388 MANAGEMENT OF HEPATIC ABSCESSES
Once the probes are confirmed by US to be in position, the abla-
tion is initiated. For RFA, tissue temperature is monitored to keep
parenchyma between 100°C and 110°C to avoid charring, which
affects impedance. For MWA, the frequency and time are chosen
depending on the probe used and ablation zone necessary. Once the
desired temperature and impedance for RFA or time duration for
MWA are reached, the ablation is completed and probe is reposi-
tioned if necessary.  and institution experience, and approach (percutaneous vs. surgical).
nn FOLLOW-­UP
After liver ablation, liver function tests should be checked because
they may acutely rise after ablation but should progressively return
to baseline. Carcinoembryonic antigen should also be followed every
3 months as a rise in carcinoembryonic antigen is concerning for
recurrence. Postablation imaging including CT scan or MRI should
be obtained to determine efficacy of the ablation. Keep in mind that
colorectal liver metastases are hypovascular in nature; therefore, it
can be difficult to distinguish between residual tumor and necrosis
resulting from the ablation. The current guidelines put out by the
International Working Group on Image Guided Tumor Ablation
recommend a baseline CT or MRI be obtained within 1 to 4 weeks
postablation. The preablation and postablation imaging should be
compared with look at size, shape, and location of the necrosis with
ideally a 5-­to 10-­mm margin of ablation around the tumor. Once
inflammation has subsided, positron emission tomography scans
have been shown to be sensitive for detection of recurrent lesions.
However, there must be at least 3 months allowed for inflammation to
resolve. National Comprehensive Cancer Network guidelines recom-
mend follow-­up imaging every 3 to 6 months postablation for the first
2 years, followed by every 6 to 12 months.  Suggested Readings
nn COMPLICATIONS
For all the liver-­directed ablative techniques, complications range
from minor skin burns to more serious ones including hemorrhage
and bile leak. Historically, cryoablation has the highest complication
rate, with some reports as high as 10% to 20%. Cryoablation has been
linked to complications including thrombocytopenia, disseminated
intravascular coagulation, acute renal injury, and cryoshock, likely
because of the repeated freeze cycles. The high complication rates
ultimately resulted in cryoablation being replaced in large part by
RFA and MWA.
Both RFA and MWA have a lower rate of complications, rang-
ing from 2.2% to 9.5%. The largest study evaluated 13,283 patients
who underwent RFA of at least one liver lesion and had a complica-
tion rate of 3.5%, with the most common being hepatic infarcts, liver
Management of Hepatic
Abscesses
Henry A. Pitt, MD
H epatic abscesses are uncommon but remain lethal if not promptly
recognized or adequately treated. Liver abscesses may be catego-
rized as pyogenic, fungal, amebic, or mixed. Pyogenic liver abscesses
(PLA) have multiple etiologies, are frequently polymicrobial, and their
management has evolved significantly over the past 2 decades. Fungal
abscesses are the least common, but their incidence is increasing espe-
cially in immunocompromised patients with cancer or who have under-
gone a transplant. Amebic liver abscesses (ALA) are caused by Entamoeba
histolytica and occur most commonly in tropical, developing countries.
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abscesses, bile duct injury, and bile leaks. Nonliver complications
