Liver abscess: Difference between revisions
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*Pyogenic |
*Pyogenic |
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**Polymicrobial in 20-50% (more in abscesses from biliary source) |
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**[[Gram-negative bacteria]] |
**[[Gram-negative bacteria]] |
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***''[[Escherichia coli]]'' |
***''[[Escherichia coli]]'' |
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***[[Klebsiella |
***[[Klebsiella]], especially hypermucoviscous [[Klebsiella pneumoniae]] |
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***Less common: ''[[Pseudomonas aeruginosa]]'', ''[[Proteus]]'', ''[[Enterobacter]]'', ''[[Citrobacter]]'', and ''[[Serratia]]'' |
***Less common: ''[[Pseudomonas aeruginosa]]'', ''[[Proteus]]'', ''[[Enterobacter]]'', ''[[Citrobacter]]'', and ''[[Serratia]]'' |
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**[[Gram-positive bacteria]] |
**[[Gram-positive bacteria]] |
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***[[Streptococcus |
***[[Streptococcus]], especially [[Streptococcus anginosus group]] |
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***[[Enterococcus |
***[[Enterococcus]] |
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***Other [[Viridans group streptococci]] |
***Other [[Viridans group streptococci]] |
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***Less common ''[[Staphylococcus aureus]]'' and ''[[Streptococcus pyogenes]]'' |
***Less common ''[[Staphylococcus aureus]]'' and ''[[Streptococcus pyogenes]]'' |
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**[[Anaerobes]] |
**[[Anaerobes]] |
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***[[Bacteroides |
***[[Bacteroides]] |
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***Less common: [[Fusobacterium]], anaerobic streptococci, [[Clostridium |
***Less common: [[Fusobacterium]], anaerobic streptococci, [[Clostridium]], ''[[Lactobacillus]]'' |
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**Fungi (rare): [[Candida |
**Fungi (rare): [[Candida]] |
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*Amebic |
*Amebic |
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**''[[Entamoeba histolytica]]'' |
**''[[Entamoeba histolytica]]'' |
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*Likely more common in [[diabetes mellitus]], cardiopulmonary disease, malignancy, and cirrhosis |
*Likely more common in [[diabetes mellitus]], cardiopulmonary disease, malignancy, and cirrhosis |
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*Neutrophil dysfunction, including [[chronic granulomatous disease]] |
*Neutrophil dysfunction, including [[chronic granulomatous disease]] |
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*[[Hemochromatosis]], especially for abscesses involving [[Yersinia enterocolitica]] |
*[[Hemochromatosis]], especially for abscesses involving [[Yersinia enterocolitica|''Yersinia enterocolitica'']] |
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==Clinical Manifestations== |
==Clinical Manifestations== |
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*Blood cultures are about 50% sensitive |
*Blood cultures are about 50% sensitive |
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*Imaging with ultrasound or CT is important |
*Imaging with ultrasound or CT is important |
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*Consider '' |
*Consider ''[[Entamoeba histolytica]]'' serology to rule out amoebic liver abscess, since the syndromes cannot reliably be distinguished clinically |
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==Management== |
==Management== |
Latest revision as of 04:02, 1 February 2022
Background
Microbiology
- Pyogenic
- Polymicrobial in 20-50% (more in abscesses from biliary source)
- Gram-negative bacteria
- Escherichia coli
- Klebsiella, especially hypermucoviscous Klebsiella pneumoniae
- Less common: Pseudomonas aeruginosa, Proteus, Enterobacter, Citrobacter, and Serratia
- Gram-positive bacteria
- Streptococcus, especially Streptococcus anginosus group
- Enterococcus
- Other Viridans group streptococci
- Less common Staphylococcus aureus and Streptococcus pyogenes
- Anaerobes
- Bacteroides
- Less common: Fusobacterium, anaerobic streptococci, Clostridium, Lactobacillus
- Fungi (rare): Candida
- Amebic
Pathophysiology
- Pyogenic
- Biliary: most common mechanism, includes ascending cholangitis
- Hematogenous via hepatic artery: from bacteremia
- Hematogenous via portal vein: from an infection abdominal organ duch as diverticulitis, pancreatitis, or appendicitis
- Contiguous spread
- Trauma: including things like ingested toothpicks
- Cryptogenic: second most common mechanism is "unknown"
- Amebic: see Entamoeba histolytica
Risk Factors
- Likely more common in diabetes mellitus, cardiopulmonary disease, malignancy, and cirrhosis
- Neutrophil dysfunction, including chronic granulomatous disease
- Hemochromatosis, especially for abscesses involving Yersinia enterocolitica
Clinical Manifestations
- Most common signs are fever, abdominal pain, leukocytosis, and an elevated alkaline phosphatase
- Often presents with fevers alone, however
- May also have weight loss, diarrhea, RUQ tenderness, and jaundice
- The classic triad is considered to be fever, jaundice, and RUQ tenderness
Investigations
- Blood cultures are about 50% sensitive
- Imaging with ultrasound or CT is important
- Consider Entamoeba histolytica serology to rule out amoebic liver abscess, since the syndromes cannot reliably be distinguished clinically
Management
- Get source control
- Antibiotics should be broad-spectrum, such as piperacillin-tazobactam, ertapenem or meropenem, ceftriaxone plus metronidazole, or ciprofloxacin plus metronidazole
- Treat for 4-6 weeks total, ensuring radiological resolution of abscess
- Can step down to oral therapy after 2 to 3 weeks if responding appropriately