Original Article / Liver

Diagnosis of bacterial hepatic abscess by CT

Cheng-Lin Wang, Xue-Jun Guo, Shui-Bo Qiu, Yi Lei, Zhi-Dong Yuan, Han-Bin Dong and Hui-An Liu
Shenzhen, China

BACKGROUND:Bacterial hepatic abscess usually is acute and progressive, often resulting in sepsis, impairment of liver function and disseminated intravascular coagulation. The mortality rate was as high as 80% in the past. For the purpose of early diagnosis and differential diagnosis of this disease, we probed the imaging manifestations and their characteristics in bacterial hepatic abscesses by CT scan. METHODS: Twenty-four lesions from 21 patients with bacterial hepatic abscesses that were confirmed by clinical features, puncture and culture were reviewed for CT manifestations. Fourteen patients were male and 7 were female, with an average age of 56.2 years. All lesions underwent CT plain scan and three-phase enhanced scan and 15 patients underwent delayed-phase imaging. Three senior radiologists read the films in accordance with a standard. RESULTS: Among 24 lesions, 18 (75%) were situated in the right liver with diameters of 1.4-9.3 cm (average 4.5 cm). Nineteen (79.2%) lesions were round or sub-round in shape, and 22 (91.7%) had smooth, uninterrupted and sharp edges. All lesions showed low attenuation of less than 20 Hu. Twenty-two enhanced lesions (91.7%) had rim-shaped enhancement in the abscess wall, and 13 (54.2%) showed single or double-ring signs. Eighteen (75%) displayed honeycomb-like, grid-like or strip-like enhancement. Eighteen (75%) were regionally enhanced in the surroundings or upper or lower layers. Only 2 (8.3%) displayed a gas-liquid surface sign.

CONCLUSIONS: The CT findings of bacterial hepatic abscess are usually typical, and the diagnosis of the abscess is not difficult. To precisely diagnose atypical cases, it is necessary to combine CT with clinical observations and follow-up. (Hepatobiliary Pancreat Dis Int 2007; 6: 271-275) KEYWORDS:hepatic abscess; bacterial; CT; imaging characteristics

Introduction
acterial hepatic abscesses are pus cavities caused by necrosis of the liver parenchyma. The necrotic tissues are liquidized and merge toformpuscavities.Thisdiseaseusuallyisacuteand progressive, often resulting in sepsis, impairment of liver function and disseminated intravascular coagulation.Inthepast,thedeathratewasashighas 80%.[1] Fortunately, with advanced technology such asUS,CTandMRI,therateofcorrectdiagnosishas risen by >90%, and the death rate has dropped to below10%-40%.[1-3]Theauthorsreviewed24bacterial hepatic abscesses from 21 patients and scrutinized their manifestations on plain and contrast-enhanced CT scans for the purpose of probing the features of the disease on CT, and furthermore, improving diagnosisanddifferentialdiagnosis.

Author Affiliations: Department of Imaging, Peking University Shenzhen Hospital (Wang CL, Guo XJ and Yuan ZD); Department ofImaging,No.2People'sHospitalofShenzhen(QiuSBandLeiY); Department of Imaging, No. 4 People's Hospital of Shenzhen (Dong HB);andDepartmentofImaging,BujiPeople'sHospitalofShenzhen (LiuHA),Shenzhen518036,China Corresponding Author: Cheng-Lin Wang, Department of Imaging, Peking University Shenzhen Hospital, Shenzhen 518036, China (Tel: 86-755-83923333;Email:ctmrizz@sina.com.cn) 2007,HepatobiliaryPancreatDisInt.Allrightsreserved.

Methods
Twenty-four lesions from 21 patients with bacterial hepatic abscess had been collected since 1995. The abscesses were confirmed by puncture and bacterial culture. Eighteen patients (75%) had a single lesion and 3 patients had two lesions. Fourteen patients were men and 7 were women. They were aged 26-81 years with an average of 56.2. Fifteen patients were

