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Hepatic Abscess
Changes in Etiology, Diagnosis, and Management
GENE D. BRANUM, M.D., GEORGE S. TYSON, M.D., MARY A. BRANUM, R.N., and WILLIAM C. MEYERS, M.D.

Most recent reviews of pyogenic hepatic abscess emphasize percutaneous versus open surgical management and devote little
time to studying the etiology or the clinical condition of the patient. In this study a detailed review was performed with a computerized analysis of multiple clinical parameters in 73 patients
treated for pyogenic hepatic abscess during a 17-year period.
The mean age of the patients was 55 years and 38 of them (52%)
were male. The mortality rate was comparable for solitary (17%)
and multiple (23%) abscesses. The likelihood of death was higher
with antibiotic treatment alone (45%) or percutaneous treatment
(25%) than with surgical treatment (9.5%). The primary determinant of outcome, however, was the underlying disease, i.e.,
malignancy or an immunocompromised patient, rather than solitary versus multiple abscesses. In addition the incidence of hepatic abscess seen at this center has doubled from the first half
to the second half of the review, reflecting a population of more
severely ill patients. It is apparent that in current clinical practice
several methods of management are effective, and the choice of
therapy should be determined by individualized selection. The
principle of timely diagnosis and prompt institution of treatment
appropriate to the specific patient remains the standard of care
in this potentially grave disease.

YOGENIC HEPATIC ABSCESS remains a major diagnostic and therapeutic challenge, despite advances in diagnostic technology and new strategies
for treatment. While the incidence is reported to be stable,
the question of increasing incidence of hepatic abscess
and underlying malignancy, immunocompromise, or advanced age remains unanswered. The development of
newer diagnostic methods, including ultrasound and
computed tomography, has not only made the diagnosis
more certain but also has introduced a range of treatment
options. This report reviews an experience with nonparasitic hepatic abscesses during the past two decades. The
study was undertaken to aid in the development of treatPresented in part at the Seventh Meeting of Hepato-Pancreato-Biliary
Surgery in Lund, Sweden, June 12 to 16, 1989.
Address reprint requests to William C. Meyers, M.D., Duke University
Medical Center, Box 3041, Durham, NC 27710.
Dr. Tyson's current address is Department of Surgery, University of
Pennsylvania, Philadelphia, Pennsylvania.
Accepted for publication August 17, 1989.

From the Department of Surgery, Duke University Medical

Center, Durham, North Carolina

ment strategies for hepatic abscess. The impact of a

changing patient population, new diagnostic methods, and
current therapy were assessed on the ultimate course of
patients with hepatic abscess.

Methods
The records of patients with the diagnosis of hepatic
abscess at Duke University Medical Center from 1970 to
1986 were reviewed. The historical record and physical
examination were reviewed in detail, as were the types of
diagnostic methods used, treatment, and results. Emphasis
was placed on characteristics of the abscesses, including
location and microbiology, primary and secondary treatment, complications, and survival time. Pyogenic hepatic
abscess was defined as one or more discrete lesions in the
liver in association with positive bacterial culture of material obtained at operation or percutaneous aspiration,
or from blood or bile in the presence of an intrahepatic
cavity observed on an imaging study. Patients diagnosed
at operation or by radiologic study without a positive culture were included in the absence of another evident diagnosis. In two patients the diagnosis was made at autopsy.
Patients with amoebic or other parasitic abscesses were
excluded. Data was entered on detailed computer sheets
and analyzed using a two-stage technique. The first stage
consisted of computation of simple frequencies. The second included the cross-correlation of multiple variables,
and chi square analysis was applied where appropriate.
Results

Demographic Information
The patients ranged in age from 3 to 85 years, with a
median of 53 years. The peak incidence of hepatic abscess
occurred in patients in the sixth decade (23%), but the

655

BRANUM AND OTH[ERS

656

distribution was roughly equal from the third decade forward. There were 38 male and 35 female patients. Twentyeight patients were treated from 1970 to 1978 (11.5/
100,000 admissions) while 55 were treated from 1979 to
1986 (22/100,000 admissions; Fig. 1).
The underlying pathologic findings changed with time.
Benign biliary disease (i.e., acute cholecystitis or choledocholithiasis) caused a lower proportion of cases after
1979, although the actual numbers were equal in both
parts of the study (Table 1). The incidence of malignant
colonic disease remained stable during the two decades.
The number and relative incidence of underlying malignant biliary disease and benign colonic disease, including
diverticulitis and appendicitis, increased between the first
and second halves of the study.

