ABSES HEPAR

Background
Bacterial abscess of the liver is relatively rare; however, 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] (See images
below.)

Computed tomography (CT) scan

findings of liver abscess are shown. A large, septated abscess of the right hepatic lobe is revealed.
Abscess was successfully treated with percutaneous drainage and antimicrobial therapy.

Computed tomography (CT) scan

findings of liver abscess are shown. A large anterior abscess involving the left hepatic lobe is
revealed. Abscess was successfully treated with percutaneous drainage and antimicrobial therapy.
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. [2]

Fungal abscess, most often due to Candida species, accounts for less than 10% of cases.

Background
Bacterial abscess of the liver is relatively rare; however, 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] (See images
below.)

Computed tomography (CT) scan

findings of liver abscess are shown. A large, septated abscess of the right hepatic lobe is revealed.
Abscess was successfully treated with percutaneous drainage and antimicrobial therapy.

Computed tomography (CT) scan

findings of liver abscess are shown. A large anterior abscess involving the left hepatic lobe is
revealed. Abscess was successfully treated with percutaneous drainage and antimicrobial therapy.
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. [2]

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 intraabdominal 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.

Epidemiology
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.[3]
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
See the list below:

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.