This document summarizes information about liver abscesses, including pyogenic and amebic types. It discusses the epidemiology, causes, clinical presentation, diagnosis, and management of both types of liver abscesses. For pyogenic liver abscesses, it notes that they are usually polymicrobial infections most commonly caused by E. coli or Klebsiella. Cryptogenic cases may indicate underlying malignancy. Diabetes is a major risk factor. Ultrasound and CT are important diagnostic tools. Treatment involves drainage and antibiotics. For amebic liver abscesses, it indicates they are endemic in India and usually caused by Entamoeba histolytica infection following travel to endemic areas. Clinical features, ultrasound and serology can aid

1. LIVER ABSCESS
Dr Wajeed Yousuf
DNB-SS
BLK HOSPITAL
DELHI-5

2. ● Liver abscess (LA) is defined as collection of purulent
material in liver parenchyma which can be due to bacterial,
parasitic, fungal, or mixed infection.

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Liver Abscesses: Indian Perspective
• ALA : 40-51%
• Pyogenic : 22-23%
• Unknown : 25-38%
Mohan S, Int Surg 2006 Sharma MP , Am J Roentgenol 1998

4. Pyogenic liver abscess
● Prevalence
➢ Liver abscesses are the most common type of visceral
abscess.
➢ The annual incidence of liver abscess has been
estimated at 2.3 cases per 100,000 populations and is
higher among men than women (3.3 versus 1.3 per
100,000)
Clin Gastroenterol Hepatol. 2004

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• In the past, most cases of pyogenic liver abscess were a
consequence of appendicitis complicated by Pyle phlebitis in
a young patient.
• Most cases now are cryptogenic or occur in older men with
underlying biliary tract disease.
● Predisposing conditions include
• Malignancy
• Immunosuppression
• Diabetes mellitus
• Previous biliary surgery or interventional endoscopy.

6. Causes of pyogenic liver abscess
● Hepatobiliary
➢ Malignant
• Common bile duct
• Gall bladder
• Ampulla
• Head of pancreas
➢Benign
•Lithiasis
•Cholecystitis
•Biliary enteric anastomosis
•Endoscopic biliary procedures
•Percutaneous biliary procedures

7. ● Portal
➢ Benign
• Diverticulitis
• Anorectal suppuration
• Pelvic suppuration
• Postoperative sepsis
• Intestinal perforation
• Pancreatic abscess
• Appendicitis
• Inflammatory bowel disease
➢ Malignant
• Colonic cancer
• Gastric cancer

8. ●Arte
rial
•Endo
●Traumatic
➢Benign
•Open or closed abdominal trauma
➢Malignant
•Chemoembolization
•Percutaneous ethanol injection or
radiofrequency
●Cryptogeni
c

9. • A study with over 600 cases of PLA
• Cryptogenic - 152 (25.3%)
• Diabetic - 229 (38.1%)
• Biliary tract diseases - 144 (24%)
• Mixed - 76 (12.6%) and
➢ Biliary cause having maximum recurrence over a mean follow-
up 6.06 years.
J Clin Gastroenterol. 2008

10. ● Cryptogenic PLA
– This group of PLA may herald the onset of cancer, especially
hepato-biliary and colon cancer.
– Elevated AFP and CA19-9 could suggest liver cancer and intra-
hepatic cholangiocarcinoma in cases of PLA.
– Contrast-enhanced computed tomography could be helpful in
patients with normal AFP and CA19-9.
Aliment Pharmacol Ther. 2012 & J Gastroenterol Hepatol.2012

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● Diabetes
– Diabetes is a strong, potentially modifiable risk factor for PLA
and is associated with a poor prognosis.
– The pathogens in DM is mostly due to Klebsiella pneumoniae
K1 strain carrying the virulence plasmid gives rise to recurrent
PLA.
Clin Infect Dis.

12. 2007
● Biliary cause
– Underlying biliary tract disease commonest cause of recurrent
abscess irrespective of DM or cryptogenic status
– Escherichia coli is mostly the causative organism.
– PLA in presence of biliary obstruction requires urgent
bilioenteric continuity.

13. Microbiology
• Most pyogenic liver abscesses are polymicrobial.
• The most frequently isolated organisms are
• Escherichia coli and Klebsiella
• Proteus
• Pseudomonas, and Streptococcus species
• The most commonly identified anaerobic species are
• Bacteroides fragilis and Fusobacterium necrophorum

14. ➢ Liver abscesses caused by Staphylococcus aureus infection are
most common in children and patients with septicemia or other
conditions associated with impaired host resistance, including
chronic granulomatous disease.
➢ Fungal abscesses of the liver may occur in immunocompromised
hosts.

