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  • GE J Port Gastrenterol. 2013;20(1):21---24

    www.elsevier.pt/ge

    CLINIC CASE

    Multiple, large pyogenic liver abscesses treated conservatively: Acase-report and review of the literature

    Christos E. Lampropoulosa,, Ioanna Papaioannoua, Zoi Antonioub, Kyriaki Ermidoua,Efi Papadimab, Nikos Spiliopoulosa, Manolis Choustoulakisc,Grigoris Apostolidisa, Konstantina Alexopouloua, Panagiotis Herasa

    a Department of Internal Medicine, General Hospital of Nafplio, Greeceb Department of Radiology, General Hospital of Nafplio, Greecec Department of Surgery, General Hospital of Nafplio, Greece

    Received 5 October 2011; accepted 5 October 2011Available online 25 October 2012

    KEYWORDSLiver abscess;Amebic abscess;Laboratory diagnosis;Treatment

    Abstract Pyogenic liver abscesses are a rare cause of admission. Treatment consists of com-bined antibiotics regimen and surgical intervention. An unusual case of a patient with multiple,large, pyogenic abscesses of the left lobe treated conservatively is described below. 2011 Sociedade Portuguesa de Gastrenterologia Published by Elsevier Espaa, S.L. All rightsreserved.

    PALAVRAS-CHAVEAbcesso heptico;Abcesso amebiano;Diagnsticolaboratorials;Tratamento

    Mltiplos abcessos hepticos proxmicos volumosos tratados de forma conservadora:relato de um caso e reviso da literatura

    Resumo Os abcessos hepticos piognicos so uma causa rara de admisso. O tratamentoconsiste num regime combinado de antibiticos e intervenco cirrgica. Um caso invulgar de umdoente com vrios abcessos piognicos volumosos no lobo esquerdo tratados conservadoramentedescrito abaixo. 2011 Sociedade Portuguesa de Gastrenterologia. Publicado por Elsevier Espaa, S.L. Todos osdireitos reservados.

    Introduction

    Pyogenic liver abscesses are a rare cause of admission,with 3.59 cases per 100,000 people. They usually appear

    Corresponding author.E-mail address: christosnina@hotmail.com (C.E. Lampropoulos).

    as an acute disease with fever, right upper-quadrant painand jaundice. Blood cultures are positive in 52% of thecases and the most common pathogens are Streptococcusspecies and Escherichia coli while in Asia the most com-mon pathogen is Klebsiella. Treatment consists of combinedantibiotics regimen and surgical intervention (aspiration,drainage or resection) except solitary or small abscesseswhich are treated with antibiotics only.

    0872-8178/$ see front matter 2011 Sociedade Portuguesa de Gastrenterologia Published by Elsevier Espaa, S.L. All rights reserved.http://dx.doi.org/10.1016/j.jpg.2012.07.016

  • 22 C.E. Lampropoulos et al.

    Figure 1 Abdominal ultrasound shows multiple hypoechoic cavities with diaphragms at the left liver lobe.

    An unusual case of a patient with multiple, large, pyo-genic abscesses of the left lobe treated conservatively isdescribed below, with her consent.

    Case report

    An 85-year-old lady presented with fever (up to 39 C)and rigors, dyspnea and abdominal pain the last 24 h.Her medical history included dementia and hypertensionunder treatment as well as cholecystectomy 35 yearsago with ERCP one year later because of cholangitis.The only clinical finding was tenderness of the righthypochondrium. Laboratory investigation showed: WBC:17,800/L, Ht: 37.7%, Hb: 12.0 g/dL, ESR: 100/1 h, glu-cose: 184 mg/dL, urea: 71 mg/dL, creatinine: 2.2 mg/dL,SGOT: 73 IU/L, SGPT: 58 IU/L, proteins: 6.5 g/dL, albu-min: 2.6 g/dL, CRP: 16.3 mg/dL (normal value < 0.5) andmetabolic acidosis with compensatory respiratory alka-losis from gas analysis. The rest of laboratory findings(ALP, GT, LDH, bilirubin, CPK, amylase and electrolytes)were normal. Chest X-ray revealed small bilateral pleuraleffusions (exudates after aspiration) and heart ultrasoundshowed small pericardial effusion. An abdomen ultrasoundshowed multiple hypoechoic cavities with diaphragms atthe left lobe (the largest were 6.2, 5.6 and 4.6 cm respec-tively, Fig. 1). Abdominal computerized tomography (CT)showed multiple hypodense cavities of left liver lobe(the largest was 7 cm) with irregular, thick, ill-definedborders, presence of air in the intrahepatic bile ductsand faint, thin wall enhancement after intravenous con-trast administration (Fig. 2). Patient was suffering frommultiple liver abscesses with sepsis (SIRS with organs dys-function: temperature > 38 C, WBC > 12,000/L, respiratoryrate > 20 breaths/min and heart rate > 90 beats/min due toinfection with acute renal failure, pleural and pericar-dial effusions). The patient was repeatedly advised bysurgeons to undergo a surgical intervention (fine needleaspiration or resection), but she denied any kind of oper-ation. A combined drug regimen was immediately started(IV ciprofloxacin 400 mg 2 with metronidazole 500 mg 3).After one week, ciprofloxacin was substituted by ampi-cillin/sulbactam (12 g/day) and amikasin (1 g/day) as therewas no improvement. Blood cultures were negative. Feverwas sustained up to 38 C the first two weeks with gradualremission the next five days. The patient was discharged

