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 Table of Contents  
ORIGINAL ARTICLE
Year : 2014  |  Volume : 4  |  Issue : 1  |  Page : 36-39

Pyogenic liver abscesses in adults: A 3-year study


1 Department of General Surgery, SVS Medical College and Hospital, Mahabubnagar, India
2 ASRAM Medical College, Eluru, Andhra Pradesh, India

Date of Web Publication14-Jul-2014

Correspondence Address:
Ramesh K Korumilli
Plot No. 70, Gruhalaxmi Colony, Old Kaskaguda, Secunderabad - 500 009, Andhra Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2278-9596.136709

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  Abstract 

Background: Pyogenic liver abscess (PLA), a potentially life-threatening disease, has undergone significant changes in epidemiology, management, and mortality over the past several decades. This study was undertaken to evaluate PLA in relation to age, sex, anatomical relation, etiological factors, and response to various lines of management.
Materials and Methods: A prospective study was conducted during the period from September 2010 to September 2013. Amebic and hydatid liver abscesses were excluded. We recorded and analyzed the clinical presentations, diagnostic modalities, and treatment programs of PLAs.
Results: A total of 423 patients were studied. The average age of patients was 42 years, ranged from 20 to 80 years. Of a total 423 patients, 386 patients (91.2%) were males and 37 (8.8%) were females. The most common symptom was fever associated with chills. The most common sign was hepatomegaly and tenderness in right hypochondrium 209 (49.4%). Alcoholism was identified as a major risk factor in 309 (73%) patients. Diabetes was present in 86 (20.3%), tuberculosis in 34 (8%), and HIV infection in 10 (2.3%) patients. Abdominal ultrasonography had a sensitivity of 97% in diagnosing liver abscess. There was a single abscess in 326 (77%) patients, the right lobe being involved in 282 (66.6%) patients. Multiple abscesses were found in 97 (22.9%). Most patients were managed conservatively with antibiotics and percutaneous drainage. 46 patients (10.8%) had ruptured liver abscesses and required peritoneal lavage at laparotomy. Death occurred in seven (2%) patients.
Conclusion: Pyogenic liver abscess is a potentially fatal disease if untreated. Early diagnosis remains the cornerstone of management. Majority can be managed conservatively with antibiotics and percutaneous drainage.

Keywords: Alcoholism, percutaneous drainage, peritonitis, pyogenic liver abscess


How to cite this article:
Korumilli RK, Ginjala GR, Mahesh SA. Pyogenic liver abscesses in adults: A 3-year study. Arch Int Surg 2014;4:36-9

How to cite this URL:
Korumilli RK, Ginjala GR, Mahesh SA. Pyogenic liver abscesses in adults: A 3-year study. Arch Int Surg [serial online] 2014 [cited 2019 Jun 20];4:36-9. Available from: http://www.archintsurg.org/text.asp?2014/4/1/36/136709


  Introduction Top


Pyogenic liver abscess (PLA), is a potentially life-threatening disease, recognized since time of Hippocrates. [1] It presents with considerable morbidity and mortality. In 1938, Ochsner and DeBakey [2] described the treatment and mortality of patients with PLA and recommended surgical treatment as the primary treatment modality. Surgery remained the therapy of choice until the mid-1980s, when percutaneous drainage was shown to be a safer alternative in many cases. Over the past decades, the advent of modern diagnostic imaging technique, use of effective antibiotics and image guided drainage of abscess substantially decreased the mortality and greatly improved the outcome of patients with PLA. [3] This study was undertaken to evaluate PLA in relation to age, sex, anatomical relation, etiological factors, and response to various lines of management.


  Materials and Methods Top


A prospective study of PLA was conducted over a 3-year period from September 2010 to September 2013. Ethical approval was obtained.

The inclusion criteria for the study are patients aged 20-80 years of both genders and clinical and ultrasonography (USG) diagnosis of liver abscess.

The exclusion criteria were patients <20 years, amebic and hydatid liver abscesses, previous abdominal and biliary surgeries and abdominal neoplasia.