15. Clinical Features and Diagnosis
➢ Malaise, nausea, anorexia and weight loss, headaches, myalgia,
and arthralgia in most of the cases.
● More Specific
• Fever, chills
• Abdominal pain
➢ Pleuritic type pain, cough and dyspnea
➢ Septic shock

16. ● Physical examination usually discloses
– Fever
– Hepatomegaly
– Liver tenderness
– In the absence of cholangitis, jaundice is present only late in the
course of the illness.
– Portal hypertension may follow recovery if the portal vein has been
thrombosed.

17. ● Laboratory findings include
– Anemia,
– Leukocytosis
– ESR elevated
– abnormal liver biochemical test results, (ALP, hypoalbuminemia)
– Blood culture specimens will identify the causative organism in at
least 50% of cases.
– Direct cultures of aspirated fluid are useful for identification of the
organism and determination of antibiotic susceptibility and should be
sent for both aerobic and anaerobic culture.

18. o Chest x-rays may show elevation of the right hemidiaphragm and
atelectasis.
o Ultrasound (USG) is the imaging modality used in the initial evaluation
with a sensitivity of 75% to 95%. The appearance on USG varies
according to the stage of evolution of the abscess.
➢ Initially the abscess is hyperechoic and indistinct.
➢ With maturation and pus formation, it becomes hypoechoic with a
distinct margin.
o CT has a sensitivity of 95 %

20. Management
• The principles of treatment are to
– Drain the pus
– Institute appropriate antibiotics
– Deal with any underlying source of infection, if present.
• Percutaneous drainage combined with antibiotics has become the first line
and mainstay of treatment for most PLAs.

21. • Initial antibiotic coverage, pending culture results, should be broad
in spectrum and include
– third-generation cephalosporin or fluoroquinolone
– metronidazole, to cover anaerobic organisms.
• Alternative regimens include carbapenems and combinations of a
beta-lactam and beta-lactamase inhibitor active against enteric
organisms, including anaerobes.

22. • Initially, antibiotics should be administered parenterally, and after 2 weeks
of systemic therapy, appropriate oral agents may be used for a further 6
weeks.
• In patients with multiple PLAs that are too small to drain, antibiotics may
be the only treatment possible.

23. • Primary treatment by percutaneous catheter drainage (PCD) is performed
when:
– The pus is too thick to be aspirated
– The abscess is greater than 5 cm in diameter
– The wall is thick and non-collapsible
– The PLA is multi-loculated

24. Surgical treatment
• The indication of primary surgical treatment of PLAs is
– initial presentation with intraperitoneal rupture
– multiple abscesses above an obstructed system that cannot be
negotiated by non-operative means.
– failure of non-operative treatment
– For complications of percutaneous drainage, such as bleeding or
intraperitoneal leakage of pus.

25. • The risk factors most commonly associated with mortality include:
– Septic shock
– Jaundice
– Coagulopathy
– Leukocytosis
– Hypoalbuminemia
– Multiple abscesses
– Intraperitoneal rupture
– Malignancy (more in hepatopancreatobiliary malignancy than other
malignant diseases)

26. Amoebic liver abscess
● The incidence of ALA has been reported to vary between 3% and 9% of
all cases of amoebiasis.
● In India ALA is endemic.

27. Clinical presentation
• Amoebic liver abscess occurs most commonly in the age group of 20 to 45
years.
years.
• Infrequent at the extremes of age.
• Seven to nine times more common in males.

28. TABLE 2 -- CLINICAL SIGNS AND SYMPTOMS OF AMEBIC LIVER ABSCESS
Signs and
Symptoms
Conter et al
1986 N = 40
Barnes et al
1987 N = 96
Shandera et
al1996 N = 49
Rockey[1999
N = 56
Pain 93 90 92 84
Fever 93 87 85 80
Chills 68 69 41 73
Nausea 50 85 45 64
Weight loss 33 45 29 29
Diarrhea 60 35 17 29
Cough -- 24 2 41
Dyspnea -- -- 2 --
tenderness 75 67 76 80
Hepatomegal
y
53 18 37 25
Peritonism -- -- 18 20

29. Jaundice 5 10 12 4
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• Most patients present with an acute illness and duration of symptoms less than 2
weeks.
– Abdominal pain, fever, and anorexia.
• Cough with or without expectoration and pleuritic chest pain is also seen in ALA.
Jaundice
➢ One-third of patients may develop clinical jaundice.
Sharma et al. reported it in only 12.7% of patients.
BMC Research Notes, vol. 3, article 21, 2010
➢ Severe icterus is usually due to a large abscess or multiple abscesses, or
to an abscess situated at the porta hepatis.

