Drugs & Diseases > General Surgery

Liver Abscess
Updated: Jun 20, 2016

 Author: Ruben Peralta, MD, FACS; Chief Editor: John Geibel, MD, DSc, MSc, AGAF more...

Background

Bacterial abscess of the liver is relatively rare; however, it has been

described since the time of Hippocrates (400 BCE), with the first published
review by Bright appearing in 1936. In 1938, Ochsner's classic review
heralded surgical drainage as the definitive therapy; however, despite the
more aggressive approach to treatment, the mortality remained at 60-80%. [1]

The development of new radiologic techniques, the improvement in

microbiologic identification, and the advancement of drainage techniques, as
well as improved supportive care, have reduced mortality to 5-30%; yet, the
prevalence of liver abscess has remained relatively unchanged. Untreated,
this infection remains uniformly fatal.

The three major forms of liver abscess, classified by etiology, are as

follows:
 Pyogenic abscess, which is most often polymicrobial, accounts for 80%
of hepatic abscess cases in the United States
 Amebic abscess due to Entamoeba histolytica accounts for 10% of
cases [2]
 Fungal abscess, most often due to Candida species, accounts for fewer
than 10% of cases

For patient education resources, see the Infections Center and

the Digestive Disorders Center, as well as Skin Abscess and Antibiotics.

Pathophysiology
The liver receives blood from both systemic and portal circulations.
Increased susceptibility to infections would be expected given the increased
exposure to bacteria. However, Kupffer cells lining the hepatic sinusoids
clear bacteria so efficiently that infection rarely occurs. Multiple processes
have been associated with the development of hepatic abscesses (see the
image below).
Table 4: Underlying etiology of 1086 cases of liver abscess compiled from
the literature.
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Appendicitis was traditionally the major cause of liver abscess. As

diagnosis and treatment of this condition has advanced, its frequency as a
cause for liver abscess has decreased to 10%.

Biliary tract disease is now the most common source of pyogenic liver
abscess (PLA). Obstruction of bile flow allows for bacterial proliferation.
Biliary stone disease, obstructive malignancy affecting the biliary tree,
stricture, and congenital diseases are common inciting conditions. With a
biliary source, abscesses usually are multiple, unless they are associated
with surgical interventions or indwelling biliary stents. In these instances,
solitary lesions can be seen.

Infections in organs in the portal bed can result in a localized septic

thrombophlebitis, which can lead to liver abscess. Septic emboli are released
into the portal circulation, trapped by the hepatic sinusoids, and become the
nidus for microabscess formation. These microabscesses initially are
multiple but usually coalesce into a solitary lesion.

Microabscess formation can also be due to hematogenous

dissemination of organisms in association with systemic bacteremia, such as
endocarditis and pyelonephritis. Cases also are reported in children with
underlying defects in immunity, such as chronic granulomatous disease and
leukemia.

Approximately 4% of liver abscesses result from fistula formation

between local intra-abdominal infections.
 Despite advances in diagnostic imaging, cryptogenic causes account
for a significant proportion of cases; surgical exploration has impacted this
minimally. These lesions usually are solitary in nature.

Penetrating hepatic trauma can inoculate organisms directly into the

liver parenchyma, resulting in pyogenic liver abscess. Nonpenetrating
trauma can also be the precursor to pyogenic liver abscess by causing
localized hepatic necrosis, intrahepatic hemorrhage, and bile leakage. The
resulting tissue environment permits bacterial growth, which may lead to
pyogenic liver abscess. These lesions are typically solitary.

PLA has been reported as a secondary infection of amebic abscess,

hydatid cystic cavities, and metastatic and primary hepatic tumors. It is also
a known complication of liver transplantation, hepatic artery embolization in
the treatment of hepatocellular carcinoma, and the ingestion of foreign
bodies, which penetrate the liver parenchyma. Trauma and secondarily
infected liver pathology account for a small percentage of liver abscess
cases.