Signs and Symptoms

Clinical and historical features were highly variable in
this diverse group of patients and were associated primarily with the intra-abdominal infectious process (Table
2). Fever and/or chills (38%) and abdominal pain (36%)
were the most common initial complaints. Anorexia and/
or malaise was next, with bleeding being the initial problem in two patients, one having a percutaneous biliary
drainage tube. The most common physical finding was a
fever of more than 38 C (61%), followed by hepatomegaly
(38%) and localized right upper quadrant tenderness
(36%). Weight loss was documented in 31%, jaundice in
23%, with ascites apparent in only three patients (4%).
No significant correlation was found between any particular symptom or symptom complex and the underlying
disease, number or microbiology of the abscesses, or ul-

Ann. Surg. - December 1990

TABLE 1. The Relative Incidence of Underlying Disease

During the Review Period

Underlying Disease

1970-1978 (n = 29)
No. (%)

1979-1986 (n = 44)
No. (%)

6 (21)
3 (10)

6 (14)
6 (14)

2 (7)
1 (3)
1 (3)
9(31)

7 (16)
1 (2)
6 (14)
11 (25)

Biliary
Benign
Malignant
Colonic
Benign
Malignant
Hematologic
Cryptogenic

Laboratory
As expected, most patients (68%) had a leukocyte count
of more than 10,000/mm3 and 40% had more than 10%
band forms. The alkaline phosphatase (78%) and serum
glutamic oxaloacetic transaminase (SGOT) (57%) levels
usually were elevated, while the bilirubin level was elevated in 36%. Two thirds of patients were anemic, due
largely to chronic disease (Table 3). No single test or combination of tests were more predictive of outcome or significantly correlated with size or number of abscesses,
complications, or time in the hospital.

Imaging Studies
The pattern of use of imaging studies changed significantly during the period of this review. Plain roentgenograms (n = 72) and sulphur colloid scanning (n = 31)
were performed throughout the period ofthe study. Before
1974 all nine patients with a positive diagnosis underwent
sulphur colloid scans. Between 1974 and 1979, 63% (14)

timate outcome.
TABLE 2. Signs and Symptoms
20

Sign/Symptom

18

Initial complaint
Fever/chills
Abdominal pain
Anorexia/malaise
Symptoms
Fever/chills

16
14
L0

12

10

Anorexia/malaise
Abdominal pain
Nausea/vomiting
Weight loss
Night sweats

4
2
0

70

71-72 73-74 75-76 77-78 79-80 81-82 83-84 85-86

Years
FIG. 1. Incidence of hepatic abscesses and underlying malignant neoplastic
disease over time.

Diarrhea
Signs
Fever (T > 38)
Hepatomegaly
RUQ tenderness
Weight loss
Right basilar rales
Jaundice
Diffuse abdominal tenderness
Ascites

No.

31
29
9

38
36
12

55
42
40
20
21
7
6

75
58
55
27
29
10
8

45
28
26
23
18
17
11
3

61
38
36
31
25
23
15
4

657

HEPATIC ABSCESS

Vol. 212 * No. 6

TABLE 3. Laboratory Data

Hematocrit < 40 mg %
WBC > 10,000/mm
Bands> 10%
Alkaline phosphatase > 110 IU
SGOT > 35 IU/dL
Bilirubin > 1.5 mg/dL

No.

(%)

49
50
29
57
42
26

67
68
40
78
57
36

WBC, white blood cell count; SGOT, serum glutamic oxaloacetic

transaminase.

and 59% (13) of patients had ultrasound and liver/spleen

scanning, respectively, and 45% (10) had both. In the period 1980 to 1986, 88% (37) of patients had CT scans,
48% (20) had ultrasound, while only 17% (17) of patients
had sulphur colloid scans. There was little difference in
the sensitivity of CT (100%), ultrasonography (84%), and
liver-spleen scans (93%) in detecting abnormalities (Table 4).
Diagnosis

Clinical suspicion by physical findings, laboratory values, and the history leading to an imaging study was the
most common route to diagnosis (88%). Six patients (8%)
were diagnosed at operation, and two (3%) at necropsy.
Seventeen patients each had positive cultures from material obtained from abscesses percutaneously or at operation. Of the six patients diagnosed at operation, two
were explored for acute cholecystitis and one for appendicitis with incidental discovery of an hepatic abscess. Two
pediatric patients, ages 3 and 10 years, underwent exploTABLE 4. Hepatic Abscess Imaging Studies