The patients were subjected to a detailed history, biochemical, and pathological investigations. Special investigations included USG of the abdomen in which number, size, and location of abscesses were recorded. Neither computed tomography nor radiographic isotopic scanning or other investigations were used to identify the abscess. Any associated comorbidities such as diabetes, tuberculosis, and HIV infection were noted. The variables studied and analyzed are age, sex, clinical features, risk factors, laboratory data, USG investigations, clinical course, treatment, and complications. Mortality is defined as death in 30 days after treatment or discharge from the hospital.

The study population was consecutive patients with clinical and USG diagnosis of PLA. All patients were initially treated by conservative management. The following antibiotics were given intravenously for 5-7 days: Ciprofloxacin 500 mg bd, metronidazole 100 mg tid, and amikacin 500 mg bd.

These were modified when sensitivity was demonstrated by bacterial cultures. Microscopic abscess was defined as abscess <2 cm in size. Percutaneous drainage was performed for abscess >2 cm in size after 3 days of conservative treatment with 14 French pigtail catheters by Seldinger technique under USG guidance. If the patient's condition improved after conservative treatment or after percutaneous drainage of the abscess, the antibiotic is continued orally for 4 weeks. Patients who continued to have abdominal pain, fever, toxicity and showed no decrease in the size of abscess on review USG for 3-5 days were considered to be unresponsive to conservative treatment. Patients who were unresponsive to conservative treatment or in whom difficulty was encountered in performing the percutaneous drainage or those who presented with complications of rupture of abscess or peritonitis were selected for operative drainage, open or laparoscopic. Data were analyzed by descriptive statistics including mean, standard deviation, and percentage.


  Results Top


Four hundred and twenty-three patients were included in this study. The mean age was 42.24 ± 4.86 (range 20-80 years). 386 (91.2%) patients were males and 37 (8.8%) were females. The most common symptom was fever associated with chills seen in 306 (72.3%), followed by pain at right hypochondrium in 254 (60%), weight loss 228 (53.9%), and jaundice in 79 (18.6%). 46 (10.8%) patients presented with ruptured liver abscess with peritonitis [Table 1]. The most common sign was tenderness in right hypochondrium seen in 209 (49.4%) followed by hepatomegaly seen in 56 (13.2%) patients.
Table 1: Clinical features

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The main laboratory findings are shown in [Table 2]. All PLAs in this series were identified by ultrasonography.
Table 2: Laboratory findings

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Single abscess was found in 326 (77%) and multiple in 97 (22.9%) patients. Right lobe of the liver was involved in 282 (66.6%) patients, left lobe in 44 (10.1%), and bilobar in 97 (22.9%). A total of 224 (52.9%) patients received conservative treatment with a hospital stay of 4-12 days. One hundred and fifty-three (36%) patients were treated by USG guided percutaneous drainage with pigtail catheter. The hospital stay in this group was 6-12 days. 46 patients (10.8%) were treated by open surgical drainage with peritoneal lavage and placement of drain in abscess area. The hospital stay in this group was 8-18 days [Table 3]. Six patients were treatment by laparoscopic drainage. The hospital stay in this group was 5-6 days. Escherichia coli was the most common pathogen seen in 268 patients (63.3%), followed by Klebsiella in 51 (12.05%). It was polymicrobial in 72 (17%). E. coli was sensitive to the following antibiotics in decreasing order of sensitivity: Ciprofloxacin, metronidazole, and ampiclox, while Klebsiella was sensitive to ciprofloxacin, levofloxacin, gentamycin, and ceftazidime.
Table 3: Treatment modalities of pyogenic liver abscess

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  Discussion Top


In our study, the most common symptoms were fever with chills and pain at right hypochondrium, which are also seen in other studies. [3],[4],[5],[6],[7],[8],[9] Alcoholism was the most common risk factor associated with PLA [Table 4]. Leukocytosis and raised alkaline phosphatase were the most common laboratory abnormalities raised in 261 (81.7%) and 307 (72.5%) of patients, respectively. [10],[11],[12],[13],[14],[15] PLA are more common in male patients. They are more common in the right lobe of liver seen in 282 (67%) of patients and most of them are solitary. [7],[15] The reason for PLA being the most common in the right lobe of the liver may be due to greater volume of blood going to the right lobe as compared with the left lobe.
Table 4: Risk factors

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The following clinical, laboratory, and USG features are assessed for 3-5 days, for identifying patients for successful conservative treatment. The clinical features are decreasing pain at right hypochondrium and fever. The laboratory features are decreasing leukocytosis and alkaline phosphatase. USG features showing a decrease in the size of abscess.

