Liver abscess: Difference between revisions
From IDWiki
(Created page with "== Management == * Get source control * Treat for 4-6 weeks, ensuring radiological resolution of abscess Category:Intra-abdominal infections") |
m (Text replacement - " species]]" to "]]") |
||
(11 intermediate revisions by the same user not shown) | |||
Line 1: | Line 1: | ||
− | == |
+ | ==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 |
||
+ | **''[[Entamoeba histolytica]]'' |
||
+ | |||
+ | ===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|''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== |
||
+ | |||
⚫ | |||
+ | *Antibiotics should be broad-spectrum, such as [[Is treated by::piperacillin-tazobactam]], [[Is treated by::ertapenem]] or [[Is treated by::meropenem]], [[Is treated by::ceftriaxone]] plus [[Is treated by::metronidazole]], or [[Is treated by::ciprofloxacin]] plus [[Is treated by::metronidazole]] |
||
⚫ | |||
+ | **Can step down to oral therapy after 2 to 3 weeks if responding appropriately |
||
[[Category:Intra-abdominal infections]] |
[[Category:Intra-abdominal infections]] |
Latest revision as of 00:02, 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