Study
Chest roentgenogram (n = 72)
Elevated right hemidiaphragm
Subdiaphragmatic air-fluid level
Subdiaphragmatic free air

Nonspecific abnormality
Abdominal roentgenogram (n = 38)
Intrahepatic air
Ileus

Hepatomegaly
Intrahepatic air-fluid level
Air in biliary tree
CT scan (n = 42)
Suspicious for abscess
Abnormal, nonspecific
Ultrasonogram (n = 37)
Suspicious for abscess
No intrahepatic lesion
Sulphur-colloid scan (n = 31)
Suspicious for abscess
Abnormal, nonspecific
Normal

CT, computed tomography.

No.

12
3
2
39

16
4
3
54

12
12
10
6
4

16
16
14
8
6

31
11

74
26

31
6

86

,14

45
48
7

15
2

14

ration without a diagnosis, one of whom had known hepatic fibrosis. One patient receiving chemotherapy for
acute lymphogenous leukemia was explored for an epigastric mass that was found to be an abscess. Both patients
diagnosed at autopsy died of underlying malignancy, one
with acute granulocytic leukemia and the other with adenocarcinoma of the pancreas.
Etiology

Benign and malignant disease of the biliary tract was

the most commonly diagnosed underlying condition.
Eight patients had malignant obstruction of the common
bile duct, four with cholangiocarcinoma, three with pancreatic carcinoma, and one with carcinoma of the colon.
Seven patients had abscess(es) associated with acute cholecystitis, including three with documented choledocholithiasis. Six patients had undergone biliary-enteric bypass
procedures, four for chronic pancreatitis and two for pancreatic malignancy. Colonic disease contributed significantly to the series with four patients with diverticulitis,
two with idiopathic or ischemic perforation, and one with
Crohn's disease with perforation. Four patients had primary or recurrent adenocarcinoma of the colon, and four
patients had hepatic abscess as a complication of appendiceal abscess or perforated appendicitis. A variety of other
conditions contributed 15% of the cases, and 20 patients
had no source identified (Table 5). Sixteen of these twenty
patients underwent exploratory operation with no underlying cause found. Thirteen of the seventy-three patients had underlying organ malignancies. Seven had hematologic disease, including acute myelogenous leukemia
in two patients and acute granulocytic leukemia, acute
lymphogenous leukemia, idiopathic thrombocytopenia,
erythroleukemia, and aplastic anemia in one patient each.
Eight patients had diabetes mellitus, but only two patients
TABLE 5. Underlying Disease

Disease
Biliary Disease
Benign
Malignant
Colonic Disease
Benign
Malignant
Hematologenous disease
Chronic granulomatous disease
Pancreatitis/ETOH
Trauma
Solid tumor-Other
Hepatic fibrosis
Ischemic bowel
Crohn's disease
Perforated ulcer

Cryptogenic

No.

12
7

16
10

11
2

14
3
10
5.5
4.2
3
3
1.2

7
4
3
2
2

1
1
1
1
20
73

1.2
1.2
1.2
27
100

658

BRANUM AND OTHERS

in the cryptogenic group were diabetic. Five patients had

underlying chronic granulomatous disease, one of whom
also had appendicitis.

Gross Characteristics

Single abscesses were present in 43 patients (59%), and

multiple abscesses were present in 30 patients (41%). Of
some 110 total abscesses, 70% were in the right lobe.
Eighty-six per cent of right lobe abscesses were solitary,
while only 9% of left lobe abscesses were solitary. Fiftytwo patients (73%) had at least one abscess measuring 3
cm or more in size. Benign conditions were the underlying
cause of solitary lesions in 22 patients (56%) and multiple
lesions in seventeen patients (44%). Single lesions were
present in seven patients and multiple lesions were present
in six patients in the 13 patients with underlying solid
tumors. Hematologic disorders were associated with multiple abscesses in 83% of cases, while cryptogenic abscesses
were solitary in 86%. There was no difference in the location of cryptogenic abscesses compared with the remaining patients of the group. The percentages of patients
with biliary or colonic disease with regard to the location
or number of abscesses was no different than in the group
as a whole.
TABLE 6. Microbiology

