Liver Abscess

Background
Bacterial abscess of the liver is relatively rare. It has been described since the time of Hippocrates (400 BC),
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
rate 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 decreased mortality rates to
5-30%; yet, the prevalence of liver abscess has remained relatively unchanged. Untreated, this infection
remains uniformly fatal.
The 3 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.
 Fungal abscess, most often due to Candida species, accounts for less than 10% of cases.

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; their relative frequencies are listed in the image below.

Table 4: Underlying etiology of 1086 cases of liver abscess compiled from the literature.
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.
Pyogenic liver abscess 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.

Frequency
United States

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 ranges from 8-16 cases per
100,000 persons. Studies suggest a small, but significant, increase in the frequency of liver abscess.

Mortality/Morbidity
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.2

Sex
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.

Age

 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.

Clinical

History
  The most frequent symptoms of hepatic abscess include the following:
o Fever (either continuous or spiking)
o Chills
o Right upper quadrant pain
o Anorexia
o Malaise
 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
  Fever and tender hepatomegaly are the most common signs.
 A palpable mass need not be present.
 Mid epigastric 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 inflammation of
Glisson capsule.
 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.

Causes
Polymicrobial involvement is common, with Escherichia coli and Klebsiella pneumoniae being the 2 most
frequently isolated pathogens. Reports suggest that K pneumoniae is an increasingly prominent cause. 3 The
image below lists the common etiologic agents.

 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.