include pleural effusions, burns to the skin, pneumothorax, intesti-
nal injury, diaphragmatic injury, gallbladder injury, and cardiac tam-
ponade. The most common complications reported with MWA were
hemorrhage requiring blood transfusion, portal vein thrombosis, bile
leak, liver abscess, and pleural effusion. Determinants of complica-
tion rates in RFA and MWA include tumor size, location, physician
Reports of complications after IRE reach 16%, with the most com-
mon complications being pneumothorax, portal vein thrombosis,
biliary obstruction, pleural effusion, and cholangitis. 
nn SUMMARY
Surgical resection remains the mainstay of treatment of metastases
from colorectal cancer. For patients who are not surgical candidates,
ablation techniques offer significant disease-­free survival. In addi-
tion, ablation offers a potential cure for patients with small lesions
that are located deep in the liver and would be technically difficult to
resect. Ablation also allows us to extend resection criteria for patients
with bilobar disease, which would previously have been deemed
unresectable, such as a patient with a large left-­sided lesion and two
to three small ones in the right lobe. This patient may benefit from
a left hepatectomy and ablation of the lesions on the right. Clinical
trials are needed to better study patient selection and outcomes with
current ablation technology. As current ablation techniques improve
and new technology is introduced with larger, more consistent abla-
tion zones, the indications for ablation of colorectal liver metastases
will extend.
Correa-­Gallego C, Fong Y, Gonen M, et al. A retrospective comparison of mi-
crowave ablation vs. radiofrequency ablation for colorectal cancer hepatic
metastases. Ann Surg Oncol. 2014;21:4278–4283.
Evrard S, Poston G, Kissmeyer-­Nielsen P, et al. Combined ablation and resec-
tion (CARe) as an effective parenchymal sparing treatment for extensive
colorectal liver metastases. PLoS One. 2014;9:e114404.
Imai K, Allard MA, Benitez CC, et al. Long-­term outcomes of radiofrequency
ablation combined with hepatectomy compared with hepatectomy along
for colorectal liver metastases. Br J Surg. 2017;104:570–579.
Leung U, Kuk D, D’Angelica MI, et al. Long-­term outcomes following micro-
wave ablation for liver malignancies. Br J Surg. 2015;102:85–91.
Martin RC, Scoggins CR, McMasters KM. Safety and efficacy of microwave
ablation of hepatic tumors: a prospective review of a 5-­year experience.
Ann Surg Oncol. 2010;17:171–178.
Oshowa A, Gillams A, Harrison E, Lee WR, Taylor I. Comparison of resec-
tion and radiofrequency ablation for treatment of solitary colorectal liver
metastases. Br J Surg. 2003;90:1240–1243.
Mixed bacterial and fungal abscesses may occur especially when
patients have been exposed to multiple antibiotic courses and/or
to broad-­spectrum antibiotics. In addition, amebic abscesses may
become secondarily infected with bacteria, but this situation is
uncommon. Management of pyogenic, fungal, amebic, and mixed
hepatic abscesses varies considerably. As with many areas within sur-
gery, nonoperative and minimally invasive treatment options have
become the norm. However, hepatobiliary surgery may be lifesav-
ing when an abscess ruptures or when less invasive approaches are
unsuccessful.
nn PYOGENIC LIVER ABSCESS
Historically, PLAs were highly lethal and were most commonly
caused by pylephlebitis secondary to appendicitis. With the advent
of antibiotics in the mid-­twentieth century and advanced imag-
ing techniques in the 1970s, diagnostic delays were shortened and
 LIVER 389