Organism
Gram-negative Aerobes
Klebsiella
E. coli
Proteus
Pseudomonas
Enterobacter
Morganella
Serratia
Eikenella
Other GNR
Gram-positive Aerobes
Enterococcus
Non-group D strep
Microaerophilic strep
Coagulase-Pos. Staph
Coagulase-Neg. Staph
Alpha hemolytic Stret
Gram-negative Anaerobes
B. fragilis
Bacteroides species
Fusobacterium
Other GNR
Other GNC
Gram-positive Anaerobes
Clostridia
Strep anaerobius
Peptostreptococcus
Actinomyces
Diptheroids
Gram-positive cocci
Fungal

Abscess Blood Bile Other Total

l1
10
5
4

9
9
2
2

2
1
1
2

6
4
4
3
3
2

2
2

2
1
1
1

1
1

7
4

2
1
2
4
1

5
4
4
12
I
4

4
I
I

3
I
1
1
2
2

20
21
7
8
1
4
1
1
3

1
1

4
2

1
1
1
2
5

Ann. Surg. * December 1990

TABLE 7. Microbial Isolates in Single and Multiple Abscesses

Isolates

Solitary (43)
Polymicrobial
Single Isolate
Fungal
None
Multiple (30)
Single Isolate
Polymicrobial
Fungal
None

No.

27
13
0
3

63
30
0
7

l1
9
4
6

37
30
13
20

Microbiology
The first positive culture was obtained from one or more
abscesses in 34 patients (47%) or from the blood in 23
patients (32%) (Table 6). Three patients had positive bile
cultures following manipulations of the biliary tree, including percutaneous stenting (two patients), and common duct exploration for retained stones (one patient).
One patient with multiple fungal abscesses had positive
sputum only, and one patient had positive cultures obtained from the liver, spleen, and lung at autopsy. Nine
patients (12%) who were treated with antibiotic therapy
for various periods before obtaining cultures from any
source had no positive cultures. Of 134 total isolates, 75%
were aerobic (Table 6). Escherichia coli and Klebsiella
were the most common bacteria, followed by Bacteroides
species and enterococci.
Characteristics of single and multiple abscesses with
regard to isolates are presented in Table 7. Solitary abscesses were more likely than multiple abscesses to be
polymicrobial: 43 patients (63%) versus nine patients
(30%). Aerobic isolates alone were found in 37 patients
(51%) and pure anaerobic abscesses were found in only
8 patients (11 %). All fungal isolates were Candida species
and were found in patients with multiple lesions. Material
from abscesses or from bile was more likely to yield positive cultures than was the blood.
Treatment
The pattern of treatment of hepatic abscess changed
considerably during the period ofthis study (Fig. 2). From
1970 to 1978, 25 of 29 patients (86%) were treated first
with operation, while from 1979 through 1986 equal
numbers of patients had a surgical procedure or percutaneous drainage as the first definitive therapy. In total
the first definitive therapy in solitary abscesses was surgical
in 65%, percutaneous drainage in 26%, antibiotics alone
in 7%, and staged percutaneous drainage followed by operation in 2%. Multiple abscesses were first treated by surgical drainage in 47%, percutaneous drainage in 29%, antibiotics alone in 23%, and staged percutaneous/surgical
drainage in 7%.

20

18

16

14

12

E 10

Surgical Drainage
Antibiotics

0 Percutaneuous

Drainage
Staged Percutaneous Surgical
Drainage
]

.0

70

659

HEPATIC ABSCESS

Vol. 212 -No. 6

71-72

73-74

75-76

77-78

79-80

81-82

83-84

85-86

Years
FIG. 2. Primary treatment of hepatic abscesses over time.

Complications were common, regardless of treatment,

with 20 following operations (48%), 12 after percutaneous
drainage (71%), and 8 after antibiotic therapy (73%).
Reaccumulation of abscesses within 2 weeks after treatment occurred in eight ( 19%) patients after surgical drainage and seven (41%) following percutaneous drainage.
Single- or multiple-system organ failure caused complications in two patients treated with percutaneous drainage
and five patients following operation. Two patients treated
with percutaneous drainage and five surgical patients had
continuing sepsis, despite antibiotics. Three surgical and
one percutaneous drainage patient developed ileus lasting
at least 1 week after therapy. One surgical patient each
developed pulmonary embolus, massive right pleural ef-

