Hepatic Pyogenic Abscess

KEY FACTS
Liver

TERMINOLOGY • Hepatic amebic abscess

• Localized collection of pus in liver due to bacterial infection
with destruction of hepatic parenchyma
IMAGING
• CT: Multiseptate mass or cluster of smaller cystic masses
○ Nonliquefied infection may simulate neoplasm
○ Often accompanied by transient hepatic attenuation
difference (THAD) due to hyperemia and
thrombophlebitis of portal vein branch
○ Gas present in < 20% of pyogenic abscesses
○ Double target sign: Pus surrounded by pyogenic
membrane surrounded by edema
• US
○ Anechoic (50%), hyperechoic (25%), or hypoechoic (25%)
○ ± debris, acoustic enhancement, or shadow
TOP DIFFERENTIAL DIAGNOSES
• Hepatic metastases
• Infarction in liver allograft
• Hepatic hydatid cyst
• Biliary cystadenocarcinoma
PATHOLOGY
• Prevalent causes in Western countries
○ Diverticulitis or ascending cholangitis
CLINICAL ISSUES
• ~ 90% of all liver abscesses are pyogenic
• Older patient with fever, RUQ pain, tender hepatomegaly,
↑ WBC
• Treatment: Percutaneous aspiration + parenteral antibiotics
(> 90% success)
DIAGNOSTIC CHECKLIST
• Ablation or transarterial chemotherapy of liver tumor may
cause necrosis with release of gas
○ May be indistinguishable from abscess by imaging alone

(Left) Graphic shows

peripheral, multiloculated
collections of pus within the
surrounding inflamed liver.
(Right) Axial CECT in this 33-
year-old woman with a
pyogenic abscess shows a
multiseptate complex mass
﬇. Note the straight line ſt
demarcation of the
hyperenhancing right hepatic
lobe, a transient hepatic
attenuation difference (THAD)
due to the hyperemic wall of
the abscess, and occlusion of
the posterior right portal vein
by thrombophlebitis (not
shown).

(Left) Axial CECT shows a liver

mass ﬈ with rim
enhancement and central
necrosis. The findings are
compatible with neoplasm or
abscess. (Right) US in the same
patient shows a complex fluid-
containing mass (calipers)
with acoustic enhancement
﬇. US-guided needle
aspiration yielded a small
amount of pus, and a catheter
was placed over a guidewire
into the abscess. Repeat CT
scan 2 months later showed
substantial resolution of the
abscess (not shown).

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 Hepatic Pyogenic Abscess

Liver
TERMINOLOGY Infarction in Liver Allograft
• Hepatic artery thrombosis → hepatic and biliary necrosis
Definitions
• Localized collection of pus in liver due to bacterial infection Hepatic Hydatid Cyst
with destruction of hepatic parenchyma • Large, cystic liver mass; peripheral daughter cysts
Biliary Cystadenocarcinoma
IMAGING
• Rare, multiseptate, water-density cystic mass
General Features • No surrounding inflammatory changes
• Best diagnostic clue
○ Multiseptate mass or cluster of smaller cystic masses PATHOLOGY
CT Findings General Features
• CECT • Etiology
○ Sharply defined, spherical, hypodense mass ○ Pyogenic abscess can develop via 5 major routes
– Nonliquefied infection may enhance and simulate – Biliary: Ascending cholangitis
neoplasm – Portal vein: Pylephlebitis
○ Double target sign □ In descending order of frequency: Diverticulitis,
– Low-attenuation central zone (liquefied necrotic appendicitis, proctitis, or IBD
tissue/pus) □ Bacterial seeding of mesenteric veins carries
– High-attenuation inner rim (pyogenic membrane) bacteria to liver
– Low-attenuation outer layer (edema of liver – Hepatic artery: Septicemia
parenchyma) – Direct extension
○ May be multiseptate or cluster of smaller abscesses □ e.g., perforated gastric or duodenal ulcer
– Rim, capsule, and septal enhancement – Traumatic: Blunt or penetrating injuries, including
– Gas present in < 20% of pyogenic abscesses surgery
○ Often accompanied by transient hepatic attenuation ○ Prevalent causes in Western countries
difference (THAD) due to hyperemia and – Diverticulitis or ascending cholangitis
thrombophlebitis of portal vein branch – Infected infarcted tissue (post liver transplant,
○ Right lower lobe (RLL) atelectasis, pleural effusion necrotic tumor)
MR Findings
CLINICAL ISSUES
• T2WI
○ Variably hyperintense mass Presentation
○ High signal intensity perilesional edema • Clinical profile
• T1WI C+ ○ Middle-aged/older patient with history of fever, RUQ
○ Hypointense pus in center pain, tender hepatomegaly, ↑ WBC
○ Rim or capsule enhancement • Diagnosis by fine-needle aspiration
○ Small abscesses < 1 cm Demographics
– May show homogeneous enhancement • Epidemiology
• DWI: Restriction ○ ~ 90% of all liver abscesses are pyogenic
Ultrasonographic Findings ○ ↑ incidence in Western countries due to ascending
• Grayscale ultrasound cholangitis and diverticulitis
○ Irregular, hypoechoic/mildly echogenic wall Treatment
○ Echogenicity of abscesses • Percutaneous aspiration + parenteral antibiotics (> 90%
– Anechoic (50%), hyperechoic (25%), hypoechoic (25%) success)
– ± septa or fluid level within abscess
– Brightly echogenic foci with posterior artifact = gas DIAGNOSTIC CHECKLIST
– ± debris and posterior enhancement
Consider
Imaging Recommendations • Clinical presentation and imaging allow confident diagnosis
• Best imaging tool: CECT in most cases
Image Interpretation Pearls
DIFFERENTIAL DIAGNOSIS
• Ablation of transarterial chemotherapy of liver tumor may
Hepatic Metastases cause necrosis with release of gas
• Usually not clustered or septate cystic mass ○ May be indistinguishable from abscess by imaging alone
• Restricted diffusion: Abscesses have ↑ T2 signal centrally;
necrotic tumors have intermediate T2 signal SELECTED REFERENCES
Hepatic Amebic Abscess 1. Kumar SK et al: Pyogenic liver abscess: clinical features and microbiological
profiles in tertiary care center. J Family Med Prim Care. 9(8):4337-42, 2020
• Peripheral, round, nonseptate; solitary (85%)
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 Hepatic Pyogenic Abscess
Liver

