Clinical Aspects of Liver Diseases 27 Liver abscess

Clinical Aspects of Liver Diseases

27 Liver abscess

Page:

1 Definition 512

2 Pathogenesis 512

3 Pathogens 512

4 Causes 513

5 Clinical picture and diagnosis 513

5.1 Clinical findings 513

5.2 Imaging procedures 513

5.3 Laboratory parameters 514

5.4 Aspiration material 514

6 Localization 515

7 Complications 515

8 Therapy 515

8.1 Conservative treatment 515

8.2 Aspiration treatment 515

8.3 Percutaneous drainage 516

8.4 Surgical drainage 516

8.5 Liver resection 516

9 Prognosis 516

앫 References (1⫺116) 517

(Figure 27.1; tables 27.1 ⫺27.4)

1 Definition

The term liver abscess describes a circumscribed, often encapsulated, purulent inflammation with necrosis of the local parenchyma caused by a multitude of pathogens (bacteria, protozoa, hel- minths) and fungi. Liver abscesses can be detected as a solitary or multiple occurrence. Microabscesses are also witnessed, diffusely affecting the entire liver, sometimes as the outcome of purulent, suppurative cholangitis.

2 Pathogenesis

Infection can develop in five different ways, whereby a weakening of the body’s defence system enormously heightens susceptibility. (13, 42, 91) (s. tab. 27.1)

1. haematogenic: via the proper hepatic artery in severe septic processes (e. g. furunculosis, osteomyelitis) as a metastatic-pyaemic liver abscess, or via the portal vein as a pylephlebitic liver abscess (such as in ap- pendicitis, colitis, diverticulitis), and occasionally via the umbilical vein as omphalophlebitis

2. biliary: via the bile ducts, arising from cholecystitis or cholangitis as well as from the invasion of para- sites or foreign bodies

3. per continuitatem: spread of inflammatory pro- cesses to the adjacent areas (e. g. gall-bladder empy- ema, subphrenic or perinephritic abscess)

4. posttraumatic: following injuries to the liver or as a result of intrahepatic haematoma

5. postoperative

Tab. 27.1: Access routes leading to the development of liver ab- scesses

3 Pathogens

Fundamental differentiation may be made between four types of liver abscess, depending on the aetiology:

1. bacterial abscess 3. helminthic abscess 2. protozoal abscess 4. fungal abscess

The causative pathogen can be detected directly from the abscess or by cultures set up from the blood or bile, sometimes even from the urine or stool. It can also be detected microscopically (e. g. evidence of parasites or their eggs and larvae) and sometimes serologically or sonographically (e. g. Ascaris lumbricoides, s. figs.

25.5 ⫺25.8). In order to reach a diagnosis, it is necessary to select the examination method which is most suitable for the detection of the respective pathogen. When applying suitable bacteriological techniques, anaerobes can be found in 30 ⫺40% of cases. Solitary liver abscesses (63%) displayed a polymicrobial pathogenic spectrum in twice as many cases as did multiple abscesses (30%). (13) Streptococcus milleri is a very com- mon cause. (72) It can be cultured in a carbon dioxide- enriched medium. (s. tab. 27.2)

Bacteria (12, 21, 24, 27, 32, 36, 39, 70, 87, 91, 97) Gram-negative aerobes

Acinetobacter

Brucella species (86, 107) Campylobacter jejuni (14) Citrobacter freundii Edwardsiella tarda (116) Eikenella corrodens Escherichia coli Klebsiella species (19) Proteus species

Pseudomonas species (108) Salmonella species (35, 95)

Yersinia species (1, 6, 26, 49, 58, 105) Gram-positive aerobes

Listeria monocytogenes (63, 84) Mycobacterium tuberculosis (18, 43) Pediococcus acidilactici (93) Staphylococcus (38, 109) Streptococcus pneumoniae (61) Streptococcus species (64, 72) Gram-negative anaerobes Aeromonas hydrophilia (96) Bacteroides species

Fusobacterium nucleatum (90) Gram-positive anaerobes Actinomyces (9, 69) Clostridium species Diphtheria species Lactobacillus (11) Peptostreptococcus Streptococcus anaerobius Protozoa

Amoebiasis Helminths

Ascaris lumbricoides Fasciola hepatica Fungi

Aspergillosis Candida species (92) Mucormycosis Torulopsis glabrata Trichosporon species

Tab. 27.2: Main pathogens (bacteria, protozoa, helminths, fungi)

of liver abscesses and microabscesses (with some references) (see

chapters 24, 25 and 26)