fusion, and an E. coli wound infection. Small bowel obstruction requiring surgical intervention occurred in two
patients following initial surgical drainage. Antibiotic
therapy with gentamicin caused acute renal failure in one
patient and partial hearing loss in another after surgical
drainage.
Secondary surgical procedures following earlier but inadequate drainage were performed in eight patients, five
of whom had operations and three of whom had percutaneous drainage initially. One patient developed shock
when percutaneous drainage of a solitary abscess of the
right lobe was attempted, necessitating hemodynamic
support and urgent surgical intervention. Percutaneous
drainage was performed for initial failure or reaccumulation of an abscess after four percutaneous procedures,
and one each ofsurgical and antibiotic failure. One patient
with a solitary abscess in the right lobe required six manipulations or catheter exchanges during a period of 2
weeks before successful drainage was obtained.
Outcome
Fourteen patients in this series died, yielding a mortality
rate of 19% (Table 8). The mean age of these patients was
53 years, which was not significantly different than the
age of those who survived, and the distribution of deaths
by decade was similar to the incidence of cases by decade.
Seven each died with single (16%) and multiple (23%)
abscesses. Seven of twenty patients (35%) with underlying
malignancy died, while death occurred in only 7 of 53
patients (13%) with benign underlying conditions or unidentified causes. Multiple-system organ failure lead to
death in five patients and sepsis superimposed on metastatic disease also was present in five patients. Three pa-

TABLE 8. Mortality

Year

Sex

Age

Underlying Disease

Number

Method of
Diagnosis

70
72
74
75

M
M
M
F

61
51
20
37

Pancreatic carcinoma
Pancreatic carcinoma
Acute granulocytic leukemia
Colon carcinoma

Single
Multiple
Multiple
Single

Autopsy
L-S scan
Autopsy
Celiotomy

Antibiotics
Antibiotics
Antibiotics

77

52

Single

L-S scan

Antibiotics

78
80
80
81
82

M
F
M
M
F

30
81
52
43
52

Pancreatic carcinoma, biliary

bypass
Pancreatitis, biliary bypass
ITP, steroid therapy

Single
Multiple
Multiple
Multiple
Single

CT scan
CT scan
CT scan
CT scan
CT scan

Surgery
Surgery
Percutaneous
Percutaneous surgery
Surgery

Sepsis, multiple-organ failure

Multiple-organ failure
Multiple-organ failure
Multiple-organ failure

83
85
86

M
F
F

63
63
81

Colon carcinoma
Lupus, steroid therapy
Ischemic bowel

Single
Single
Single

Percutaneous surgery
Percutaneous
Antibiotics

Sepsis, metastatic disease

86

50

Pancreatic CA, s/p Whipple

Multiple

CT scan
CT scan
CT scan
Ultrasound
CT scan

Percutaneous

Multiple-organ failure,
metastatic disease

Cholangiocarcinoma
EtOH, ulcer perforation
Gangrenous cholecystitis,
colon perforation

Complications

Treatment

Surgery

Sepsis, metastatic disease

Sepsis, metastatic disease
Sepsis, immunosuppression
Abdominal abscess,
metastatic disease
Sepsis, metastatic disease

Sepsis
Sepsis, immunosuppression
Sepsis, DIC

BRANUM AND OTHERS

660

tients were immunocompromised from steroids or chemotherapy, and one patient had profound sepsis. Of the
14 deaths, 10 had polymicrobial infections, and no organism predominated among the group.
Underlying benign conditions leading to death included
complications from biliary tract surgery for stones, diverticulitis, gangrenous bowel, perforated gastric ulcer, and
two patients with exogenous steroids, one for idiopathic
thrombocytopenia and one for systemic lupus erythematosis. No patient with a cryptogenic abscess died.
Discussion
In 1938 Ochsner and DeBakey' published the largest
series of pyogenic abscess of the liver then in the literature.
Their series included 139 cases of amoebic abscess and
47 cases of pyogenic abscess. This classic review emphasized the uniform rate of mortality of nonoperative treatment and the 95% mortality rate of multiple abscesses.
The authors showed clearly in their review of the literature,
as well as in their own series, the importance of primary
abdominal disease and of portal venous drainage in the
development of liver abscesses.
Many subsequent series, including those by Barber and
Juniper,2 and Lee and Block3 emphasized the changing
clinical patterns ofhepatic abscess. One summary in 19754
noted a marked decrease in the incidence of appendicitis
and other acute colonic diseases as sources of hepatic abscess.5-7 An apparent increase in the age of patients occurred with effective treatment of various intra-abdominal
disease processes in the younger patients. Despite changes
in the epidemiology, the incidence has remained stable
during the past five decades ih this country, with six to
ten cases per 100,000 admissions.
The importance of biliary and colonic disease as an
underlying source of contamination in a large percentage
of patients is evident in this series, with 40% of patients
with these sites as the source of infection. Despite diagnostic advances and aggressive evaluation in most cases,
27% ofthese patients had no underlying source identified,
thus making cryptogenic abscess the largest single group
in the study. Sixteen of the twenty patients with cryptogenic abscess underwent operative procedures for drainage
of their abscesses, indicating that even direct visual and
manual exploration does not guarantee identification of
8-11