30. • Tender hepatomegaly is detected in upto 80% of patients.
• The liver surface is generally smooth.
➢ A left lobe abscess may manifest as toxemia, deep jaundice, and
encephalopathy.
➢ Ascites developing in a patients with ALA suggests development or
presence of inferior vena cava obstruction.
➢ Cough with copious expectoration suggests rupture into the
communication with the right lower lobe bronchus.

32. CLINICAL FEATURES OF AMEBIC VERSUS PYOGENIC LIVER ABSCESS
Clinical Features Amebic Abscess Pyogenic Abscess
Age (years) 20-40 >50
Male: female ratio 10:1 1:1
Number of abscesses Solitary abscess in majority ( 80%)
of chronic ALA cases and in
approximately 50% of acute ALA
Multiple abscesses in
approximately 50% of all cases
Location of abscess Usually right lobe Usually right lobe
Recent travel Yes No
Diabetes mellitus Less common, ~ 2% of patients More common, ~ 27% of
patients
Alcohol use Yes Yes
Jaundice Uncommon Common
Pruritus Uncommon Common
Elevated bilirubin Uncommon Common
Elevated AST Uncommon Common
Elevated alkaline
phosphatase
Common Common
Inf Dis Clin North Amer 2001

33. • ALA usually occurs in the right lobe of the liver and is solitary (30%
- 70%).
• Unusual presentations include
– Multiple abscesses,
– Left lobe abscesses,
– Abscesses presenting as compressive lesion, and
– Abscesses rupturing into viscera.
• These are clinically important due to the curable nature of this
disease and potentially fatal outcome in untreated abscesses.

34. • Multiple liver abscesses
– Fifteen per cent of patients may have multiple abscesses.
– Present with fever, toxemia, deep jaundice, and encephalopathy.
– E.coli and Klebsiella are the commonly cultured organisms.
– These patients may present with a clinical picture indistinguishable
from hepatic encephalopathy due to acute hepatocellular failure.

35. Diagnosis

36. • Ultrasonography
– Diagnostic accuracy ~95%
– Slightly less sensitive than CT
– Less expensive, easily available, noninvasive
• Round to oval lesion
• Hypoechoic, fine internal echo
• Homogenous
• Absence of significant wall echo
• Near capsule

37. • CT scan
– Can detect small lesion also, highly sensitive
– Hypodense lesion
• Internal septations ~30%
• Peripheral enhancing.
• Lack of central enhancement
• Ill defined border
• Lack of air unless superinfected
– Surrounding liver shows edema- low attenuating area

38. • Serology :
– Serum antibodies are detected in 85-95% of all .
– The absence of serum antibodies to E. histolytica after 1 week of
symptoms is strong evidence against the diagnosis of invasive
amoebiasis of the colon or liver.
➢ Purified native and recombinant parasitic antigens
• More than 95% of the patients with amoebic liver abscess have
serum antibodies to the 170 KD subunit of the galactose
inhibitable adherence lectin.
• This antigen is highly specific for differentiating acute phase
serum from convalescent phase serum in areas of high
endemicity.

39. ● Serodiagnosis in the endemic area remains doubtful due to, high antibody
titers.
Two new tests
➢ Pyruvate phosphate dikinase
Clin Vaccine Immunol. 2011
➢ Parasite DNA demonstration in saliva are useful in such situation.
J Health Popul Nutr. 2008

40. PCR for EH in Pus from ALA
• Positive in 83% ALA
• Negative in all pyogenic LA
• Sensitivity: 83%, Specificity: 100%
• More reliable and a better alternative diagnostic modality for ALA
Sharma MP Indian J Gastroenterol 2006
• Fresh fecal sample may detect trophozoites containing erythrocytes,
preferably within 30 minutes of the passage of stool.

42. • Pharmacotherapy for E. histolytica infection in adults
• Intraluminal infection
– Diloxanide furoate 500 mg tid X 20 days
– Paromomycin 30 mg/kg/day X 10 days (in 3 divided doses)
– Iodoquinol 650 mg tid X 20 days
• Invasive colitis
– Metronidazole 800 mg tid X 5 days
– Tinidazole 1 gm bd X 3 days
• Amoebic liver abscess
– Metrinidazole 800 mg tid PO X 10 days (500 mg qid IV)

43. • Nitroimidazoles (including metronidazole) are effective in over 90%
of cases.
• Therapy should continue for at least 10 days.
• Relapses have been reported with this duration of therapy and the
drug may be administered for upto 3 weeks.
• The dose of metronidazole is 40 mg/kg/day in divided dosages.