outcomes improved. During this time, surgical drainage was required

but evolved from extraperitoneal to transperitoneal approaches. Over
the past 30 to 40 years, however, the evolution of image-­guided aspi-
ration, percutaneous catheter drainage (PCD) as well as percutaneous
and endoscopic biliary procedures and minimally invasive surgery
(MIS) have dramatically altered PLA management. With all these
advances, the outcomes for most patients with PLA have continued
to improve. However, the development of advanced hepatopancrea-
tobiliary (HPB) surgery, liver transplantation, and various ablative
techniques for managing liver tumors has created new etiologies and
treatment challenges.
Pathophysiology
PLAs may arise by several mechanisms including: (1) via the bile
ducts, (2) via the portal vein, (3) by direct extension, (4) via the
hepatic artery, (5) as the result of trauma, or (6) without an obvi-
ous cause, cryptogenic. In recent years, especially at western tertiary
referral centers, PLAs of biliary origin are most common. Frequently,
these patients will have a biliary malignancy that is being managed
with biliary stents. Patients with benign biliary strictures, those with
a prior biliary-­enteric anastomosis, and Asian patients with hepa-
tolithiasis also are prone to PLA formation. In the first half of the
twentieth century, appendicitis was the most common cause of PLAs.
Currently, diverticulitis is the most frequent underlying infection that
reaches the liver via the portal vein.
Severe forms of cholecystitis may cause a liver abscess by direct
extension. Bacterial endocarditis may lead to multiple liver and/or
splenic abscesses with the infection transmitted via the hepatic artery.
Liver trauma may result in an intrahepatic hematoma that can become
secondarily infected. Segmental hepatic infractions following hepato-
biliary surgery or ablative hepatic arterial therapies also may result in
bacterial colonization and abscess formation. These various etiologies
of PLAs require multiple therapeutic options and also are associated
with different types of bacterial of fungal contamination.
The organisms most commonly associated with PLAs of benign
biliary origins are Escherichia coli, Enterococcus, and Klebsiella
spp. (Table 1). In patients with cholangitis and severe cholecystitis,
anaerobes including Clostridium perfringens may also be isolated. In
patients with biliary malignancies who have been exposed to many
antibiotics, Pseudomonas spp., vancomycin-­ resistant Enterococcus
(VRE), multidrug-­resistant (MDR) gram-­negative aerobes, and yeast
are also frequently cultured. In addition, these biliary PLAs often
will be polymicrobial. In patients with diverticulitis or appendici-
tis Bacteroides fragilis, other anaerobes and gram-­negative aerobes
are found most often in the associated PLA. The organisms isolated
most frequently in patients with endocarditis are Staphylococcus and
Streptococcus spp. Similarly, if a liver abscess occurs as the result of
a subcutaneous abscess, Staphylococcus spp., including methicillin-­
resistant Staphylococcus aureus, are cultured most often. Cryptogenic
abscesses, especially in Asia, frequently grow K. pneumoniae, and
anaerobes are also isolated more commonly in these patients.  tation should be initiated immediately. The choice of antibiotic(s)
Diagnosis
Almost all patients with PLAs present with fever and/or chills. Malaise
and anorexia often are associated findings. The majority of patients
will have some abdominal discomfort, frequently in the right upper
quadrant. However, if diverticulitis or appendicitis is the underlying
cause, the pain will be in the left or right lower quadrant, respectfully.
Nausea, vomiting, and weight loss also may be part of the presenta-
tion. In patients with a biliary etiology, jaundice may be present, but
in those with biliary stents and cholangitis, PLAs may evolve without
clinical jaundice. Physical examination will vary with etiology, but
most patients will have no obvious abdominal findings.
The majority of patients with PLAs will have an elevated white
blood cell count and some elevation of alkaline phosphatase. Mild
increases of other liver function tests and hypoalbuminemia also
TABLE 1 Typical Bacteria Associated With
Underlying Etiologies of Pyogenic Liver Abscesses
Underlying Etiology Typical Bacteria
Benign biliary Escherichia coli
Enterococcus spp.
Klebsiella spp.
Cholangitis and severe Anaerobes
­cholecystitis Clostridium perfringens
Biliary malignancies Pseudomonas spp.
VRE
MDR aerobes
Yeast
Diverticulitis, appendicitis Bacteroides fragilis
Other anaerobes
Gram-­negative aerobes
Endocarditis Staphylococcus spp.
Streptococcus spp.
Subcutaneous abscesses Staphylococcus spp.
MRSA
Cryptogenic Klebsiella pneumoniae
Anaerobes
MDR, Multidrug-­resistant; MRSA, methicillin-­resistant Staphylococcus
aureus; VRE, vancomycin-­resistant Enterococcus.
are common. C-­reactive protein usually is elevated, but serum lac-
tate levels are normal unless the patient presents with septic shock.
In some patients, gas may be seen in the liver on plain abdominal
x-­rays. Ultrasound (US) is helpful in screening for biliary pathology,
but contrast-­enhanced computed tomography (CT) is diagnostic in
more than 95% of cases (Fig. 1). Magnetic resonance imaging (MRI)
is equally sensitive and may provide additional useful information
with respect to the biliary tree. In patients with indwelling biliary
stents, direct cholangiography may also demonstrate the abscess(es)
(Fig. 2). Culture of the bile in patients with abscesses of biliary origin
will almost always be positive and can guide antibiotic therapy. In
comparison, blood cultures will grow organisms in only half of the
patients with PLAs. 
nn TREATMENT
Antibiotics
As with any serious infection, blood cultures should be drawn before
antibiotics are initiated. If the patient presents with sepsis or septic
shock, a serum lactate should be sent, and aggressive fluid resusci-
should be based on the suspected underlying etiology, and therefore
the likely bacteriology (Table 1). Patient factors such as a known peni-
cillin allergy or alerted renal function should also inform the choice
of antibiotic(s).
For PLAs of biliary etiology, a broad-­spectrum penicillin with
good coverage for gram-­negative aerobes and Enterococcus spp. is
one option for an antibiotic naive patient. However, broader coverage
for anaerobes, Pseudomonas spp., VRE and MDR aerobes is indicated
for patients with indwelling stents who have received multiple prior
courses of antibiotics. Ideally, these patients will have prior bile cul-
tures that will guide antibiotic choices. In patients with diverticulitis
or appendicitis, metronidazole to adequately cover B. fragilis should
be part of the antibiotic regimen. If endocarditis or a subcutaneous
abscess is the suspected source, vancomycin should be included in
the antibiotic regimen until sensitivities are available. As blood, aspi-
rate, or percutaneous drainage culture data become available, the

