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Liver abscess

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Abscesses involving K pneumoniae have been associated with multiple cases of endophthalmitis.

Summary

Cause	Clinical Features	Diagnostic Tests	Treatment
Pyogenic Abscess	High and persistent fever, sometimes with chills and rigors. Right upper quadrant pain, often radiating to the right shoulder. Jaundice, particularly with biliary tract involvement. Malaise and unintended weight loss. Hepatomegaly may be palpable.	Ultrasound: Identifies abscesses and guides drainage. CT Scan: Detailed imaging, useful for small abscesses. Blood Tests: Elevated WBC count, abnormal LFTs, and blood cultures. Aspiration and Culture: Fluid analysis for microbiological identification.	Antibiotics: Broad-spectrum antibiotics tailored based on culture results. Drainage: Percutaneous drainage under ultrasound or CT guidance. Surgery: Considered if drainage is not feasible or complications arise. Supportive Care: Includes hydration and monitoring for sepsis.
Amoebic Abscess	Gradual onset of fever, often without chills. Right upper quadrant pain, sometimes radiating to the shoulder. Diarrhea may be present, especially with co-existing intestinal amoebiasis. Weight loss and general malaise.	Ultrasound: Can identify the abscess, often single and located in the right lobe. Serology: Anti-amoebic antibodies are usually positive. CT Scan: Provides further detail if needed. Aspiration: May be performed if diagnosis is uncertain or for therapeutic reasons.	Metronidazole: First-line treatment for amoebic abscess. Drainage: May be required if the abscess is large, persistent, or at risk of rupture. Supportive Care: Includes pain management and hydration.
Fungal Abscess	Fever, often persistent and unexplained. Right upper quadrant pain. More common in immunocompromised patients (e.g., HIV, post-transplant). Weight loss and malaise may be prominent.	CT Scan: Useful for detecting multiple small abscesses. Blood Cultures: May identify fungal organisms, although sensitivity is variable. Biopsy or Aspiration: Fluid analysis or biopsy may be necessary for diagnosis.	Antifungal Therapy: Typically with agents like amphotericin B or fluconazole, depending on the organism. Drainage: Considered in cases of large or non-responding abscesses. Supportive Care: Crucial in immunocompromised patients, including addressing the underlying immune deficiency.

About

Pus-filled mass (es) inside the liver
Differential can be metastases

Aetiology

Amoebic abscess: Entamoeba Histolytica 10%
Bacterial: Often polymicrobial. E.coli, Klebsiella, Staphylococcus (endocarditis), Streptococcus. Bacterial infection on background of Cholangitis and Cholecystitis with RUQ pain and jaundice or from diverticulitis or appendicitis or penetrating injury.
Fungal abscess: Candida species, < 10% of cases. Immunocompromised.
Echinococcosis: chronic infection caused by the larval stage of several animal cestodes (flat worms) of the genus Echinococcus. It is common in many areas of the world, especially the Middle East.

Clinical

Fever, chills, tender RUQ pain, Sweats, Anorexia
Right shoulder and pleuritic chest pain
Cough or hiccoughs, Fever of unknown origin
Echonicoccosis - cyst rupture will allergic reactions = urticaria, angioedema, or anaphylaxis

Differentials

Liver malignancy, Simple cysts
Polycystic liver disease

Complications

Sepsis, Empyema, or Peritonitis

Investigations

FBC: High WCC, U&E
LFT: elevated ALP in 95% and AST/ALT in 50% and low albumin
Check coagulation : Prothrombin time
Blood cultures: should be sent - aerobic and anaerobic
USS/CT : may detect abscess. The right lobe is more commonly affected. The right hepatic lobe drains the superior mesenteric and portal veins, whereas the left drains inferior mesenteric and splenic drainage. Lesions usually well-demarcated and imaging allows guided biopsy.
Entamoeba Histolytica: Enzyme immunoassay should be performed to detect E histolytica but does not differentiate acute from old infections. Stool samples for E. histolytica trophozoites (positive in 10-15%)
Echonicoccosis: Antibody assays (ELISA, latex agglutination, and Western blot): 90% sensitive and specific for liver cysts, but less accurate for cysts in other sites. A PCR assay is now available for problematic cases.

Management

ABC, pain relief, involve interventional radiologist to drain lesion
Pyogenic: meropenem until sensitivities are known
Amoebic abscess: give Metronidazole, which will be curative in 90%. (nitroimidazole, followed by a luminal agent.)
Fungal abscess: give Amphotericin B.
Percutaneous needle aspiration or catheter placement or drainage
Echonicoccosis: liver involvement: Treatment of choice for echinococcal cysts is surgical resection. If resection is not feasible, perform percutaneous drainage with instillation of 95% ethanol to prevent dissemination. Surgical therapy is followed by medical therapy with albendazole

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