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admitted to the emergency department because of fever, 13 (86.7%) having a fever higher than 38.5 . Abdominal pain was the most frequent symptom (16 patients, accounting for 76.2%). Eleven (68.8%) patientscomplainedofpaininthehepaticregion,13 (81.3%)complainedofpercussiontendernessoverthe hepaticregion.Seventeenpatients(81%)hadawhite blood cell (WBC) count higher than 10 000/mm3, and 4 had WBC counts within the normal range. As for differentiation of WBCs, 21 (100%) patients displayed increments of neutrophils and monocytes anddecreasedlymphocytes.Sixpatients(28.6%)were complicated with diabetes, 3 with cholecystitis and cholelithiasis,2withhepatolithiasis,and1withlung cancer. Twenty patients (95.5%) were cured, and 1 patientdiedofrelapseandmetastasisoflungcancer. All21patientsunderwentplainandenhancedCT scans,7werescannedbyspiralCTmanufacturedby ShimadzuofJapan,and15werescannedbyspiralCT manufacturedbySiemensofGermany.Theliverwas scanned from the top of the diaphragm to the lower edgeoftheliver,layerbylayer,eachlayerwithsection thickness 5-10 mm, or 3 mm for very small lesions. All enhanced scans used Ominipaque contrast agent. One hundred ml of contrast agent was injected via the cubital vein at 3 ml/s. Three-phase scans were conducted at the arterial, venous and equilibrium phases. Fifteen patients were subjected to delayedphase scans. Three senior radiologists read the films inaccordancewithastandard.

Edges of lesions Uponplainscan,11lesionshadaclearedgealong thefullrange,10hadaclearedgeinsomeparts,and 3hadablurrededge.Uponenhancedscan,15lesions had a clear edge along the full range, 7 had a clear edgeinsomeparts,and2hadablurrededge.Twentytwo lesions (91.7%) showed clear edges after being enhanced. Those lesions that showed clear edges in plain scans also showed them in enhanced scans. Thosethatshowedclearedgesinsomepartsbecame clearer after enhancement. Notably, the bigger the lesionwas,themoreblurredtheedgewas.Twolesions inthisstudywereuncleareitherbyplainorenhanced scans,andtheiraveragediameterwas8.2mm. CT value of lesions in plain scan ThehighestandlowestCTvalues(excludingthose collected from gas, hemorrhage and calcification) withinthelesionwereobtainedandaveragedtogive aCTvalue.TheaveragemaximumCTvalueofthe24 lesions was 28.8 Hu, and the average minimum was 18.4Hu,indicatingthatCTvaluesfromplainscansof hepaticabscesseswereusuallyoflowattenuation,less than19Hu. Features of enhanced wall of abscess (Fig. 1) The enhanced wall of an abscess can be rim-

Results
Location of lesions The liver can be divided into three lobes and five segments. Among the 24 lesions, 18 (75%) were situatedintherightlobe,6(25%)intheleftlobe,and none in the beaver tail. Ten lesions were situated in the right posterior segment, 8 in the right anterior segment,4intheleftlateralsegment,and2intheleft medial segment. Lesions had a predilection for the rightlobe,especiallytherightposteriorsegment. Sizes and shapes of lesions Of the 24 lesions, the smallest diameter was 1.4 mmandthegreatest9.3cm,theaveragebeing4.5cm. Twenty lesions (83.3%) had diameters >3 cm, and 4 (16.7%)<3cm.Elevenlesionswereround,8weresubround,and5wereirregularlyshaped.Theformertwo shapesweremorefrequent,totaling19(79.2%).The5 (20.8%)irregularlyshapedlesionswereusuallybigger, measuring6.9cmindiameteronaverage.
Fig. 1. A: Plain CT scan showing low attenuation round lesionmeasuring5cmindiameterintherightlobe,anterior segment. CT value was 5 Hu, the edge was clear, and top ofupperandanterioredgeshowedgas-containingsign;B: Contrast-enhancedCTscandidnotshowenhancementon arterialphase;C:Theedgeofabscesswassmoothandclear onvenousphase.Thewallofabscesswasenhanced,featuring typicalsingleordouble-ringsign;D:Thewallofabscesswas notobviouslyenhancedatequilibriumphase,buttheedge wasclearerthanthatobtainedbyplainscan.

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Diagnosis of bacterial hepatic abscess by CT

showedsingleordouble-ringsigns.

Contrast-enhanced septa in lesions (Fig. 2) Among the 24 lesions, 6 (25%) had no central enhancement,and18(75%)hadlesionenhancement, including 12 (66.7%) that were honeycomb-like or grid-like, and 6 (33.3%) that were strip-like. The averagediameterwas6.1cm. Regional enhancement (Fig. 3) According to the extent of regional enhancement, 11/24 lesions were obviously enhanced (45.8%), 7/24 slightly enhanced (28.2%) and 6/24 non-enhanced (25%). Collectively, 18 (75%) lesions were enhanced tosomedegree. Gas-liquid surface sign This sign was less frequent, only 2/24 lesions (8.3%) showing it. Both lesions were from the same patient,whowascomplicatedwithcholelithiasis.

