Agnė Kavaliauskaitė1, Roberta Buginytė1
1Lithuanian University of Health Sciences, Academy of Medicine, Kaunas, Lithuania
Abstract
Pyogenic liver abscess (PLA) is one of the most common visceral abscesses. The main path of development is retrograde microorganism migration from the biliary tract. Other intra-abdominal infections, haematogenous dissemination or liver trauma can also be one of the reasons for the PLA formation. Nowadays these abscesses are more common between 60-70 years old patients. The main risk factors are diabetes mellitus, liver cirrhosis, biliary tract and pancreatic diseases. Usually abscesses are caused by polymicrobial gastrointestinal flora, which consists of aerobes and anaerobes. The main pathogens are E. Coli and K. pneumoniae. The most common symptoms of liver abscesses are fever and upper abdominal pain. Other symptoms may include chills, night sweats, malaise, nausea or vomiting, right shoulder pain, cough, dyspnoea, anorexia or recent unexplained weight loss. Laboratory tests are usually associated with an increase in liver enzymes such as aspartate aminotransferase (AST), alanine aminotransferase (ALT) and alkaline phosphatase (ALP). Other significant laboratory tests may show hyperbilirubinemia or increase of international normalized ratio (INR). The main imaging test to confirm the diagnosis of liver abscess is ultrasonography (US). In order to determine a pyogenic liver abscess and causes of it, it is important to take blood culture and fine needle aspiration. Treatment of the PLA consists of antimicrobial therapy and drainage of the abscess. Cefuroxime and metronidazole or aminoglycoside cover gram-positive and gram-negative microorganisms and are the main antibiotics for PLA. Percutaneous needle aspiration (PNA) or percutaneous drainage (PCD) must be performed when abscesses are larger than 5 cm or patients did not improve clinically under antimicrobial therapy.
Key words: liver abscess, pyogenic, upper right quadrant abdominal pain, percutaneous drainage, percutaneous needle aspiration.
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Medical Sciences 2021 Vol. 9 (2), p. 242-250
Pyogenic liver abscess: literature review
Agnė Kavaliauskaitė
1
, Roberta Buginytė
1
1
Lithuanian University of Health Sciences, Academy of Medicine, Kaunas, Lithuania
Abstract
Pyogenic liver abscess (PLA) is one of the most common visceral abscesses. The main path of
development is retrograde microorganism migration from the biliary tract. Other intra-abdominal
infections, haematogenous dissemination or liver trauma can also be one of the reasons for the PLA
formation. Nowadays these abscesses are more common between 60-70 years old patients. The main risk
factors are diabetes mellitus, liver cirrhosis, biliary tract and pancreatic diseases. Usually abscesses are
caused by polymicrobial gastrointestinal flora, which consists of aerobes and anaerobes. The main
pathogens are E. Coli and K. pneumoniae. The most common symptoms of liver abscesses are fever and
upper abdominal pain. Other symptoms may include chills, night sweats, malaise, nausea or vomiting, right
shoulder pain, cough, dyspnoea, anorexia or recent unexplained weight loss. Laboratory tests are usually
associated with an increase in liver enzymes such as aspartate aminotransferase (AST), alanine
aminotransferase (ALT) and alkaline phosphatase (ALP). Other significant laboratory tests may show
hyperbilirubinemia or increase of international normalized ratio (INR). The main imaging test to confirm
the diagnosis of liver abscess is ultrasonography (US). In order to determine a pyogenic liver abscess and
causes of it, it is important to take blood culture and fine needle aspiration. Treatment of the PLA consists
of antimicrobial therapy and drainage of the abscess. Cefuroxime and metronidazole or aminoglycoside
cover gram-positive and gram-negative microorganisms and are the main antibiotics for PLA. Percutaneous
needle aspiration (PNA) or percutaneous drainage (PCD) must be performed when abscesses are larger than
5 cm or patients did not improve clinically under antimicrobial therapy.
