30/M, intermittent

fever and RUQ pain of 2

weeks duration

History

Pertinent positives:
Intermittent fever
continous, non-radiating RUQ pain
Jaundice
(+) Loss of appetite
(+) body malaise
(+) grayish stools
(+) dark-colored urine

Pertinent negatives:
No history of travel

PE:
Pertinent Positives:
HEENT: (+) icteric sclerae
Abdomen: Hepatomegaly, RUQ tenderness
DRE: Acholic stools on examining finger

Pertinent Negatives:
Abdomen: no striae, jaundice, or spider angiomas; normoactive bowel
sounds; typmanitic; no organomegaly
DRE: no external lesions, good sphincteric tone, no palpable mass, no
bleeding

Differential diagnosis:

Acute Cholangitis Acute Viral Hepatitis Hepatocellular carcinoma

Rule in: Rule in:

Rule in:
(+) Jaundice, RUQ pain, fever, (+) RUQ pain
(+) Charcot's triad: fever, RUQ pain,
hepatomegaly, generalized body (+) Jaundice
jaundice
weakness (+) Murphy's sign

Rule out: Rule out:

Rule out:
(+) dark-colored urine (-) significant weight loss
(-) Hypotension, altered mental
(-) exposure to hepatitis (-) muscle wasting
status
(-) history of chronic liver disease

Request Laboratory Tests

& Imaging Study

Laboratory Tests:
CBC:
decreased hemoglobin, hematocrit,
RBC count; elevated WBC count with
neutrophilic predominance
Imaging:
Coagulation studies: Abdominal CT scan
Prolonged PT and aPTT

Serum chemistry:
Hyponatremia, hypokalemia
Hyperbilirubinemia
Increased ESR, ALP

Impression:
Pyogenic liver abscess

MANAGEMENT

NON SURGICAL SURGICAL

Broad-spectrum IV Antibiotic Therapy Ultrasound-guided Anatomic surgical

percutaneous drainage and Surgical drainage
resection
Should cover gram-negative and anaerobic catheter drainage
organisms
Duration: for at least 8 weeks Indication: Indication:
- When initial therapies fail recalcitrant abscess
- Failure of medical therapy
or percutaneous aspiration
or drainage
- co-existing
intra-abdominal diseases
requiring surgery