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Pyogenic Liver Abscess

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Book cover The IASGO Textbook of Multi-Disciplinary Management of Hepato-Pancreato-Biliary Diseases

Abstract

Pyogenic liver abscess (PLA) is the most common type of liver abscess, accounting for up to 48% of all visceral abscesses and 13% of intra-abdominal abscesses with estimated mortality of 10–40% despite advances in healthcare. Risk factors for PLA include male gender, proton-pump inhibitors, hepatobiliary or pancreatic disease, diabetes mellitus, human immunodeficiency virus (HIV), immunosuppressant medications, and liver cirrhosis. Primary PLA is defined as direct seeding of pathogens into biliary system, such as hepatobiliary infection from biliary obstruction, or less commonly, from colonic source or haematogenous spread from systemic infections. Secondary PLA is defined as PLA due to complications from underlying pathology, such as hepatocellular carcinoma (HCC), or interventions, such as transarterial chemoembolization, radiofrequency ablation or endoscopic biliary procedures. Clinical presentation of PLA is with non-specific symptoms. Serum biochemistry findings of raised inflammatory markers and deranged liver enzymes is non-specific too. Diagnosis is often achieved via imaging. Ultrasound scan and Computerized tomography (CT) scan are widely used as first-line imaging modality. Principles of PLA management are in accordance with the Surviving Sepsis guidelines. Empirical antibiotics should be guided by local antibiotogram. The common antibiotic regimes include combination of third-generation cephalosporin and metronidazole, or amoxicillin-clavulanic acid and once dose of gentamicin. Duration of antibiotics is guided by clinical and radiological response to source control. Drainage of PLA may be attempted percutaneously, endoscopically or surgically (open or laparoscopic). Percutaneous drainage (PD) has superior outcomes compared to antibiotics alone for abscess >4 cm. Giant PLA (size ≥10 cm), multiple loculations, gas formation, and patient co-morbidities predict poor outcomes and risk of failure of PD. In selected patients, surgical intervention is warranted. After treatment of acute PLA, it is prudent for follow-up with repeat imaging to rule out any abdominal pathology. A screening colonoscopy should be offered especially to patients with Klebsiella pneumoniae PLA. A PLA care bundle with integration of surgical and nursing care including drain care, interventional radiology and microbiology team (including transition to outpatient antibiotic therapy) is proposed to provide multimodal care and improved outcomes for PLA.

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Authors and Affiliations

  1. Ministry of Health Holdings Limited, Singapore, Singapore

    Kai Siang Chan

  2. Department of General Surgery, Tan Tock Seng Hospital, Singapore, Singapore

    Kai Siang Chan & Vishal Shelat

  3. Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore, Singapore

    Vishal Shelat

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  1. Kai Siang Chan
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Correspondence to Vishal Shelat .

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Editors and Affiliations

  1. Emeritus Professor, The University of Tokyo, Tokyo, Japan

    Masatoshi Makuuchi

  2. National Center for Global Health and Medicine, The University of Tokyo, Tokyo, Japan

    Norihiro Kokudo

  3. “Dan Setlacec” Center of General Surgery and Liver Transplantation, Fundeni Clinical Institute, Bucharest, Romania

    Irinel Popescu

  4. Emeritus Professor University Paris Cité, Paris, France

    Jacques Belghiti

  5. Department of Surgery, Seoul National University College of Medicine Seoul National University Bundang Hospital, Seoul, Korea (Republic of)

    Ho-Seong Han

  6. Nagahama City Hospital Network, Shiga, Japan

    Kyoichi Takaori

  7. Massachusetts General Hospital, Harvard Medical School, Boston, USA

    Dan G. Duda

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Chan, K.S., Shelat, V. (2022). Pyogenic Liver Abscess. In: Makuuchi, M., et al. The IASGO Textbook of Multi-Disciplinary Management of Hepato-Pancreato-Biliary Diseases. Springer, Singapore. https://doi.org/10.1007/978-981-19-0063-1_66

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