Key words: liver abscess, pyogenic, upper right quadrant abdominal pain, percutaneous drainage,
percutaneous needle aspiration.
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243
1.
Introduction
Liver abscess is a puss filled mass inside
the liver that can develop because of direct contact
with infection of the biliary tract, liver injury or
abscess leakage of other intra-abdominal infection
via portal vein. It is a relatively rare, but a critical
disease with 2-12% mortality if untreated [1-3].
Liver abscesses can be classified into three forms:
pyogenic (usually caused by polymicrobial
infection), amoebic (Entamoeba Histolytica) and
fungal (most often Candida spp.). Pyogenic liver
abscess (PLA) is the most common and accounts
for 80% of all liver abscesses [4]. PLA can be
distinguished by size and localization into large
solitary abscesses localised in one liver lobe or
small multiple abscesses localised throughout the
parenchyma. Large abscesses cause subacute
symptoms and must be drained, meanwhile small
abscesses manifest by acute clinical symptoms and
antimicrobial treatment is required first.
2. Epidemiology
Liver abscess is one of the most common
visceral abscesses. The incidence of PLA is about
2,3 cases per 100,000 people. Several studies have
found that PLA develops more often in men than
in women [5-7]. In the past, PLA used to be more
common between 40-50 years old people and the
main cause was perforated appendicitis. In recent
times, patients with PLA mean age has become 60-
70 years whilst biliary system diseases are the
leading cause [1, 4]. The most common risk factor
is diabetes mellitus (DM), because hyperglycaemia
weakens the immune system by altering neutrophil
functions. Other risk factors include liver cirrhosis,
malignancy, immunosuppressive disorders, liver
transplants and hepatobiliary or pancreatic diseases
[2, 8].
3. Pathogenesis
Focal infection of the liver can be divided
into several groups depending on the way the
microorganisms entered the liver. Retrograde
migration of microorganisms from the biliary tract
to the liver parenchyma is the major source of PLA
formation and accounts for about 60% of all ways
[4]. Bile duct obstruction caused by gallstone or
malignant obstruction leads to bile stasis, which is
a great medium for the proliferation of bacteria [8].
Another common source is through the portal vein
when microorganisms from another intra-
abdominal infection enter the bloodstream, form
emboli and travel to the liver. Also, PLA may be
complicated by portal vein inflammation called
pylephlebitis. Haematogenous dissemination from
infection in the body such as infectious
endocarditis or pyelonephritis also occurs as a
possible source for PLA [1-3, 8]. About 3% of PAL
are caused by liver trauma, which can either be
penetrating and cause direct bacteria entry or be
blunt and cause hemorrhage or necrosis which
results in the formation of an abscess [1, 4]. In rare
cases, foreign bodies, parasites, intrahepatic
tumors or cysts can cause PLA [9-11].
4. Etiology
Most cases are polymicrobial; consist of
aerobes and anaerobes. Gastrointestinal flora is
the main source of microorganisms causing PLA.
The most common pathogens are E. Coli and K.
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pneumoniae [2, 4, 8]. Other gram-negative aerobes
(Pseudomonas spp., Proteus spp., Citrobacter spp.)
are more common in patients with biliary tract
diseases [8]. Infection of K. pneumoniae is an
increasing problem in Asia, where it is the main
pathogen and accounts for about 80% cases of all
PALs [12,13]. Furthermore, in most cases it occurs
in patients with DM [8, 13]. The most common
gram-positive aerobes are S. milleri, Enterococcus
spp., S. aureus, S. epidermidis and Streptococcus
spp. If S. aureus is identified as an isolated
pathogen it is a sign to search for another source of
infection in the body, which spreads
hematogenously to the liver [1]. Anaerobic
pathogens such as Bacteroides spp.,
Fusobacterium spp., Actinomycetes spp,
Clostridium perfringens and anaerobic
streptococcus usually occur as a combination with
aerobic bacteria but can be found without it. The
initial source for these microorganisms is pelvic
abscess, appendicitis, diverticulitis and other
gastrointestinal diseases [4, 8]. In patients with
immunodeficiency fungal abscesses, especially
caused by Candida spp. are common. Other
important organisms are Entamoeba histolytica,
which causes amoebic abscess, and parasite
Echinococcus granulosus, which causes hydatid
cyst. The frequency of most common pathogens
compiled from the literature is shown in Table 1.