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390 Management of Hepatic Abscesses

A B

FIG. 1  (A) Computed tomography (CT) scan demonstrating a large pyogenic liver abscess (PLA) with an air-­fluid level in segments V and VI. (B) CT scan 4
months later in the same patient demonstrating complete resolution of the PLA after percutaneous catheter drainage.

repeat aspiration may be indicated if clinical response is slow. How-

ever, many patients will have a large abscess, a multiloculated abscess,
thick viscous pus, and/or multiple abscesses. In these patients, aspira-
tion alone will not be adequate and should not be undertaken. An
alternate for patients with a larger, multiloculated, and/or viscous
abscess is PCD. 

FIG. 2  Tube cholangiogram demonstrating a pyogenic liver abscess that
has been percutaneously drained in a patient with an unresectable biliary
malignancy and transhepatic biliary stents.
antibiotic regimen should be tailored to cover the sensitivities of the
isolated bacteria. Most experts recommend a 4 to 6 week antibiotic
course, but a shorter regimen may be appropriate if adequate drain-
age and a good clinical response have been achieved. Also, if oral anti-
biotics will cover the involved bacteria, not all patients will require
home intravenous antibiotics.  In the preantibiotic era, several retroperitoneal approaches to abscess
Aspiration
Percutaneous image-­guided aspiration should be performed to con-
firm the diagnosis and to obtain samples for culture. In selected
patients with a small, solitary, safely accessible abscess, aspiration and
appropriate antibiotics may be adequate therapy. In these patients,
Percutaneous Drainage
Over the past 3 decades, a shift has occurred so that the majority
of patients with PLAs are managed with PCD. This procedure can
be performed under US or CT guidance. Most of these procedures
can be accomplished under local anesthesia with minimal seda-
tion. After aspiration of pus for culture, a guidewire is placed into
the abscess followed by placement of an 8Fr to 14Fr digital catheter
(Fig. 3). Contrast is injected to define the cavity, but care is taken not
to aggravate sepsis by over injection. The catheter is left to gravity
drainage, but frequently, small volume irrigations with sterile saline
solution are indicated to ensure catheter patency. Subsequent proce-
dures to increase catheter size and/or to interrupt loculations may be
indicated.
In recent series of PLAs, approximately 85% of patients have been
managed by PCD. In addition, in most reports the success rate for
intravenous antibiotics and PCD has been 90% or greater. Factors
that may lead to failure include a chronic abscess with thick, fibrous
walls; a cluster of smaller abscesses as opposed to loculation within
one abscess; or biliary communication with proximal obstruction.
Bilateral abscesses or a difficult location, for example, high in seg-
ments VII or VIII, may be contraindications to PCD. In addition, a
ruptured abscess or association with an intraabdominal problem that
requires laparotomy, such as appendicitis or infected peripancreatic
necrosis, are situations in which surgery is preferred. 
Surgical Drainage
drainage were described. In the 1960s and 1970s, a transperitoneal
approach was preferred and was said to have the advantage of pro-
viding the opportunity for an exploratory laparotomy to find an
undiagnosed abscess source. This strategy became less necessary as
cross-­sectional imaging improved in the 1980s and 1990s. Since then,
the evolution of MIS and intraoperative US have led to these tech-
niques being preferred when surgery is required.

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 LIVER 391

#3

#2 #1

#4

A B

FIG. 3  (A) Initial placement of two percutaneous drainage catheters into the pyogenic liver abscess in the patient in Fig. 1. (B) Placement of two additional
percutaneous catheters 4 days later to fully drain this large abscess.

In those rare situations in which open surgery will be required,

the choice of incision will depend on the abscess location. As these
operations will be classified as “dirty,” a wound protector should be
used. The abscess should be localized with intraoperative US, and
the adjacent peritoneum should be protected with laparotomy pads
(Fig. 4). After aspiration for aerobic and anaerobic cultures, the liver
capsule is incised. The cavity is then irrigated, and loculations can be
disrupted gently with a finger being careful not to injure major vessels
or bile ducts. Both soft Penrose and large suction drains are placed
and brought out via a separate stab incision. In rare situations, hepa-
tectomy of a very diseased segment or segments may be indicated.
In performing these operations, care must be undertaken to avoid
severe sepsis due to massive bacteremia caused by manipulation of
the abscessed liver. 

