Liver abscess: Difference between revisions

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
- 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

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

@@ Line 1: / Line 1: @@
-== Background ==
+==Background==
-=== Microbiology ===
+===Microbiology===
-* Pyogenic
-** [[Gram-negative bacteria]]
-*** ''[[Escherichia coli]]''
-*** [[Klebsiella species]]
-*** Less common: ''[[Pseudomonas aeruginosa]]'', ''[[Proteus]]'', ''[[Enterobacter]]'', ''[[Citrobacter]]'', and ''[[Serratia]]''
-** [[Gram-positive bacteria]]
-*** [[Streptococcus species]], especially ''anginosus'' group
-*** [[Enterococcus species]]
-*** Other [[Viridans group streptococci]]
-*** Less common ''[[Staphylococcus aureus]]'' and ''[[Streptococcus pyogenes]]''
-** [[Anaerobes]]
-*** [[Bacteroides species]]
-*** Less common: [[Fusobacterium]], anaerobic streptococci, [[Clostridium species]], ''[[Lactobacillus]]''
-* Amebic
-** ''[[Entamoeba histolytica]]''
+*Pyogenic
-=== Etiology ===
+**Polymicrobial in 20-50% (more in abscesses from biliary source)
-* Pyogenic
+**[[Gram-negative bacteria]]
-** '''Biliary:''' most common mechanism, includes ascending cholangitis
+***''[[Escherichia coli]]''
-** '''Hematogenous via hepatic artery:''' from bacteremia
+***[[Klebsiella]], especially hypermucoviscous [[Klebsiella pneumoniae]]
-** '''Hematogenous via portal vein:''' from an infection abdominal organ duch as diverticulitis, pancreatitis, or appendicitis
+***Less common: ''[[Pseudomonas aeruginosa]]'', ''[[Proteus]]'', ''[[Enterobacter]]'', ''[[Citrobacter]]'', and ''[[Serratia]]''
-** '''Contiguous spread'''
+**[[Gram-positive bacteria]]
-** '''Trauma:''' including things like ingested toothpicks
+***[[Streptococcus]], especially [[Streptococcus anginosus group]]
-** '''Cryptogenic''': second most common mechanism is "unknown"
+***[[Enterococcus]]
-* Amebic: see ''[[Entamoeba histolytica]]''
+***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===
-== 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
+*Pyogenic
-== Investigations ==
+**'''Biliary:''' most common mechanism, includes ascending cholangitis
-* Blood cultures are about 50% sensitive
+**'''Hematogenous via hepatic artery:''' from bacteremia
-* Imaging with ultrasound or CT is important
+**'''Hematogenous via portal vein:''' from an infection abdominal organ duch as diverticulitis, pancreatitis, or appendicitis
-* Consider ''E. histolytica'' serology to rule out amebic liver abscess, since the syndromes cannot reliably be distinguished clinically
+**'''Contiguous spread'''
+**'''Trauma:''' including things like ingested toothpicks
+**'''Cryptogenic''': second most common mechanism is "unknown"
+*Amebic: see ''[[Entamoeba histolytica]]''
-== Management ==
+===Risk Factors===
-* Get source control
+*Likely more common in [[diabetes mellitus]], cardiopulmonary disease, malignancy, and cirrhosis
-* 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]]
+*Neutrophil dysfunction, including [[chronic granulomatous disease]]
-* Treat for 4-6 weeks total, ensuring radiological resolution of abscess
+*[[Hemochromatosis]], especially for abscesses involving [[Yersinia enterocolitica|''Yersinia enterocolitica'']]
-** Can step down to oral therapy after 2 to 3 weeks if responding appropriately
+==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 [[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]]
+*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
 [[Category:Intra-abdominal infections]]