Table 1. Microbiologic etiology of PLA.
Pathogens
Frequency, %
Gram-negative aerobes
E. coli
K. pneumonia
Pseudomonas spp.
Proteus spp.
Citrobacter spp.
16 – 30
5,6 – 16
3,8 – 6,1
1,4 – 1,9
1,9
Gram-positive aerobes
S. milleri
Enterococcus spp.
S. aureus
Streptococci spp.
11 – 12,2
9,3 – 11,3
7,5 – 7,7
1,1 – 13,2
Anaerobic organisms
Bacteroides spp.
Fusobacterium
Anaerobic streptococci
11,2 – 13,2
4,2
6,1
Fungi
Candida albicans
Aspergillus spp.
0,3 – 3,8
0,3
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5.
Symptoms
The most common symptoms of liver
abscesses are fever and upper abdominal pain,
with both presented in about 90% of the patients
[14]. Other symptoms may include chills, night
sweats, malaise, nausea or vomiting, right
shoulder pain (due to phrenic nerve irritation),
right upper quadrant pain, cough, dyspnoea,
anorexia or recent unexplained weight loss. Also,
sometimes patients could describe a presence of
dark urine or clay-coloured stools [15]. If the
abscess ruptures (a rare complication) then
patients may present in distress or even septic or
anaphylactic shock [1].
The most common findings during physical
examination in patients with liver abscesses is
hepatomegaly and right upper quadrant
tenderness. It has been noticed that jaundice is
also a common finding if abscess is pyogenic
origin [16]. Splenomegaly or ascites is an
unusual sign of liver abscess and both are only
present in advanced stages of the illness [17]. If
abscess is caused by Klebsiella, it also may send
septic emboli to the eye, meninges, and brain.
Symptoms of these systems may last even after
liver abscess treatment [1].
6. Diagnostics
Enzymes describing liver function like
aspartate aminotransferase (AST) and alanine
aminotransferase (ALT) may increase in about
half of the patients with liver abscess, while
alkaline phosphatase may be present in more than
80% of the cases. AST and ALT may evaluate
higher if the process is acute. Hyperbilirubinemia
is present in only a small proportion of patients
(30%), while lower serum albumin levels, and
increase of international normalized ratio (INR)
are observed in about 80% of the patients [18]. It
was also observed that the value of these
indicators may depend on the size of the abscess.
For example, INR, alkaline phosphatase, and
liver enzymes (ALT, AST) increase, and serum
albumin decreases with the size of the abscess
[19]. While these tests may not have real value in
differentiating pyogenic liver abscess from
others, it may give us preliminary opinion about
the size of the abscess and effect of the treatment.
To determine a pyogenic liver abscess and causes
of it, it is important to take blood culture and fine
needle aspiration under ultrasonography (US) or
computed tomography (CT) guidance. Blood or
aspirate culture are positive only in 50% and 40%
of the cases, respectively. Despite not that high
accuracy, these tests can provide useful
information prior to antimicrobial treatment [20].
The main imaging test to confirm the
diagnosis of liver abscess is ultrasonography
(US). US sensitivity in the diagnosis of liver
abscesses is about 85%. It may also depend on
the location of the abscess. Sensitivity may
increase if abscess is localized in 4th or 5th liver
segments. But location in segment 8 is mostly
associated with delayed diagnosis by US [21].
The pathological visual aspect of abscess is hyper
or hypoechoic lesions with occasional debris or
septation [1]. When ultrasound is not informative
enough, we should use additional instrumental
examinations. Some studies have shown that
about 50% of the patients with liver abscesses
needed a computed tomography and 3% of the
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patients needed a magnetic resonance imaging to
confirm the diagnosis [7].
