Liver Abscess

Aka: Liver Abscess, Hepatic Abscess

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II. Causes

  1. Amebiasis or Entamoeba histolytica (10-15%)
    1. Fecal-oral transmission in endemic regions (asia, africa, latin america)
  2. Fungal including candida (<10%)
  3. Bacterial Infection (80%)
    1. Aerobic Gram Negative Bacteria (Enterobacteriaciae, esp. Klebsiella species)
    2. Streptococcus species
    3. Enterococcus
    4. Staphylococcus aureus
    5. Anaerobic Bacteria (Clostridium difficile)
    6. Syphilis (Treponema pallidum)
    7. NeisseriaGonorrhea
    8. Bartonella (AIDS)
    9. Yersinia enterocolitica (rare, except in Hemochromatosis)

III. Pathophysiology

  1. Bacterial causes are associated with identified GI or biliary tract source in 50% of cases
  2. Sources
    1. Portal Vein infection
    2. Systemic bacteremia
    3. Ascending Cholangitis
    4. Direct extension
      1. Appendicitis
      2. Diverticulitis
      3. Ruptured Peptic Ulcer
      4. Empyema
  3. Majority of abscesses are single
  4. Subacute onset over weeks

IV. Symptoms

  1. Fever
  2. Chills
  3. Nausea
  4. Anorexia
  5. Weight loss
  6. Right Upper Quadrant Abdominal Pain (50%)
    1. Pain may radiate to right Shoulder

V. Signs

  1. Hepatomegaly
  2. Right upper quadrant tenderness
  3. Jaundice

VI. Labs

  1. Complete Blood Count (CBC)
    1. Anemia
    2. Leukocytosis
  2. Liver Function Test abnormalities
    1. Alkaline Phosphatase increased
    2. Aspartate Aminotransferase (AST) elevated
    3. Alanine Aminotransferase (ALT) elevated
  3. Blood Cultures (50% sensitive)
  4. Obtain AmebiasisSerology on all patients

VII. Imaging

  1. CT Abdomen or RUQ Ultrasound
    1. Fluid filled Liver masses

VIII. Management

  1. Initial empiric broad spectrum Antibiotics
    1. Metronidazole 30-40 mg/kg/day divided every 8 hours IV (or 500 mg every 6-8 hours orally) AND
    2. Choose one second Antibiotic
      1. Ceftriaxone 1-2 g IV every 24 hours OR
      2. Piperacillin-Tazobactam 3.375 g IV every 4-6 hours OR
      3. Ciprofloxacin 400 mg IV every 12 hours OR
      4. Levofloxacin 400 mg IV every 12 hours OR
      5. Ertapenem 1 g IV every 24 hours
  2. Focus Antibiotic coverage with Blood Culture results
  3. After sufficient abscess drainage, Antibiotic course of 4-5 days is typically adequate (up to 8-10 day course)
    1. Sawyer (2015) N Engl J Med 372:1996-2005 +PMID:25992746 [PubMed]
  4. Surgery or percutaneous drainage

IX. References

  1. (2019) Hepatic Abscess, Sanford Guide, accessed 9/26/2018
  2. Akhondi (2019) Liver Abscess, StatPearls +PMID:30855818

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