Outcomes
Historically, the majority of patients with PLAs died with outcomes
being worst in patients with bilateral abscess, malnutrition, and
underlying malignancies. Currently, fewer than 10% of patients with
PLAs die. However, patients with HPB malignancies and those who
are immunosuppressed after liver transplantation are at greatest risk
for mortality. For the remainder of patients with a relatively good
prognosis, recent debate has centered around the relative risks and
benefits of percutaneous needle aspiration (PNA) versus PCD. A
recent systematic review and meta-­analysis of five randomized con-
trolled trials involving 306 patients clearly favored PCD. Compared
to PNA, the success rate for patients with PCD was higher (96% vs
78%; P < .04); the time to clinical improvement was shorter (<.001);
and the days to achieve a 50% reduction in abscess size was shorter
(P <.001). Thus, when expert interventional radiologists are available,
PCD should be performed. 

nn FUNGAL HEPATIC ABSCESS

Immunocompromised patients, including those receiving chemo-
therapy for an underlying malignancy and those who have under-
gone a liver transplantation, are more prone to develop a fungal liver
abscess. Patients with biliary malignancies and indwelling stents, who
receive multiple courses of antibiotics for recurrent cholangitis, also
FIG. 4  Operative drainage of a PLA. Laparotomy pads are placed to
prevent contamination when the abscess is incised and cultured (top).
Loculations are gently disrupted with a finger (middle). The cavity is exten-
sively irrigated (bottom) before large drains are placed. (From Cameron JL,
Sandone C. Atlas of Gastrointestinal Surgery, vol II, 2nd ed. Shelton, CT: People’s
Medical Publishing; 2014.)

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392 Management of Hepatic Abscesses

are at increased risk for mixed bacterial and fungal liver abscesses.
Patients with hepatic tumors who undergo ablative procedures also TABLE 2  Clinical Characteristics of Patients
have an increased risk for development of a fungal hepatic abscess. With Pyogenic and Amebic Abscesses
Pyogenic Amebic
Treatment Age >50 years Age <50 years
The principles outlined earlier for bacterial liver abscesses also apply to Male/female 1:1 Male/female 10:1
fungal hepatic abscesses. PCD should be undertaken as the preferred
initial procedure. Biliary stent placement or change is also indicated No ethnic predisposition Hispanic descent
when the underlying etiology is biliary obstruction. Approximately No recent travel Travel to endemic area
80% of fungal abscesses will have Candida spp. In some patients,
Aspergillus or Cryptococcus will be isolated. Historically, amphotericin Underlying malignancy No malignancy
B was the treatment of choice, but currently, micafungin and caspo- High fevers Fever
fungin should be utilized to treat these patients. Prolonged antifun-
gal therapy is indicated, and oral fluconazole should be used only if Pain unusual Pain common
Candida spp. are sensitive. In patients with mixed bacterial and fungal Tenderness uncommon Tenderness common
liver abscesses, appropriate antibiotic therapy also should be provided. 
No diarrhea Diarrhea common

Outcomes Jaundice occasionally Jaundice rarely

Patients with a pure or mixed fungal liver abscess are at high risk Severe sepsis Mildly septic
for mortality. Patients who receive adequate drainage and antifungal
therapy still have a 20% risk of mortality. Patients who have fungemia
and those with a delay in diagnoses who develop severe sepsis before
adequate drainage and/or appropriate antifungal therapy is initiated
are also at increased risk for mortality. As a result, approximately 50%
of patients with a fungal liver abscess do not survive. 

nn AMEBIC LIVER ABSCESS

Amebiasis is a common global parasitic infection caused by the proto-
zoan E. histolytica. The vast majority of these infections occur in tropical
and subtropical areas in the developing world including African, Indo-
nesia, Central and South America. High-­risk groups in developed coun-
tries include immigrants, tourists who have travelled to endemic areas,
sexually active homosexual men, institutionalized patients, and those
with HIV. Amebiasis occurs with a bimodal age distribution, with one
peak at age 2 to 3 years and the second peak is in middle age. ALA is 10
times more common in men than in women. Low socioeconomic status
and unsanitary conditions are independent risk factors for amebiasis.