Computed tomography is not the first-
line test for diagnosing liver abscesses, but it has
sensitivity of 95-100% [22]. If possible, it is
better if CT scan is done with intravenous
contrast. There are several signs common with
liver abscesses. The „Double target sign“ is
described as a well-defined, round lesion with
central hypoattenuation. The inner layer
represents the pyogenic membrane, and the outer
layer is due to edema of the hepatic parenchyma
[23, 24]. Peripheral rim enhancement or
surrounding edema are not common findings but
are specific for liver abscess [ 2]. The “cluster
sign” may also be present and occurs when
multiple low-attenuation lesions aggregate in a
localized area to form a solitary larger abscess
cavity.
Magnetic resonance imaging (MRI) is
also a sensitive imaging test for detection of liver
abscess, but it is less rapidly available. On MRI,
abscesses often appear to have central low signal
intensity on T1-weighted imaging and high
signal intensity on T2-weighted imaging [23,24].
7. Treatment
The treatment of PLAs depends on the
stage of the disease and the size of abscess.
Empirical antimicrobial therapy should be started
at the onset of clinical sign of the infection.
Antibiotics should cover the most common
pathogens such as gram-positive coccus and
gram-negative bacilli [25, 20]. The most used
combination is intravenous cefuroxime and
metronidazole or aminoglycoside. Antibiotics
can be subsequently adjusted according to the
susceptibility of the microorganisms. The
duration of antibiotics treatment usually lasts
from 21 to 35 days, parenteral therapy is
recommended for the first 14 days and can be
changed to oral if there is a favorable clinical
response. [20, 27]. Antimicrobial therapy alone
is enough treatment for smaller than 5cm abscess
or small multiple abscesses in about 80-90% of
cases [25, 26]. In patients with hepatic abscess
due to bile duct infection, biliary hypertension
should be eradicated ensuring bile drainage [1].
This is usually done during endoscopic
retrograde cholangiopancreatography, but
sometimes percutaneous bile duct drainage or
even open surgery is required. US or CT guided
percutaneous needle aspiration (PNA) or
percutaneous drainage (PCD) is used for larger
than 5cm abscesses or smaller abscesses which
did not improve clinically [28]. PNA is
performed by a 17-27 Gauge needle. Once the
needle tip is within the abscess cavity the pus is
aspirated and then the needle is removed [29].
During PCD, a 6-10 French pig-tail catheter is
used. It is placed via the Seldinger or trocar
techniques [22]. Then a catheter is secured to a
skin for continuous external drainage. The
removal of the percutaneous drain is based on the
patient's clinical and laboratory response. The
median duration of drainage may vary from 12.6
± 14 days, and catheter is often removed when
daily output is less than 10 ml/day [22,26]. Both
PNA and PCD are safe methods of draining liver
abscesses. However, several studies have shown
that PCD (100%) is more effective than PA (67
%) in the management of liver abscess [29 - 31].
Surgical interventions are rare, but should be
considered in patients with large, complex, or
multiple abscesses, underlying disease, or with
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those who have failed percutaneous drainage
[32].
8. Prognosis
The current mortality rate in people
with PLA is low, ranging from 0,5 - 4%, because
of new drainage methods and antibiotics
effectiveness for specific microorganisms [33 -
35]. Older age, immunosuppressive condition,
delayed treatment and complications, like
rupture of the abscess and peritonitis are
associated with a higher mortality rate of 12%
[36].
9. Conclusion
There are lots of causes of the PLA, but
the main remains to be infection of the biliary
tract. Despite usual gastrointestinal flora, K.
pneumoniae is getting more common, especially
in Asia. US is considered as the gold standard for
diagnosing PLA. Best results in PLA
management and treatment are reached using
antimicrobial therapy and percutaneous drainage
of the abscess together. However, for older,
immunosuppressed patients or if treatment is
delayed, causing complications such as
peritonitis, mortality rate is higher and counts up
to 12%.
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