44. • Aspiration or drainage of abscess
• Routine aspiration of liver abscess is not indicated for diagnostic or
therapeutic purpose.
• Aspiration has been indicated in the following circumstances:
– Lack of clinical improvement in 48-72 hours
– Left lobe abscess
– Thin rim of liver tissue around the abscess (< 10 mm) and
– Seronegative abscesses.
– Large abscess having impending rupture / compression sign
• The aspirate is anchovy sauce type in half of the patients.
• The chocolate color is due to admixture of blood with liver tissue.

45. Experience with aspiration in cases of amebic liver abscess
in an endemic area
• N= 144
• Multiple abscesses were seen in 40 (27.7%) patients
• Six (4.1%) patients died
• Seventy-one (49.3%) patients responded to metronidazole alone
• A total of 73 (50.69%) patients required aspiration of the abscess.
• This study shows that almost 50% of the patients with amebic liver
abscess failed to respond to metronidazole and required aspiration.
Khanna S et al, Eur J Clin Microbiol Infect Dis

46. • In one study 966 liver abscess
– amebic in 661 (68%) patients, pyogenic in 200 (21%),
indeterminate in 73 (8%) and mixed in 32 (3%)
– Patients with advanced age, abscess size > 5 cm, both lobes of
the liver involvement and duration of symptoms > 7 d were
likely to undergo aspiration of the liver abscess, regardless of
etiology
– It is suggested that needle aspiration can improve response to
antibiotic treatment, reduce hospital stay and the total cost of
treatment
World J Gastroenterol 2008

47. • Razak et al showed that catheter drainage is more effective than needle
aspiration (100% vs 60%) in the treatment of ALA.
– Am J Roentgenol 1998
• Saraswat et al found that the percutaneous catheter could be removed
after a mean period of 7 days (range 3 20), when the patient was
– afebrile,
– catheter drainage had come down to <10 mL/day and
– Cavitogram showed a negligible cavity size.
– Clin Radiol 1992

49. ● In 27% patients resistant to medical treatment
● More commonly associated with:
• Jaundice (67% vs. 0%)
• Longer duration of illness (20 vs. 12 days)
• Larger lesions (600 vs. 320 ml)
• Longer catheter drainage ( 17 vs. 6.5 days)

50. Endoscopic Biliary drainage in patients with
amebic liver abscess and biliary communication

51. N=115, percutaneous treatment
N=90, catheter drainage
Needle aspiration: 25
Further treatment: 0 N=77 catheter
removed in 1 wk.
In patients with abscess-biliary communication biliary stenting hastens clinical
recovery and allows early catheter drain
N=13 (14%),
Communication
on ERCP
• Cather output: 88ml/d at day 2, 54ml/d at 2
wks
• 10 F catheter or NBD
• In 11 pts. catheter removed in 1 wk
Indian J Gastroenterol

52. • All the 13 patients needing ERCP had
– a long duration of symptoms (median 45 [25-60] days);
– nine had fever exceeding >38°C,
– six had anemia (median hemoglobin 9.1 [6.8-11.2] g/dL) and
– four had jaundice.
• Investigations showed
– leukocytosis (>12,000 cells/dL) in 10 patients,
– hyperbilirubinemia (median serum bilirubin 3.6 [2.5-8.0] mg/ dL) and
hypoalbuminemia (median 2.3 [1.8-3.2] g/ dL) in eight patients each;
– six patients had both hyperbilirubinemia and hypoalbuminemia.
– Eleven patients had a solitary liver abscess (right lobe 7, left lobe 4)
and two had abscesses in both the lobes.

53. • In an another study:
– 586 patients with liver abscesses,
– 38 (30 amebic, 8 pyogenic) patients who developed a biliary
fistula.
– They performed either endoscopic sphincterotomy with insertion
of a nasobiliary drain (n = 18) or endoscopic sphincterotomy
with biliary stenting (n = 20).
– The fistulas healed in all patients after a median time of 6 days
(range 4-40 days) after endoscopic treatment.
– The nasobiliary drainage catheters and stents were removed after
8-40 days of their placement. Sharma BC et al , Digestive dis.& sci.2012

54. Sharma B et al Endoscopy 2006
R IHBR 22
L IHBR 4
Fistulas healed in all patients after a mean time of 4 days (range 2±20 days)
after endoscopic treatment.
Were able to remove the nasobiliary drainage catheters and stents 6±34 days
after their placement

55. • Long term follow-up
• The mean time for disappearance of the sonographic abnormality is
6-9 months.
• Relapses are very uncommon, and the sonographic abnormality does
not warrant continued therapy.

56. THANKY
OU