The right hepatic lobe is affected more often than the left hepatic lobe
by a factor of 2:1. Bilateral involvement is seen in 5% of cases. The
predilection for the right hepatic lobe can be attributed to anatomic
considerations. The right hepatic lobe receives blood from both the superior
mesenteric and portal veins, whereas the left hepatic lobe receives inferior
mesenteric and splenic drainage. It also contains a denser network of biliary
canaliculi and, overall, accounts for more hepatic mass. Studies have
suggested that a streaming effect in the portal circulation is causative.

Etiology
Polymicrobial involvement is common, with Escherichia
coli and Klebsiella pneumoniae being the two most frequently isolated
pathogens (see the image below). Reports suggest that K pneumoniae is an
increasingly prominent cause. [3]
 Table 2: Microbiologic results from 312 cases of liver abscess compiled
from the literature.
View Media Gallery

Enterobacteriaceae are especially prominent when the infection is of

biliary origin. Abscesses involving K pneumoniae have been associated with
multiple cases of endophthalmitis.

The pathogenic role of anaerobes was underappreciated until the

isolation of anaerobes from 45% of cases of pyogenic liver abscess was
reported in 1974. Since that time, increasing rates of anaerobic involvement
have been reported, likely because of increased awareness and improved
culturing techniques. The most frequently encountered anaerobes
are Bacteroides species, Fusobacterium species, and microaerophilic and
anaerobic streptococci. A colonic source is usually the initial source of
infection.

Staphylococcus aureus abscesses usually result from hematogenous

spread of organisms involved with distant infections, such as endocarditis. S
milleri is neither anaerobic nor microaerophilic. It has been associated with
both monomicrobial and polymicrobial abscesses in patients with Crohn
disease, as well as with other patients with pyogenic liver abscess.

Amebic liver abscess is most often due to E histolytica. Liver abscess

is the most common extraintestinal manifestation of this infection.

Fungal abscesses primarily are due to Candida albicans and occur in

individuals with prolonged exposure to antimicrobials, hematologic
malignancies, solid-organ transplants, and congenital and acquired
immunodeficiency. Cases involving Aspergillus species have been reported.
 Other organisms reported in the literature
include Actinomyces species, Eikenella corrodens, Yersinia enterocolitica,
Salmonella typhi, and Brucella melitensis.

A small case series in Taiwan investigated pyogenic liver abscess as

the initial manifestation of underlying hepatocellular carcinoma. In regions
with a high prevalence of both pyogenic liver abscess and hepatocellular
carcinoma, clinicians should be aware of the possibility of underlying
hepatocellular carcinoma in patients with risk factors for the disease. [4]

Epidemiology
United States statistics
The incidence of pyogenic liver abscess has essentially remained
unchanged by both hospital and autopsy data. Liver abscess was diagnosed
in 0.7%, 0.45%, and 0.57% of autopsies during the periods of 1896-1933,
1934-1958, and 1959-1968, respectively. The frequency in hospitalized
patients is in the range of 8-16 cases per 100,000 persons. Studies suggest
a small, but significant, increase in the frequency of liver abscess.
Age-related demographics
Prior to the antibiotic era, liver abscess was most common in the fourth
and fifth decades of life, primarily due to complications of appendicitis. With
the development of better diagnostic techniques, early antibiotic
administration, and the improved survival of the general population, the
demographic has shifted toward the sixth and seventh decades of life.
Frequency curves display a small peak in the neonatal period followed by a
gradual rise beginning at the sixth decade of life.

Cases of liver abscesses in infants have been associated with

umbilical vein catheterization and sepsis.

When abscesses are seen in children and adolescents, underlying

immune deficiency, severe malnutrition, or trauma frequently exists.
Sex-related demographics
While abscesses once showed a predilection for males in earlier
decades, no sexual predilection currently exists. Males have a poorer
prognosis from hepatic abscess than females.

Prognosis
 Untreated, pyogenic liver abscess remains uniformly fatal. With timely
administration of antibiotics and drainage procedures, mortality currently
occurs in 5-30% of cases. The most common causes of death include sepsis,
multiorgan failure, and hepatic failure. [5]

Indicators of a poor prognosis have been described since 1938 and

include multiplicity of abscesses, underlying malignancy, severity of
underlying medical conditions, presence of complications, and delay in
diagnosis. [5]

Indicators of a poor prognosis in amebic abscess include a bilirubin

level of greater than 3.5 mg/dL, encephalopathy, hypoalbuminemia (ie,
serum albumin level of <2 g/dL), and multiple abscesses; all are independent
factors that predict poor outcome.