Liver abscess

4 Causes

The frequency of cryptogenic liver abscesses (at one time 30 ⫺40%) has now been reduced to 10⫺15% as a result of modern contrast-medium imaging pro- cedures and improved or more advanced serological, bacteriological and parasitological methods. Improved diagnostic clarification of the clinical picture in terms of respective pathogens and other causes has con- tributed to better treatment results and a clear drop in mortality. (91, 113)

1. Biliary diseases

⫺ cholecystitis

⫺ cholangitis

⫺ cholelithiasis, choledocholithiasis (5, 31)

⫺ biliary tract surgery (16, 65, 111)

⫺ parasitosis

⫺ malignant tumours (114)

⫺ strictures

⫺ Sump syndrome following choledochoduodenostomia 2. Intestinal diseases

⫺ appendicitis with perityphlitic abscess

⫺ diverticulitis (79, 110)

⫺ colitis

⫺ Crohn’s disease (7, 29, 52, 62, 68, 73, 89, 102, 106)

⫺ malignant tumours (104, 114)

⫺ intestinal surgery 3. Gastric diseases

⫺ perforation of an ulcer

⫺ gastric surgery 4. Pancreatic diseases

⫺ pancreatitis (3, 82)

⫺ pancreatic carcinoma (114)

⫺ pancreatic surgery 5. Trauma, abdominal injuries 6. Abscesses of adjacent organs

⫺ perinephritic abscess

⫺ subphrenic abscess

⫺ retrocaecal abscess

⫺ gall-bladder empyema

⫺ gall-bladder carcinoma (114) 7. Parasitoses

⫺ amoebiasis

⫺ Fasciola hepatica

⫺ Ascaris lumbricoides 8. Thrombophlebitis

⫺ portal vein (pylephlebitis)

⫺ umbilical vein (omphalophlebitis) 9. Alcohol injections for HCC (28, 44, 75, 94) 10. Leukaemia

11. Chronic granulomatosis (37, 41) 12. Arterial embolization (88)

13. Ligature of the hepatic artery (46, 101) 14. Haemosiderosis and yersiniosis (6, 105) 15. Haemorrhoidectomy (76)

16. Infected liver cysts and echinococcus cysts

17. Passage of a swallowed toothpick (2, 47) or fish bone through the stomach into the liver

18. Cryptogenic diseases

Tab. 27.3: Underlying diseases causing the development of liver abscesses (with some references)

The spectrum of causative diseases in the development of a liver abscess has changed significantly over the past 10 years, as have the respective frequency rates. The perityphlitic abscess, once predominant in appendicitis, is now relatively rare; in contrast, traumatic injuries to the liver or adjacent organs as a result of accidents have increased in frequency (some 10%); the biliary infection route has acquired much greater significance (35 ⫺40%).

Of note is the rising number of liver abscesses caused by the Yersinia species in patients suffering from haemo- siderosis or haemochromatosis, or following long-term substitution of iron, since the metabolism of the Yersin- iae is iron-dependent. • With regard to all these caus- ative factors, a weakening of the body’s own defence sys- tem (s. tab. 26.1), such as in diabetes mellitus and alcoholism or during a course of treatment with im- munosuppressants, glucocorticoids and chemotherapeu- tic agents, increases the risk of infection. (13, 15, 25, 57, 71, 90) The causes of abscesses hitherto reported have been numerous and diverse. (48) (s. tab. 27.3)

5 Clinical picture and diagnosis

5.1 Clinical findings

In clinical terms, continuous or intermittent fever pre- dominates. (54) In children with fever of unknown aeti- ology, a liver abscess should always be considered when setting up the differential diagnosis. Additional signs of febrile infection include bursts of perspiration, night sweats, lack of appetite, loss of weight, nausea, weakness and a general malaise. Local symptoms are abdominal pain in the right upper quadrant, radiation of pain to the right shoulder, occasional respiratory pain on the right side and irritable (dry) cough. The liver is often enlarged and tender on pressure; guarding of abdominal muscles is usually in evidence. (54) The clinical course can proceed gradually, yet may also show dramatic symptoms (e. g.

shivers, sepsis, jaundice, shock), especially in the case of purulent cholangitis.