Conservative treatment with empirical antibiotics may be sufficient in most cases, and particularly in those who are unfit to undergo invasive approaches and also for those with multiple abscesses not suitable for drainage interventions. Several studies have reported that inadequate empirical antibiotic therapy may result in increased failure rate and increased mortality rate. [13],[15] In our study and in others, conservative treatment with empirical antibiotic therapy and percutaneous drainage are both effective treatment modalities for PLA. [16],[17],[18],[19] Surgical drainage was only indicated in patients who developed complications such as rupture and peritonitis. [4],[20],[21] We explored 40 patients with open surgery who were discharged in 8-18 days. In our study, there was no significant difference in the outcome of treatment in HIV infected patients compared to other patients.

The most common organism causing PLA was E. coli in our study, which is similar to other studies. [17],[18] It was followed by Klebsiella, which is emerging as the most common cause of PLA in the developed countries such as USA, Taiwan and Korea. [22],[23],[24],[25]


  Conclusion Top


Pyogenic liver abscess is a potentially life-threatening disease if in-adequately treated. It requires a high index of suspicion for early diagnosis. Conservative treatment with antibiotics and ultrasound guided percutaneous drainage are the most effective methods for treatment of PLA unless complicated by rupture and peritonitis when laparotomy is indicated.

 
  References Top

1.Adams F. The Genuine Works of Hippocrates. New York: W. Wood; 1886.  Back to cited text no. 1
    
2.Ochsner A, DeBakey M, Murray S. Pyogenic abscess of the liver. Am J Surg 1938;40:292-314.  Back to cited text no. 2
    
3.Rahimian J, Wilson T, Oram V, Holzman RS. Pyogenic liver abscess: Recent trends in etiology and mortality. Clin Infect Dis 2004;39:1654-9.  Back to cited text no. 3
    
4.Chen SC, Yen CH, Lai KC, Tsao SM, Cheng KS, Chen CC, et al. Pyogenic liver abscesses with Escherichia coli: Etiology, clinical course, outcome, and prognostic factors. Wien Klin Wochenschr 2005;117:809-15.  Back to cited text no. 4
    
5.McDonald MI, Corey GR, Gallis HA, Durack DT. Single and multiple pyogenic liver abscesses. Natural history, diagnosis and treatment, with emphasis on percutaneous drainage. Medicine (Baltimore) 1984;63:291-302.  Back to cited text no. 5
    
6.Yang PW, Lin HD, Wang LM. Pyogenic liver abscess associated with septic pulmonary embolism. J Chin Med Assoc 2008; 71:442-7.  Back to cited text no. 6
    
7.Zibari GB, Maguire S, Aultman DF, McMillan RW, McDonald JC. Pyogenic liver abscess. Surg Infect (Larchmt) 2000;1:15-21.  Back to cited text no. 7
    
8.Nah BK, Kim YS, Moon HS, Park KO, Kim SM, Lee YS, et al. Recent changes of organism and treatment in pyogenic liver abscess. Taehan Kan Hakhoe Chi 2003;9:275-83.  Back to cited text no. 8
    
9.Lederman ER, Crum NF. Pyogenic liver abscess with a focus on Klebsiella pneumoniae as a primary pathogen: An emerging disease with unique clinical characteristics. Am J Gastroenterol 2005;100:322-31.  Back to cited text no. 9
    
10.Fang CT, Lai SY, Yi WC, Hsueh PR, Liu KL, Chang SC. Klebsiella pneumoniae genotype K1: An emerging pathogen that causes septic ocular or central nervous system complications from pyogenic liver abscess. Clin Infect Dis 2007;45:284-93.  Back to cited text no. 10
    