An underlying malignant etiology and an Acute Physiology and

Chronic Health Evaluation (APACHE II) score greater than 9 increases the
relative mortality by 6.3-fold and 6.8-fold, respectively.

Chen et al examined prognostic factors for elderly patients with

pyogenic liver abscess. [6] Results from the study, which included 118
patients aged 65 years or older and 221 patients below age 65 years,
indicated that age and an APACHE II score of 15 or greater at hospital
admission were risk factors for mortality. The evidence ultimately suggested
that outcomes for older patients with pyogenic liver abscess are on a par with
those for younger patients. The investigators also found that in the younger
patient group, there was greater frequency of males suffering from
alcoholism, a cryptogenic abscess, and K pneumoniae infection.

History
The most frequent symptoms of hepatic abscess include the following (see
the image below):
 Fever (either continuous or spiking)
 Chills
 Right upper quadrant pain
 Anorexia
 Malaise
 Table 1: Presenting symptoms and signs in 715 patients diagnosed with
liver abscess.
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Cough or hiccoughs due to diaphragmatic irritation may be reported.

Referred pain to the right shoulder may be present.

Individuals with solitary lesions usually have a more insidious course

with weight loss and anemia of chronic disease. With such symptoms,
malignancy often is the initial consideration.

Fever of unknown origin (FUO) frequently can be an initial diagnosis

in indolent cases. Multiple abscesses usually result in more acute
presentations, with symptoms and signs of systemic toxicity.

Afebrile presentations have been documented.

Physical Examination
Fever and tender hepatomegaly are the most common signs. A
palpable mass need not be present. Midepigastric tenderness, with or
without a palpable mass, is suggestive of left hepatic lobe involvement.

Decreased breath sounds in the right basilar lung zones, with signs of
atelectasis and effusion on examination or radiologically, may be present. A
pleural or hepatic friction rub can be associated with diaphragmatic irritation
or Glisson capsule inflammation.

Jaundice may be present in as many as 25% of cases and usually is

associated with biliary tract disease or the presence of multiple abscesses.
Complications
Complications of liver abscess may include the following:
 Sepsis
 Empyema resulting from contiguous spread or intrapleural rupture of
abscess
 Rupture of abscess with resulting peritonitis
 Endophthalmitis when an abscess is associated with K
pneumoniae bacteremia

Differential Diagnoses
 Acute Gastritis
 Bacterial Pneumonia
 Biliary Disease
 Cholecystitis
 Hepatocellular Carcinoma
 Hydatid Cysts
 Parapneumonic Pleural Effusions and Empyema Thoracis

Laboratory Studies
Laboratory studies may include a complete blood count (CBC) with
differential (to identify anemia of chronic disease or neutrophilic leukocytosis)
and liver function studies (hypoalbuminemia and elevation of alkaline
phosphatase are the most common abnormalities; elevations of
transaminase and bilirubin levels are variable.

Blood cultures are positive in roughly 50% of cases. Culture of abscess

fluid should be the goal in establishing microbiologic diagnosis.
Enzyme immunoassay should be performed to detect E histolytica in
patients either from endemic areas or who have traveled to endemic areas.

Imaging Studies
Advances in radiologic techniques has been credited with the
improvement in mortality. The various radiologic techniques have differing
benefits and limitations with regard to their diagnostic utility (see the image
below).
Table 3: Comparison of the radiologic procedures used in the diagnosis of
liver abscess.
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Computed tomography
Computed tomography (CT) with contrast and ultrasonography remain
the radiologic modalities of choice as screening procedures and also can be
used as techniques for guiding percutaneous aspiration and drainage.

With advancements in multidetector CT technology, image quality has

improved dramatically, allowing improved detection. CT has a sensitivity of
95-100% in this setting (see the images below).

