LIVER ABSCESS

Marc RichardsMorning Report

September 8th, 2009

CLASSIFICATIONS

• PYOGENIC• Gram Positive• Gram Negative• Anaerobic• (Polymicrobial)

• AMEBIC

• CANDIDA

• TB (rare)

EPIDEMIOLOGY

• Pyogenic Abscesseso Bacterialo Most common o M > F 3:1

• Entamoebao M > F 7:1o 40-50 million amoeba infections/year

worldwideo Age Extremeso Endemic Areas most susceptible

o Country of origin or Travel

RISK FACTORS

• PYOGENIC• DM• Cancer• Liver Transplant

• ENTAMOEBA• Pregnancy• Steroids• Cancer• Endemic area travel (short

or long term)• EtOH?

PATHOPHYS.

• PYOGENIC:o Peritonitis

To liver via portal circulation

o Direct Spreado Biliary infections

o Hematogenous Seedingo Look for bacteremia!

o Sites: R lobe most commono Blood supply

PATHOPHYS.

• ENTAMOEBA:o Fecal-Oral transmission into GI Tract

To liver via portal circulation

o Can also spread to other extraintestinal siteso Hearto Braino Lungs

CLINICAL MANIFESTATIONS

o SYMPTOMSo Fever (90%)o RUQ pain (50-75%)o Constitutional Sxo Diarrhea (<30%)

o SIGNSo Hepatomegaly (50%)o RUQ tendernesso Jaundiceo Acute abdomen

(<7%)

WORKUP• CBC (leukocytosis)

• LFTs • AlkPhos elevated (67-90%)• AST/ALT elevated (50%)• TBili elevated (50%)

• Blood Cultures• Bacteremia (50%)• E Histolytica Ab• Echinococcus Ab

• Imaging- US, CT, MRI• Can not differentiate types of abscess

ULTRASOUND

CT/MRI

Fluid Collection w/ surrounding stranding, edema, and inflammation

DIAGNOSTIC PROCEDURE

***IMAGING-GUIDED DRAINAGE***

***SEND FOR CULTURE***

WHAT MAY GROW…• POLYMICROBIAL (including anaerobes)• GRAM NEGATIVES (think gut bugs)• E. Histolytica

• Money is in the serum Ab (95%)• Less yield with wet-mount of abscess or fecal microscopy

(<20%)

• OTHERS• Strep Milleri group• S Aureus (chemoembo) • S Pyogenes (chemoembo)• Candida (s/p chemo)• Klebsiella• TB• Burkholderia

TREATMENT

• TO DRAIN OR NOT TO DRAIN:• <5cm, single abscess- needle aspiration or catheter• >5cm- catheter• Also: Surgery, ERCP

• Amoeba: drainage not usually required• Exceptions:

• Verge of rupture• Abx not working• Imminent need to exclude other dx

TREATMENT-ABX

• Pyogenic: Gram Neg + Anaerobe cov.• Unasyn• Zosyn• 3rd gen Ceph (Rocephin) + Flagyl• PCN Allergy: FQ + Flagyl, Carbapenem

• Course: 4-6 weeks• IV duration depends on f/u imaging• Suitable PO Abx: Augmentin OR FQ + Flagyl

• Amoeba: Flagyl 500-750mg TID 7-10days• Then follow with lumenal antiamebic

• Usually Paromomycin TID 10d

PROGNOSIS & NATURAL HISTORY

• Mortality 2-12%• Often due to comorbidities, not necessarily

abscess itself

TAKE HOME MESSAGE

• Think Pyogenic (usually gram neg/anaerobe) or E.Histolytica

• Broad Spectrum Abx at first• Image Image Image• Imaging-Guided Culture +/- JP Drain• Treat for 4-6 weeks

• MIAMI > FLORIDA STATE

REFERENCESeMedicine

Current 2007

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