Fig. 2.A:PlainCTscanshowingalowattenuationlesionthat wasconfinedanduneveninrightlobe,posteriorsegment. Theedgewasnotclear;B:Contrast-enhancedCTscandid notshowobviousenhancementinlesionatarterialphase;C: Contrast-enhancedCTscanatvenousphaseshowedthatedge oflesionwasclearerthanthatobtainedbyplainscan.The shapewasirregularandseptawereseeninsidethelesion;D: Contrast-enhanceCTscanatequilibriumphaseshowedvery clearedgeandseptaofthelesion.

Discussion
Features and locations of lesions Hepatic abscesses can be single or multiple with the former predominant. Alvarez et al[4] reported that among133cases,72.9%hadasinglelesionand27.1% had multiple lesions. Zibari et al[5] reported that among20cases,70%hadasinglelesionand30%had multiplelesions.Amongthe21casesinourstudy,18 (85.7%)hadasinglelesionand3(14.3%)hadmultiple lesions. The former was more frequent, and higher in rate than that reported in the literature. It was reported[6-9] that multiple lesions in hepatic abscess are of biligenic origin in liver trauma, gallbladder diseases and surgical operation, frequently seen in senileandfrailpatients,andbearingahighdeathrate. ResultsobtainedfromthisstudyconfirmedAlvarez's finding[4] in that 2 out of 3 cases of multiple lesions were complicated with gallbladder diseases, all of the 3 cases were very old, and one died. A review of theliteratureindicatedthatasinglelesioninhepatic abscessusuallyoccursintherightlobeoftheliver,[5, 10] and our results showed the same scenario, that is to say,18(75%)lesionsoccurredintherightlobeand6 (25%)intheleftlobe. Sizes, shapes and edges The size of a hepatic abscess is associated with diseasecourse,numberandtreatment.[4]Usually,the shorter the disease course, the smaller the lesion. A

Fig. 3.A:PlainCTscanshowingaround,even,lowattenuation lesionmeasuring3cmindiameterinrightlobe,posterior segment. The edge was smooth and clear; B: ContrastenhancedCTscanatarterialphaseshowedtransientregional enhancement with a wedge-like distribution in hepatic parenchymaoverthelesion;C:Contrast-enhancedCTscan atarterialphaseshowedwedge-likeregionalenhancement aroundlesion.Edgeoflesionwassmoothandclear.Noseptum appeared inside lesion; D: Contrast-enhanced CT scan at arterial phase showed transient regional enhancement in hepaticparenchymabelowthelesion.

shapedorirregular.Thoselessthanahemicirclewere definedasrim-shapedenhancement,andgreaterthan ahemicircleassingleordouble-ringsigns.Amongthe 24 lesions, 22 (91.7%) had rim-shaped enhancement, 2 (8.3%) had irregular enhancement and 13 (54.2%)

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singlelesionisusuallybiggerandmultiplelesionsare smaller. Timely treatment and appropriate medical intervention may result in a smaller lesion. Of the 24lesionsinthisstudy,theaveragediameterwas4.5 cm, being larger than usual; this may be attributed to delay of diagnosis and treatment. The 3 cases of multiple lesions (6 abscesses) showed smaller diameters, the maximum being 4.2 cm and the average 2.8 cm. Usually, small lesions are round or sub-round with smooth and clear edges. Among the 24lesionsinthisstudy,19(79.2%)wereroundorsubround and 5 were irregular. After enhanced scan, 22 lesions(97.1%)hadclearedgesalongthefullrangeor inmostoftheedge,only2largeandirregularlesions hadblurrededges.

CT manifestations in varying pathological phases At an early stage, the lesion is usually confined, manifesting inflammatory consolidation. Plain scans display confined low attenuation and low CT values, and the edge is often blurred, difficult to distinguish from hepatocellular carcinoma and hepatichemangioma.[11]Twocasesinthisstudywere misdiagnosedashepatocellularcarcinomaorhepatic hemangioma at an early stage. As a lesion develops, tissues in the abscess are liquidized and merge to formapuscavity.Atthisstage,plainCTscansshow lowattenuationwithCTvalueslessthan20Hu,and enhancedCTscansshowclearerandsmootheredges of the lesion, and the wall of the pus cavity can be enhanced. The lesion develops further forming a typical liver abscess. At this stage, the wall of the pus cavity has a 3-layer structure, fresh granulation tissue, old fibrous-granulation tissue and an outer inflammatoryedemabelt.[12]Typically,thewallofan abscess displays iso-attenuation in plain CT scans, andrims,singleordouble-ringsignsinenhancedCT scans.[11, 13] Twenty-two (91.7%) of the 24 lesions in thisstudyshowedtheabove-mentionedenhancement signs. Larger lesions are prone to have septa. The septaareuneveninthicknessanddiversifiedinshape, showing honeycomb-like or grid-like enhancement on enhanced CT scans.[14] Eighteen (75%) of the 24 lesions had septa, with honeycomb-like or grid-like septapredominant(12lesions,62%).Theremaining6 weredevoidofsepta,allofwhichweresmallerinsize, thelargestdiameterbeing4.3cmandtheaverage2.7 cm. Genesis of regional enhancement around lesions and its clinical meaning It is agreed that regional enhancement is due