Computed tomography (CT) scan findings of liver abscess are shown. A

large, septated abscess of the right hepatic lobe is revealed. Abscess was
successfully treated with percutaneous drainage and antimicrobial therapy.
View Media Gallery
 Computed tomography (CT) scan findings of liver abscess are shown. A
large anterior abscess involving the left hepatic lobe is revealed. Abscess
was successfully treated with percutaneous drainage and antimicrobial
therapy.
View Media Gallery
Lesions on CT evaluation are well-demarcated areas hypodense to the
surrounding hepatic parenchyma. Peripheral enhancement is seen when
intravenous (IV) contrast is administered. Gas can be seen in as many as
20% of lesions.

CT is superior in its ability to detect lesions less than 1 cm. This

technique also enables evaluation for an underlying concurrent pathology
throughout the abdomen and pelvis. Indium-labeled white blood cell (WBC)
scans are somewhat more sensitive in this regard.

A retrospective study was undertaken using patient records from a

group of 131 patients with confirmed pyogenic liver abscesses to determine
CT scan characteristics of those abscesses caused by monomicrobial K
pneumoniae infection versus other causes. A comparison was performed
between the K pneumoniae liver abscess patients and a comparison group.
Notably, only 70.2% of the cases were determined to be monomicrobial K
pneumoniae liver abscesses. CT scan characteristics more likely to be seen
in these monomicrobial liver abscesses were (1) a single abscess, (2)
unilobar involvement, (3) solid appearance, (4) association with
thrombophlebitis, and (5) hematogenous appearance. [7]
Ultrasonography
Ultrasonographic evaluation (sensitivity, 80-90%) reveals hypoechoic
masses with irregularly shaped borders. Internal septations or cavity debris
may be detected. [8] It allows close evaluation of the biliary tree and
simultaneous aspiration of the cavity. The major benefits of this modality are
its portability and diagnostic utility in patients who are too critical to undergo
prolonged radiologic evaluation or to be moved out of monitored setting.
Operator dependence affects its overall sensitivity.

Radionuclide scanning
The initial studies are used in diagnosis. [9] Gallium and technetium
radionuclide scanning use the fact that the radiopharmaceuticals share the
same uptake, transport, and excretion pathways as bilirubin and, thus, are
effective agents in evaluating liver disease. Sensitivity varies with the
radiopharmaceutical utilized, technetium (80%), gallium (50-80%), and
indium (90%). Limitations include a delay in diagnosis and the need for
confirmatory procedures; thus, they offer no benefit over other imaging
modalities.

Chest radiography
Chest radiographic findings of basilar atelectasis, right hemidiaphragm
elevation, and right pleural effusion are present in approximately 50% of
cases; before advancements in radiologic technique, these served as
diagnostic clues. Pneumonias or pleural diseases often are initially
considered because of the radiographic findings.

Percutaneous Aspiration and Drainage

Percutaneous needle aspiration
Under CT or ultrasonographic guidance, needle aspiration of cavity
material can be performed. Needle aspiration enables rapid recovery of
material for microbiologic and pathologic evaluation. It can be performed with
the initial diagnostic procedure.

Percutaneous catheter drainage

Percutaneous drainage has become the standard of care and should
be the first intervention considered for small cysts. Advantages include
reduced costs, recovery time, and postprocedure recovery rate; it eliminates
the need for general anesthesia. This also allows for gradual, controlled
drainage. For cysts larger than 5 cm, ruptured cysts, and multiloculated
cysts, surgical drainage is generally recommended over percutaneous
intervention.

A catheter is placed under ultrasonographic or CT guidance via the

Seldinger or trocar techniques. The catheter is flushed daily until output is
less than 10 mL/day or cavity collapse is documented by serial CT.

Multiple abscesses have been drained successfully by this method.

Failure to respond to catheter drainage is the main reported complication
and is also an indication for surgical intervention. Other complications
reported (rarely) are bleeding at the catheter site, perforation of hollow
viscus, and peritonitis from intraperitoneal spillage of cavity fluid.

Contraindications include coagulopathy; a difficult access path to the

cavity; peritonitis; and/or a complicated, multiloculated, thick-walled abscess
with viscous pus.

Medical Care
An untreated hepatic abscess is nearly uniformly fatal as a result of
complications that include sepsis, empyema, or peritonitis from rupture into
the pleural or peritoneal spaces, and retroperitoneal extension. Treatment
should include drainage, either percutaneous or surgical.