Diagnosis
The vast majority of people who become infected with E. histolytica
are asymptomatic. However, without symptoms, patients may shed
amebic cysts for years. The most common form of invasive disease
is colitis that presents with gradually worsening diarrhea, abdominal
pain, and weight loss. In this setting, trophozoites may reach the liver
via the portal system and cause focal hepatocyte necrosis and micro-
abscesses. After coalescence, a single abscess will contain a thick liq-
uid that typically is red/brown and has been described as “anchovy FIG. 5  Ultrasound demonstrating large amebic liver abscess in the right
paste.” Clinical presentation may be acute with fever and right upper lobe.
quadrant pain or subacute with weight loss and intermittent fever and
pain. Simultaneous presentation with colitis and an ALA is unusual. a suspected ALA to establish a diagnosis is questionable. In addition,
Clinical characteristics distinguishing patients with ALA from those no level I data are available to demonstrate that aspiration of an ALA
with pyogenic hepatic abscesses are presented in Table 2. has a survival benefit. Thus, diagnostic aspiration is reserved for the
Patients with an ALA will have a mild to moderate elevation of the rare patients with a negative serology or when secondary bacterial
white blood cell count. These patients also may have mild elevations contamination is suspected. 
of alkaline phosphatase and transaminases, but jaundice is rare. Stool
samples for trophozoites may be positive in up to half of the cases. nn TREATMENT
Chest radiographs will frequently demonstrate a pleural effusion,
atelectasis, or elevation of the right hemidiaphragm. US, CT, and MRI Antibiotics
are all excellent methods for detecting ALAs (Fig. 5). Approximately Metronidazole is the antibiotic of choice for ALA. The oral dose is 500
three-­fourths of ALAs appear as solitary lesions in the right lobe. to 750 mg three times a day for 7 to 10 days. The response to metronida-
Amebic serology is highly sensitive and specific in differentiat- zole is usually profound with symptomatic improvement in 3 to 4 days.
ing ALA from PLA. Serum antibodies are positive in 99% of patients At 5 days, 85% of patients with an ALA have responded and that rate
with ALA and in 85% of those with invasive colitis. Serologic data increases to 95% at 10 days. Tinidazole 2 g orally for 5 days is an alterna-
are usually available in 24 to 48 hours; therefore the need to aspirate tive for the rare patient with a metronidazole allergy. Another alternative