a source.

Of particular note in the present study was that 20 patients (27%) of this series also had an underlying solid
malignancy or hematologic disease. Other reports included a growing population of immunosuppressed patients or those with malignant neoplastic disease.4"2 In
this subset of patients in the present study, only five presented from 1970 to 1978, while the remaining 15 patients
presented between 1979 and 1986. The mortality rate in

Ann. Surg. - December 1990

the group with malignancy was 35%, compared to 13%

in patients with benign or cryptogenic conditions. This
particular group now represents the largest group of patients with hepatic abscess and an identified concomitant
illness. Therefore, considering all of the characteristics of
the total group, malignancy was the most important determinant of outcome.
Early diagnosis remains important in the present series.
Physical signs, symptoms, and laboratory evaluation have
remained relatively unchanged with this disorder during
the two decades. Clinical suspicion based on physical
findings or complaints, along with abnormal laboratory
tests leading to appropriate radiologic studies with confirmation were the most common means of diagnosis.
Less than one third of patients in this series, however,
had the complete symptom triad of right upper quadrant
pain, fever or chills, and malaise. Indeed, in immunocompromised and elderly patients, a high index of clinical
suspicion is necessary to initiate appropriate diagnosis.'3
Both ultrasound and CT scans were very sensitive to abnormality (86% and 100%, respectively), but even with
recent technological advances, the literature continues to
indicate a group of patients diagnosed only by operation
or autopsy.'4" 5 There were eight such patients (11%) in
this series.

A review ofthe Duke series by McDonald et al. 16 ending

in 1982 emphasized an evolving microbiology of pyogenic
hepatic abscess. This was confirmed in other reports that
identified an increase in the isolation of anaerobic and
microaerophilic organisms.'7 This is thought to be secondary to improved culture techniques, as well as attention to detail in the collection of specimens. Pure anaerobic abscesses reportedly make up a small proportion of
cases, indicating the importance of broad spectrum therapy if anaerobes are cultured. There may be a subset of
patients with no diagnostic cultures obtained but who have
received antibiotics. If hepatic abscess is the clinical diagnosis, but the contents and other cultures remain sterile,
broad coverage with antibiotics necessarily continues for
an adequate therapeutic course.
During the 18 years of this study, the mortality rate
remained stable, 18% in the first 9 years and 16% for the
following 8 years, despite a higher incidence of malignancy
and hematologic disease during the latter period. In contrast to other series, the mortality rate was not related to
age, multiplicity of lesions, or primary treatment (Fig. 3).
After 1978 a marked change in the choice of primary
therapy occurred, when percutaneous drainage became a
useful adjunct to surgical drainage, as well as a primary
therapeutic option.
Bertel et al. 18 emphasized the ease of treatment by percutaneous techniques, with successful results in as many
as 83% of patients and morbidity as low as 20%. The most
amenable abscesses to percutaneous drainage are those in

HEPATIIIC ABSCESS

Vol. 212 - No. 6

60
Total
* Deaths (X)

50
40
La)

30

20
10
13%
0

Character

Underlying Disease 1' Treatment

FIG. 3. Deaths secondary to hepatic abscess compared by character, underlying disease, and primary treatment. SD, surgical drainage; PD, 10
percutaneous drainage. AB, antibiotics alone.