(Left) Axial CECT in a 37-year-

old woman who presented
with a history of recurrent
episodes of cholangitis
demonstrates considerable
dilation of the intrahepatic
ducts st, which also contain
gas ﬇. A multiloculated
pyogenic abscess is also noted
ſt. (Right) Coronal MRCP in
the same patient reveals
massive dilation of the
intrahepatic and proximal
extrahepatic bile ducts ﬇, a
type 4 choledochal cyst,
responsible for the ascending
cholangitis and abscess.

(Left) Axial CECT in an older

woman with RUQ pain and
fever following arterial
chemoembolization for HCC
shows high-density retained
ethiodized oil (Lipiodol) ﬇
within the treated tumor.
There is a collection of gas and
fluid at the center of the mass
ſt that was aspirated and
proved to be an infected,
necrotic tumor. (Right) Axial
CECT in a patient with
pyogenic abscess is shown. A
cluster of multiple rim-
enhancing collections are
present ſt with adjacent low
attenuation of the liver due to
edema st.

(Left) Axial CECT in a 46-year-

old man who had a recent
cholecystectomy shows an
abscess ſt containing gas and
fluid within the liver and the
gallbladder bed. (Right)
Transverse US in the same
patient shows a complex fluid
collection ﬇, which yielded
pus from US-guided pigtail
catheter drainage. Two weeks
later, the patient was clinically
well and required no further
treatment, though a residual
liver mass was still present.

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Hepatic Pyogenic Abscess

Liver
(Left) Axial CECT of a 41-year-
old man with fever and a
tender epigastric mass shows
a complex cystic mass ſt
containing small foci of gas
﬇. Note the straight line
demarcation of the hyperemic
left lobe st (THAD) due to the
abscess and narrowing of the
left portal vein ﬉.
Thrombophlebitis and abscess
were due to diverticulitis.
(Right) Double-target sign of
an abscess is shown. Low-
attenuation central zone (pus)
ſt, high-attenuation inner rim
(pyogenic membrane) ﬇, and
low-attenuation outer layer
(edema) st are noted.

(Left) Axial T1 C+ MR shows a

complex multiseptate mass ſt
with hypointense contents and
enhancing septa. (Right) Axial
T2 MR in the same patient
shows a multiloculated
abscess with heterogeneous
fluid content that is variably
hyperintense st with other
foci of lower intensity ﬇,
reflecting the proteinaceous
nature of the pus.

(Left) Axial NECT shows a

cluster of adjacent liver
masses ſt with contents
ranging in attenuation from
near water to > 100 HU. On
needle aspiration, purulent
material was drained via
pigtail catheter. (Right) Axial
MR in 47-year-old man with
HIV and disseminated
Streptococcus anginosus
bacteremia shows T2-bright
ſt, round lesions with areas of
↓ T2 st and slightly ↑ T1 ﬈
signal due to pus, peripheral
diffusion restriction ﬇, and
multiseptated rim
enhancement ﬉ of liver
abscesses.

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