to involvement of Glisson's capsule, which can cause peripheral portal phlebitis, narrowing and even obstruction of the portal vein, and ensuing compensatory dilation of the hepatic arteries. Under these circumstances, dynamic enhanced CT scans can detect transient regional enhancement around the lesion at an early stage.[11-16] In our study, 18 (75%)ofthe24lesionsdisplayedthissortofregional enhancement, with 11 very obvious. In this study, 75% of regional enhancement manifested wedgelike distribution around the lesion at the early stage of the arterial phase, sharply demarcated with the lesion itself. Sometimes regional enhancement only appeared at the upper and lower layers of the lesion, which may be attributed to the locations of lesions and scan maneuvers. Moreover, 25% of lesions were not regionally enhanced, which may be attributed to location, size, scan maneuvers and speed of feeding contrast agent. Six lesions that were not regionally enhanced in this study were mostly located near the scissura, boundary area of lobe and segment, and hilus.Thelesionswereunusuallylargeorsmall.

Differential diagnosis for bacterial hepatic abscess The diagnosis of bacterial hepatic abscess is not difficult according to its characteristic CT manifestations. If the CT characteristics of the bacterial hepatic abscess are atypical, it must be differentiated from intrahepatic duct cell cancer, intrahepaticmetastaticcarcinomaandfungalhepatic abscess.Thering-shapedandregionalenhancementin intrahepaticductcellcancerisfamiliar,butthiskind of ring-shape is discontiguous, varies in thickness, andisgenerallyirregular.Theregionalenhancement is consecutive. These characteristics can help to differentiate it from a liver abscess that disappears afteranti-inflammatorytreatment.[17]Thering-shaped enhanced wall in intrahepatic metastatic carcinoma is intact and consecutive, but it is thicker, has no definite organization, no septa, and delayed internal enhancement,allofwhichdifferfromliverabscess.[18] It was reported that diffusion-weighted MR imaging is advantageous for differential diagnosis, since the signalwithintheliverabscessishyperintense,andits diffusioncoefficientisprominentlylowerthanthatof intrahepatic metastatic carcinoma.[19] Fungal hepatic abscesses are generally multiple, and they are easily confused with bacterial abscess in the earlier stages because the clustered microabscesses are similar to bacterial abscesses with cellular septa. Most fungal hepatic abscesses occur in patients with leukemia andsystemicimmunediseases,andaremultipleand

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Diagnosis of bacterial hepatic abscess by CT simultaneous in liver and spleen.[14, 20] Moreover, T2weighted MR imaging of fungal hepatic abscesses has characteristic manifestations: a hyperintense fungal ball or necrosis areas in the center of the abscess, hyperintense inflammatory edematous areas in the mesosphere and hypointense fibrous tissue in the periphery. However, there is little research and understandingaboutthisproblem.[21] In conclusion, the CT findings of bacterial hepatic abscess are typical. The characteristic signs involve ring-shape or honeycomb-shaped or regional enhancement and the gas-liquid surface sign. The characteristic signs contribute to the diagnosis and differential diagnosis of bacterial hepatic abscess. To precisely diagnose the few atypical cases, it is necessary to combine CT with clinical observations andfollow-up.
Funding: This study was supported by a grant from the Clinical Research Division, Wujieping Medical Foundation of China(No.2005-86-F). Ethical approval:Notneeded. Contributors: WCL proposed and wrote the first draft. WCL and GXJ analyzed the data. All authors contributed to the designandinterpretationofthestudyandfurtherdrafts.WCL istheguarantor. Competing interest:Nobenefitsinanyformhavebeenreceived orwillbereceivedfromacommercialpartyrelateddirectlyor indirectlytothesubjectofthisarticle.

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