz (1) in his classic description of appen- dicitis, who recorded 11 cases in 257 appendec- tomies. By the turn of the century, "le fois ap- pendiculaire" (2) was well known to French clinicians as a condition from which recovery Was extremely rare. However, Dieulafoy was fiware that recovery was possible through time- ly surgery and strongly urged early and ag- gressive surgical intervention in all suspected cases of appendicitis. The soundness of this ex- hortation was clearly demonstrated by the progressive decline in the hepatic complication of appendicitis, even before the advent of chemotherapy, from 0.5% to less than 0.1%. With the availability of antibiotics and improved operative technics, suppurative appendicitis has become less dangerous and is no longer the most common cause of portal pyemia.

Despite the almost total eradication of "le fois appendiculaire," the incidence of pyogenic liver disease has remained constant and has not become, as anticipated, "rarer owing to im- proved treatment of appendicitis" (3). In 3 consecutive 5-year periods (1955-1970) the number of patients observed with pyogenic liver abscesses was essentially the same (4).

The dramatic surgical success in the treat- ment of appendicitis has eluded, by a wide

From the Peter Bent Brigham Hospital, Boston, Mass. Address for reprint requests: Dr Americo Abbruzzese,

Peter Bent Brigham Hospital, 721 Huntington Ave, Bos- ton, Mass 02115.

measure, the management of pyogenic liver ab- scesses. Hepatic pyemia has always had a high mortality rate. Prior to 1900, survivors of this affliction were rare, and little progress w a s

made in the next 40 years. New and potent an- timicrobials coupled with sophisticated surgical advances and refined diagnostic skills have im- proved, but not greatly altered, the ultimate prognosis. The recent literature (1960-1970) shows a 50 to 90% mortality rate among pa- tients with pyogenic liver abscesses (4 7) . However, many deaths are unavoidable, either because the primary disease process is often lethal in its own right or because the primary focus becomes complicated by metastatic liver abscesses which are rarely responsive to any form of therapy. Conversely, the solitary ab- scess is a curable lesion; the high mortality rate associated with it is clearly ascribable to de- creased awareness of this entity. There are sev- eral reasons for this default: a) the abscess is frequently cryptogenic and, without ante- cedent evidence of sepsis or t rauma, the possi- bility of portal pyemia is not aggressively pursued; b) the septic focus seeding the liver may be clinically silent or considered a benign condi t ion--eg , diverticulitis or conservatively treated calculous biliary disease; c) lack of local symptoms and signs, together with only minor chemical changes in liver function, sug- gest that the liver is uninvolved and encour- age a shift in at tention to other organs.

Despite a paucity of consistently reliable clinical and chemical indicators~ suppurative hepatic necrosis can be diagnosed accurately and treated successfully provided the clinician has some knowledge of this condition and an awareness that a liver abscess may underlie any case of prolonged, unexplained fever. Vitally

Digestive Diseases, Vol. 17, No. 9 (September 1972) 829

important at this point is hepatic scintiscanning with mult iple views. The scintogram is the most consistently useful diagnostic aid avail- able. It is simple, nontraumatic and has a high degree of overall accuracy for locating lesions 2 cm or larger. Improved technics and special equipment can now identify defects 1 cm in size (8).

Wi th this overview in mind, the pyogenic liver abscess should no longer continue to humble the diagnostic acumen of skilled and imaginative physicians.

REFERENCES

1. Fitz RH: Perforating inflammation of the vermi- form appendix. Am J Med Sci 92:321 346, 1886

ABBRUZZESE

2. Dieulafoy: Le foie appendiculaire: ab~es du foie consecutifs ~. l'appendicite. Semaine Medicale (Paris) 18:449-452, 1889

3. Peri- and intrahepatic abscess. Proc Roy Soc Med 63:319-325, 1970

4. Altemeier WA, Schowengerdt CG, Whiteley DH: Abscess of the liver. Arch Surg 101:258-265. 1970

5. Cronin K: Pyogenic abscess of the liver. Gut 2:53 61, 1961

6. Joseph WL, Kahn AM, Longmire WP .Jr: Pyo- genic liver abscess. Am J Surg 115:63-68, 1968

7. Butler T J, McCarthy CF: Pyogenic liver abscess. Gut 10:389-399, 1969

8. Samuels LD: Liver abscesses and other intrahe- patic disorders. Clin Pediatr 10:731-735, 1971

830 Digestive Diseases, Vol. 17, No. 9 (September 1972)