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is secnidazole 2 g for 5 days in patients who do not tolerate the side
effects of metronidazole. However, with metronidazole treatment, the
parasites persist in the intestines in up to half of the patients. Therefore,
an additional luminal agent such a paromomycin (30 mg/kg three times
a day for 5 to 7 days), diiodohydroxyquin (650 mg orally three times
daily for 20 days), or diloxanide furoate (500 mg orally three times a day
for 10 days) should be utilized to eradicate intestinal colonization.
Therapeutic Aspiration
In 2003, Bessmann and colleagues reported a prospective, random-
ized trial in patients with ALA, comparing oral metronidazole alone
with US-­guided aspiration plus oral metronidazole. ALA aspiration
improved liver tenderness within the first 3 days, but no difference in
other clinical findings or laboratory testes was observed between the
two groups. The authors concluded that this minor clinical benefit
was insufficient to justify routine needle aspiration. Thus, therapeutic
needle aspiration is reserved for patients with (1) no clinical response
after 5 to 7 days, or (2) a large abscess, especially in the left lobe, with
increased risk for rupture into the peritoneum or pericardium.  Bessman J, Binh HD, Hang DM, et al. Treatment of amebic liver abscess with
Catheter and Surgical Drainage
In patients with a very large (>10 cm) ALA, PCD has been shown to be
better than needle aspiration with respect to duration of clinical symp-
toms. PCD is useful in patients with pulmonary, peritoneal, or peri-
cardial complications. However, large catheters are usually required
because of the high viscosity of the amebic abscess fluid. Additionally,
catheter drainage may lead to secondary bacterial contamination. Sur-
gical drainage of ALAs is rarely required, and indications include (1)
failure of response to more conservative measures; (2) erosion into
neighboring organs including the stomach, duodenum, and colon; (3)
sepsis related to secondary bacterial infection; or (4) life-­threatening
hemorrhage, not amenable to angiographic therapy. 
Transarterial
Chemoembolization
for Liver Metastases
Quang Nguyen, MD, and Christos S. Georgiades, MD, PhD
T ransarterial chemoembolization (TACE) has become the stan-
dard of care for the treatment of unresectable hepatocellular car-
cinoma. In patients with hepatocellular carcinoma, catheter-­based,
image-­guided delivery of chemotherapy agents and embolization
particles has been shown to result in significant improvement in
objective tumor response, progression-­free survival, cancer-­specific
survival, and overall survival. TACE is also used to treat a number
of secondary, liver-­predominant malignancies. Studies have indeed
shown many benefits for patients treated with TACE, including
downstaging into resectability, improving survival and disease pro-
gression, and controlling symptoms. In this chapter, we describe how
TACE can be incorporated into a multidisciplinary approach for the
treatment of patients with metastatic malignancies to the liver. A vari-
ety of spinoff intraarterial modalities have been developed including
bland transarterial hepatic arterial embolization (TAE), TACE, and
selective internal radioembolization therapy. These therapies offer
reduced systemic toxicity and more effective local tumor control. As
a result, some procedures have been included in the National Com-
prehensive Cancer Network treatment guidelines.
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LIVER 393
nn OUTCOMES
The majority of patients with an ALA respond to oral antibiotics
within 3 to 5 days. However, if the presentation is very late and adja-
cent organ or free rupture has occurred, an ALA may be fatal. Fac-
tors associated with a poor prognosis include presentation with (1)
encephalopathy, (2) a serum albumin of less than 2.0 g/dL, (3) a total
bilirubin of greater than 3.5 mg/dL, (4) an abscess volume of greater
than 500 mL, (5) multiple abscesses, (6) adjacent organ erosion, and
(7) free rupture. Fortunately, these factors are present in only a small
percentage of patients with ALA. The fact that most patients with
an ALA, unlike many with PLA, are young, otherwise healthy, and
unlikely to be immunosuppressed or have a malignancy, means that
their likelihood for full recovery is excellent. Although clinical recov-
ery is usually rapid, radiologic resolution of the abscess may take
many months.
Suggested Readings
metronidazole alone or in combination with ultrasound guided needle as-
piration: a comparative, prospective and randomized study. Trop Med Int
Health. 2003;8:1030–1036.
Cai YL, Xiong XZ, Lu J, et  al. Percutaneous needle aspiration versus cath-
eter drainage in the management of liver abscess: a systematic review and
meta-­analysis. HPB. 2015;17:195–201.
Huang CJ, Pitt HA, Lipsett PA, et al. Pyogenic liver abscess: changing trends
over 42 years. Ann Surg. 1996;223:600–606.
Lipsett PA, Huang CJ, Lillemoe KD, et al. Fungal hepatic abscess: character-
ization and management. J Gastrointest Surg. 1997;1:78–84.
Pandey S, Gupta GK, Wanjari SJ, et al. Comparative study on tinidazole ver-
sus metronidazole in treatment of amebic liver abscess: a randomized
­controlled trial. Indian J Gastroentrol. 2018;37:196–201.
nn CHEMOEMBOLIZATION OPTIONS
The efficacy of TACE relies on the fact that normal liver parenchyma
is mainly supplied by the portal vein (∼70%), whereas primary or
secondary liver neoplasms are exclusively fed by hepatic artery
branches (neo-­angiogenesis); therefore, the intra-­arterial delivery of
a tumoricidal drug will primarily target neoplasms and spare liver
parenchyma.
There are three slightly different options for treating patients using
a catheter-­based, transarterial approach.
1. Bland embolization alone. Operators use embolic particles to
effect complete stasis in the hepatic artery branch that feeds the
target tumor. TAE is predicated on the assumption that all dam-
age to the tumor is due to ischemia and that chemotherapy plays
no role. Studies have shown TAE is nearly as effective as TACE;
therefore, if chemotherapy administration is contraindicated
(e.g., maximum lifetime doxorubicin amount reached, allergy),
the patient may still benefit from TAE.
2. Lipiodol-­based TACE. This is the originally described conven-
tional TACE method. It involves the transcatheter delivery of
a cocktail (chemotherapy and lipiodol) into the target tumor,
followed by particle embolization. The chemotherapy cocktail
consists of any combination of cisplatin 100 mg, doxorubicin
50 mg, and mitomycin C 10 mg. This is mixed with lipiodol
(Ethiodol) in a 1:1 or a 2:1 volume ratio depending on flow
characteristics. A 1:1 ratio is more viscous and used for high
flow states, whereas 2:1 (chemo:lipiodol) is less viscous and
used in low flow states.