    afebrile five days later with per os treatment (ciprofloxacin1 g/day and metronidazole 1.5 g/day) for two weeks. Herblood tests were normal apart from Ht (28.3%) and Hb(9.4 g/dL) and the effusions (both pleural and pericardial)were absorbed.

    Although the patient had a previous history of biliary dis-ease, no underlying pathology was identified as cholangitiswas not apparent (normal bilirubin), no malignancy or anyother intra-abdominal inflammation was detected and norecent surgery was performed on the patient, suggesting aprobable cryptogenic disease. Antibodies against echinococ-cus and Entamoeba histolytica were twice negative (indirectfluorescent antibody test, IFAT) with four weeks interval(to avoid any initial false-negative results). Although symp-toms and imaging suggested pyogenic abscesses, serologywas twice repeated to exclude other abscesses etiologyas there are neither diagnostic (but only highly suggestive)clinical nor radiological criteria for their differentiation. Inaddition, negative blood cultures and the patients refusalfor surgical intervention complicated differential diagnosis.Serial ultrasounds and CT scans every two months revealedgradual reduction of abscesses size (less than 2 cm in thelast examination, Fig. 2).

    Discussion

    Liver abscesses are more commonly pyogenic or amoebic.Pyogenic abscesses may be caused mainly by ascendingbiliary (gallstones, cholangitis and malignancies) or por-tal tract sepsis (diverticulitis, inflammatory bowel disease,intra-abdominal inflammation and malignancies) and inlesser degree by superinfection of cysts or necrotic tis-sue, trauma or hematogenous dissemination. Nevertheless,in many cases (up to 25% of patients) no underlying causeis found and the disease is defined as cryptogenic. Themost common pathogens are Streptococcus species (29.5%),E. coli (18.1%), Staphylococcus species (10.5%) and Kleb-siella (9.2%)1. E. coli is the most organism in abscesses ofbiliary or portal origin while Gram-positive cocci accountfor most cases of hematogenous or cryptogenic disease.Abscesses are usually present in elderly patients with historyof diabetes and they are multiple in many cases. Jaun-dice, low albumin and pulmonary complications (pleuraleffusions) are common. In ultrasound they may appear asa cavity with thick or irregular borders and hypoechoic or

  • Multiple liver abscesses 23

    Figure 2 Abdominal CT depicts multiple abscesses of left liver lobe before treatment (A, B, C, D) and during follow-up (E, F).Intravenous contrast administration (D) causes a thin enhancement of the cavity wall. There is a gradual decrease of abscessessize two (E) and four months (F) after treatment.

    hyperechoic content. They may be unilocular or with inter-nal septa. In CT scan the fibrous tissue around the abscessis often a centimeter or thicker and gradually merges intothe liver parenchyma. A common finding is the presenceof air in the cavity. After intravenous contrast administra-tion there is a faint, thin, rim enhancement and perilesionaledema. Conservative treatment alone usually fails as mor-tality fluctuates between 45% and 95%, unless abscesses aresolitary or small enough. Treatment should include antibi-otics administration (usually cephalosporins or quinolonesplus metronidazole and/or aminoglycosides) and simulta-neous surgical intervention (aspiration and drainage seemequally effective and have substituted surgical resectionexcept for serious cases with multiple abscesses and/orsepsis).2 Combined treatment shows encouraging results asoverall mortality for multiple abscesses fluctuates from 0%to 22% in different series.3,4 Indications for surgical inter-vention are: age > 55 years, size 5 cm, involvement of leftor both lobes and duration of symptoms more than 7 days.5,6

    Mortality is increased among elderly patients and those with

    co-morbidities, such as cirrhosis, chronic renal failure ormalignancy.

    Amoebic abscesses usually present as solitary lesions ofthe right lobe. Patients are younger, more acutely ill thanwith pyogenic abscesses and from high-prevalence areas.Serum antibodies may be negative in acute disease (butpositive after 7---10 days) or false-positive if the patienthad amebiasis in the past. In ultrasound they appear asround or oval lesions with hypoechoic content, thin wall andwell-defined margins, in contrast to thick and ill-definedborders of pyogenic abscesses. In CT scan they appearas well-circumscribed lesions, encapsulated by thick wallwith intermediate density between abscess and adjacentparenchyma. Intravenous contrast administration depictsa characteristic thick enhancement (isodense or slightlyhyperdense relative to hepatic parenchyma) with a periph-eral zone of edema.7,8 The central abscess cavity mayshow multiple septa. Extrahepatic extension is relative

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