11.Fung CP, Chang FY, Lee SC, Hu BS, Kuo BI, Liu CY, et al. A global emerging disease of Klebsiella pneumoniae liver abscess: Is serotype K1 an important factor for complicated endophthalmitis? Gut 2002;50:420-4.  Back to cited text no. 11
    
12.Cheng HP, Chang FY, Fung CP, Siu LK. Klebsiella pneumonia Liver abscess in Taiwan is not caused by a clonal spread strain. J Microbiol Immunol Infect 2002;35:85-8.  Back to cited text no. 12
    
13.Chung DR, Lee HR, Lee SS, Kim SW, Chang HH, Jung SI, et al. Evidence for clonal dissemination of the serotype K1 Klebsiella pneumoniae strain causing invasive liver abscesses in Korea. J Clin Microbiol 2008;46:4061-3.  Back to cited text no. 13
    
14.Han SH. Review of hepatic abscess from Klebsiella pneumoniae. An association with diabetes mellitus and septic endophthalmitis. West J Med 1995;162:220-4.  Back to cited text no. 14
    
15.Liew KV, Lau TC, Ho CH, Cheng TK, Ong YS, Chia SC, et al. Pyogenic liver abscess - A tropical centre's experience in management with review of current literature. Singapore Med J 2000;41:489-92.  Back to cited text no. 15
    
16.Civardi G, Filice C, Caremani M, Giorgio A. Hepatic abscesses in immunocompromised patients: Ultrasonically guided percutaneous drainage. Gastrointest Radiol 1992;17:175-8.  Back to cited text no. 16
    
17.Giorgio A, Tarantino L, Mariniello N, Francica G, Scala E, Amoroso P, et al. Pyogenic liver abscesses: 13 years of experience in percutaneous needle aspiration with US guidance. Radiology 1995;195:122-4.  Back to cited text no. 17
    
18.Alvarez Pérez JA, González JJ, Baldonedo RF, Sanz L, Carreño G, Junco A, et al. Clinical course, treatment, and multivariate analysis of risk factors for pyogenic liver abscess. Am J Surg 2001;181:177-86.  Back to cited text no. 18
    
19.Seeto RK, Rockey DC. Pyogenic liver abscess. Changes in etiology, management, and outcome. Medicine (Baltimore) 1996;75:99-113.  Back to cited text no. 19
    
20.Hsieh HF, Chen TW, Yu CY, Wang NC, Chu HC, Shih ML, et al. Aggressive hepatic resection for patients with pyogenic liver abscess and APACHE II score > or =15. Am J Surg 2008;196:346-50.  Back to cited text no. 20
    
21.Mandel SR, Boyd D, Jaques PF, Mandell V, Staab EV. Drainage of hepatic, intraabdominal, and mediastinal abscesses guided by computerized axial tomography. Successful alternative to open drainage. Am J Surg 1983;145:120-5.  Back to cited text no. 21
    
22.Yang CC, Chen CY, Lin XZ, Chang TT, Shin JS, Lin CY. Pyogenic liver abscess in Taiwan: Emphasis on gas-forming liver abscess in diabetics. Am J Gastroenterol 1993;88:1911-5.  Back to cited text no. 22
    
23.Wang JH, Liu YC, Lee SS, Yen MY, Chen YS, Wang JH, et al. Primary liver abscess due to Klebsiella pneumoniae in Taiwan. Clin Infect Dis 1998;26:1434-8.  Back to cited text no. 23
    
24.Chang SC, Fang CT, Hsueh PR, Chen YC, Luh KT. Klebsiella pneumoniae isolates causing liver abscess in Taiwan. Diagn Microbiol Infect Dis 2000;37:279-84.  Back to cited text no. 24
    
25.Lau YJ, Hu BS, Wu WL, Lin YH, Chang HY, Shi ZY. Identification of a major cluster of Klebsiella pneumoniae isolates from patients with liver abscess in Taiwan. J Clin Microbiol 2000;38:412-4.  Back to cited text no. 25
    



 
 
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  [Table 1], [Table 2], [Table 3], [Table 4]



 

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