the posterior right lobe, deep-seated lesions, and ones that

are adherent to the abdominal wall. Superficial lesions or
peripheral abscesses of the right lobe are easily treated by
percutaneous drainage, and assuming no other intra-abdominal procedure is necessary, such drainage should be
associated with fewer complications. Surgical therapy often remains necessary for abscesses ofthe left lobe or those
that are multiloculated, or when this approach is advisable
because of concomitant intra-abdominal disease. The determination of outcome of various therapeutic modalities
of hepatic abscesses must include underlying conditions,
location, and accessibility ofthe lesions. Raw comparisons
of surgical versus percutaneous treatment are not appropriate without these considerations. As recommended in
previous series,4"12 antibiotic treatment alone should be a
last resort, even considering the newer generation antibiotics.
In 1984 Miedma and Dineen'9 presented a series of
106 patients with pyogenic hepatic abscess and reported
that despite easier diagnosis, the mortality rate remained
high (53%). They also postulated that only 30 of their 106
patients would have qualified for percutaneous drainage,
of which only three died. Following this presentation
Nabseth20 emphasized his previously reported series of 18
hepatic abscesses, 16 of which were successfully managed
by percutaneous drainage with no deaths. Several subsequent series have been published comparing surgical to
percutaneous treatment of hepatic abscess. 8'21'22 Percutaneous drainage clearly has emerged as an alternative in
many patients with hepatic abscess.
A surgical procedure was the primary treatment in 28
patients with solitary and 14 patients with multiple abscesses. Six patients required further treatment because
of inadequate drainage of the primary abscess, or occurrence of a secondary abscess. Percutaneous drainage was

661

the primary treatment in 11 solitary and seven multiple

cases. Four repeat percutaneous drainage procedures and
three surgical drainage procedures were required (a 41%
primary failure rate). The overall morbidity rate was 48%
for operation and 71% for percutaneous drainage, including all major complications. These were prolonged ileus,
small bowel obstruction, pulmonary embolus, pneumonia, pleural effusion requiring drainage, and recurrent abscess. It should be re-emphasized that percutaneous redrainage is usually a less morbid procedure than operative
drainage.
Most surgical series cite morbidity rates in the range of
40%, with septicemia the most common complication.4"5"8 Common pleural complications, include enlarging effusions, empyema, rupture into the right subphrenic space, and pneumonia. Other complications, such
as bile duct obstruction, generalized peritonitis, and extrahepatic abdominal abscess are considerably less common. Percutaneous drainage complications are somewhat
more difficult to define because of variability in the definition of complications between series. However most
studies comparing surgical and percutaneous drainage
quote complication rates of 40% to 60%.23.24 This high
incidence probably reflects the greater severity of illness
in these patients. Crass25 reported a high rate of acute
sepsis with development of shock, ranging up to 25% either
during or following the procedure. One patient in the
present series required emergent operative intervention
after percutaneous drainage when profound shock developed from peritoneal soilage by contents of the abscess.
One patient died after percutaneous diagnostic aspiration
without surgical consultation. These emphasize the importance of continued early surgical involvement with
these patients.
This review re-emphasizes the findings of others4'26 that
successful treatment exchanges high mortality rates for
high morbidity rates. The current therapy of pyogenic
hepatic abscess should be individualized, with consideration of whether the abscess is solitary or multiple, whether
additional problems requiring surgical therapy are present,
and most significantly, the nature of the patient's underlying disease. McCorkel27 recently proposed an evaluation
of percutaneous aspiration followed by antibiotics as the
primary therapy. Several immunocompromised patients
in this series developed diffuse microabscesses not amenable to surgical or percutaneous drainage and were managed with antibiotics alone. Such patients had the highest
mortality rate (45%) in this series and represent a special
problem.
Some authors'2'28 advocate hepatic resection in cases
of abscess localized to one lobe. Resection is probably
most useful in selected cases of chronic granulomatous
disease, although closed and open drainage are still important techniques.

BRANUM AND OTHERS

662

Pyogenic hepatic abscess remains a difficult problem.

Although relatively uncommon, its incidence is not decreasing and should be expected to increase with contemporary aggressive treatment of malignant disease. In the
present experience death is more consistently related to
the underlying disease and overall condition of the patient
than to the mode of therapy chosen, i.e., percutaneous
versus surgical drainage. On the other hand, morbidity is
more related to treatment. The principal of timely diagnosis and prompt institution of treatment appropriate to
the individual patient remains the standard of care in this
potentially grave disease and usually leads to a successful
ultimate result.

12.
13.
14.

15.
16.

17.

18.

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