Antibiotic therapy as a sole treatment modality is not routinely

advocated, though it has been successful in a few reported cases. It may be
the only alternative in patients too ill to undergo invasive procedures or in
those with multiple abscesses not amenable to percutaneous or surgical
drainage. In these instances, patients are likely to require many months of
antimicrobial therapy with serial imaging and close monitoring for associated
complications.

Antimicrobial treatment is a common adjunct to percutaneous or

surgical drainage.

Surgical Care
Surgical drainage was the standard of care until the introduction of
percutaneous drainage techniques in the mid-1970s. With the refinement of
image-guided techniques, percutaneous drainage and aspiration have
become the standard of care.
 Current indications for the surgical treatment of pyogenic liver abscess
are for the treatment of underlying intra-abdominal processes, including
signs of peritonitis; existence of a known abdominal surgical pathology (eg,
diverticular abscess); failure of previous drainage attempts; and the
presence of a complicated, multiloculated, thick-walled abscess with viscous
pus.

Shock with multisystem organ failure is a contraindication for surgery.

Open surgery can be performed by either of the following two approaches:
 A transperitoneal approach allows for abscess drainage and abdominal
exploration to identify previously undetected abscesses and the location
of an etiologic source
 For high posterior lesions, a posterior transpleural approach can be
used; although this affords easier access to the abscess, the
identification of multiple lesions or a concurrent intra-abdominal
pathology is lost

A laparoscopic approach is also commonly used in select cases. This

minimally invasive approach affords the opportunity to explore the entire
abdomen and to significantly reduce patient morbidity. A growing literature
is defining the optimal population for this mode of intervention.

A retrospective chart review compared surgery versus percutaneous

drainage for liver abscesses greater than 5 cm. Morbidity was comparable
for the two procedures, but those treated with surgery had fewer secondary
procedures and fewer treatment failures.

Postoperative complications are not uncommon and include recurrent

pyogenic liver abscess, intra-abdominal abscess, hepatic or renal failure,
and wound infection.

Consultations
Obtain an interventional radiology consultation as soon as the
diagnosis is considered to allow rapid collection of cavity fluid and the
potential for early therapeutic drainage of abscess.

Immediately seek a consultation with a general surgeon if the source

of the abscess is a known underlying abdominal pathology or in cases with
peritonitis. In cases undergoing percutaneous drainage, seek the
involvement of a general surgeon if drainage of the abscess cavity is
unsuccessful.
 Gastroenterology involvement may be useful after successful drainage
to evaluate for underlying gastrointestinal disease using colonoscopy or
endoscopic retrograde cholangiopancreatography (ERCP).

Infectious disease consultation should be considered in complicated

cases and when the involved pathogens are unusual or difficult to treat, such
as in fungal abscesses.

Long-Term Monitoring
Aggressively seek an underlying source of the abdominal pathology.
Perform weekly serial computed tomography (CT) or ultrasound
examinations to document adequate drainage of the abscess cavity.
Continue radiologic evaluation to document progress of therapy after
discharge.

Drain care may be required. Maintain drains until the output is less
than 10 mL/day.

Monitor fever curves. Persistent fever after 2 weeks of therapy may

indicate the need for more aggressive drainage.

For patients with an underlying malignancy, definitive treatment, such

as surgical removal of the mass, should be pursued if at all possible.

Patients will require prolonged parenteral antimicrobial therapy that

may continue after discharge. Monitoring of medication levels, renal function,
and blood counts may be needed. Enteral nutrition is the preferred route
unless it is clinically contraindicated.

Medication Summary
Until cultures are available, the choice of antimicrobial agents should
be directed toward the most commonly involved pathogens. Regimens using
beta-lactam/beta-lactamase inhibitor combinations, carbapenems, or
second-generation cephalosporins with anaerobic coverage are excellent
empiric choices for the coverage of enteric bacilli and anaerobes.
Metronidazole or clindamycin should be added for the coverage
of Bacteroides fragilis if other employed antibiotics offer no anaerobic
coverage.

Amebic abscess should be treated with metronidazole, which will be

curative in 90% of cases. Metronidazole should be initiated before serologic
test results are available. Patients who do not respond to metronidazole
should receive chloroquine alone or in combination with emetine or
dehydroemetine.

Systemic antifungal agents should be initiated if fungal abscess is

suspected and after the abscess has been drained percutaneously or
surgically. Initial therapy for fungal abscess is currently amphotericin B. Lipid
formulations may offer some benefit in that the complexing of drug to lipid
moieties allows for concentration in hepatocytes. Further investigation is
required for definitive proof. Cases of successful fluconazole treatment after
amphotericin failure have been reported; however, its use as an initial agent
is still being studied.

Ultimately, the organisms isolated and antibiotic sensitivities should

guide the final choice of antimicrobials.

Duration of treatment has always been debated. Short courses (2 wk)

of therapy after percutaneous drainage have been successful in a small
series of patients; however, most series have reported recurrence of
abscess even after more prolonged courses. Currently 4-6 weeks of therapy
is recommended for solitary lesions that have been adequately drained.
Multiple abscesses are more problematic and can require up to 12 weeks of
therapy. Both the clinical and radiographic progress of the patient should
guide the length of therapy.

Antibiotics
Class Summary
Empiric antimicrobial therapy must be comprehensive and should
cover all likely pathogens in the context of the clinical setting.

Meropenem (Merrem)
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Bactericidal broad-spectrum carbapenem antibiotic that inhibits cell-
wall synthesis. Effective against most gram-positive and gram-negative
bacteria.

Has slightly increased activity against gram negatives and slightly

decreased activity against staphylococci and streptococci species compared
to imipenem.
Imipenem and cilastatin (Primaxin)
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For treatment of multiple organism infections in which other agents do
not have wide-spectrum coverage or are contraindicated due to potential for
toxicity.

Cefuroxime (Ceftin)
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Second-generation cephalosporin maintains gram-positive activity that
first-generation cephalosporins have; adds activity against Proteus
mirabilis, Haemophilus influenzae, Escherichia coli, Klebsiella pneumoniae,
and Moraxella catarrhalis. Condition of patient, severity of infection, and
susceptibility of microorganism determine proper dose and route of
administration.

Cefotetan (Cefotan)
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Second-generation cephalosporin indicated for infections caused by
susceptible gram-positive cocci and gram-negative rods.

Dosage and route of administration depends on condition of patient,

severity of infection, and susceptibility of causative organism.

Cefoxitin (Mefoxin)
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Second-generation cephalosporin indicated for gram-positive cocci
and gram-negative rod infections. Infections caused by cephalosporin-
resistant or penicillin-resistant gram-negative bacteria may respond to
cefoxitin.

Cefaclor (Ceclor)
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Second-generation cephalosporin indicated for infections caused by
susceptible gram-positive cocci and gram-negative rods.
Determine proper dosage and route based on condition of patient, severity
of infection, and susceptibility of causative organism.
Clindamycin (Cleocin)
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Lincosamide for treatment of serious skin and soft tissue
staphylococcal infections. Also effective against aerobic and anaerobic
streptococci (except enterococci). Inhibits bacterial growth, possibly by
blocking dissociation of peptidyl t-RNA from ribosomes causing RNA-
dependent protein synthesis to arrest.

Metronidazole (Flagyl)
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Imidazole ring-based antibiotic active against various anaerobic
bacteria and protozoa. Used in combination with other antimicrobial agents
(except for Clostridium difficile enterocolitis).

Antifungal agents
Class Summary
Their mechanism of action may involve an alteration of RNA and DNA
metabolism or an intracellular accumulation of peroxide that is toxic to the
fungal cell.

Amphotericin B (AmBisome)
 View full drug information
Produced by a strain of Streptomyces nodosus; can be fungistatic or
fungicidal. Binds to sterols, such as ergosterol, in the fungal-cell membrane,
causing intracellular components to leak with subsequent fungal-cell death.

Fluconazole (Diflucan)
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Synthetic oral antifungal (broad-spectrum bistriazole) that selectively
inhibits fungal cytochrome P-450 and sterol C-14 alpha-demethylation.