5.2 Imaging procedures

Sonography is the method of choice for identifying a

liver abscess (sensitivity 71 ⫺92% for foci >1.5 cm). Fre-

quently, especially with small and multiple foci, the liver

structure is initially inhomogeneous; clearly definable

focal lesions only develop during the further course of

disease. As a rule, sonographic morphology shows circu-

lar foci which are hypoechoic to anechoic. The echo-

genic focus usually appears as fluid-filled with several

internal echoes. Sometimes, however, a fluid level can

actually be detected. Multiple small abscesses aggregate,

suggesting the beginning of coalescence into a single

larger abscess ( ⫽ cluster sign). ⁽⁴⁵⁾ Should no gas be

present in the abscess, a dorsal reduction in sound waves

( ⫽ comet tail) is observed. Splenomegaly is frequently

witnessed. In addition, particularly with mycotic abscesses, an anechoic focus is visible with a centre that is rich in echoes ( ⫽ target phenomenon); such an abscess occasionally presents an anechoic centre inside the echo-rich area ( ⫽ double wheel structure). (15, 17, 18, 33, 40, 58, 109) (s. p. 132) (s. figs. 6.11; 25.1!)

Computer tomography, besides establishing the diagnosis (in 86 ⫺93% of cases with foci >0.5 cm), also makes it possible to locate the abscess exactly. (s. fig. 27.1) When enhanced with a contrast medium, CT can differentiate an abscess from an intrahepatic metastasis. Pyogenic and mycotic abscesses are visible as hypodense areas both in their natural state as well as after administration of a contrast medium; occasionally, the contrast medium is visible as a ring-shaped enhancement. A small amount of ascites may be detectable. With the help of ultrasonography and computer tomography, it is possible to carry out guided aspiration or drainage of an abscess reliably. (15, 58, 71) (s. p. 175)

Fig. 27.1: CT scan shows multiple pyogenic liver abscesses in seg- ment 4 (a and b) following perforation in diverticulitis (E. coli).

Full recovery

X-ray examination of the chest and abdomen is still imperative, despite the paramount importance of ultra- sonography. These standardized routine techniques are usually applied prior to computer tomography because of the wide spectrum of findings acquired as well as the considerably lower costs involved. (13, 36, 80) • In the case of liver abscess, the following findings can be detected in the area of the thorax: (1.) lack of diaphrag- matic motion or right-sided diaphragmatic elevation (40 ⫺65%), (2.) masking of the right-sided phrenicocos- tal angle, (3.) pleural effusion on the right (40 ⫺50%), (4.) hypoventilation and atelectasis of the right lower pulmonary lobe, (5.) subdiaphragmatic air-fluid level, (6.) free air in the subdiaphragmatic area, and (7.) infiltration of the lungs. • In the abdominal area, the

following findings are occasionally observed: (1.) evi- dence of intrahepatic air, (2.) intrahepatic air-fluid level, (3.) free air in the biliary tract, and (4.) foreign bodies.

Cholangiography: In the event that a biliary cause is suspected, cholangiography (i.v., ERC, PTC) may be indicated. With PTC, multiple abscesses mimic the picture of sclerosing cholangitis.

(55, 98)

Angiography is deemed indispensable during the course of pre- operative preparations for an extensive partial resection of the liver in order to demonstrate atypical arteries. It can also be helpful in detecting multiple small abscesses, where vessels as well as hyper- vascular zones surrounding small avascular areas are typically pushed aside or displaced.

Scintigraphy, preferably using

^99m

Tc sulphur colloid or

⁶⁷

Ga-cit- rate, detects a focal lesion with an abscess of > 1.5 ⫺2 cm in approximately 80% of cases. (s. fig. 9.2) However, the rate of false- negative findings is quite high, and differentiation cannot be made between abscess, tumour, cyst or haemangioma. For this reason, scintigraphy is of no clinical relevance for diagnosing an abscess.

Magnetic resonance imaging produces different elevations of the signal intensity in the T

₂

-weighted image in 70 ⫺75% and hypoin- tensity in the T

1

-weighted image in approx. 60% of cases. A peri- focal oedema (pointing to an inflammatory process), which receded rapidly after good response to therapy, was detected in 30 ⫺40% of cases. After administration of a contrast medium, over 80% of cases displayed wheelspoke-like enhancement. (67)

5.3 Laboratory parameters

Laboratory investigation reveals signs of infection as well as liver disease depending on the degree of severity, the course of disease and the extent of involvement of the bile ducts. (10, 13, 24, 36, 40, 48, 50, 66, 74, 80, 91, 97, 113)

(s. tab. 27.4)

1. Signs of infection

앫 changes in the blood count (leucocytosis, left shift, anaemia) 앫 BSR 앖, CRP reaction ⫹ 앫 fibrinogen, LDH 앖 앫 serum iron 앗

앫 changes in electrophoresis

( α

2

- and γ-globulins 앖, albumin 앗) 2. Signs of liver disease

앫 GPT, GOT, GDH 앖

앫 γ-GT, alkaline phosphatase 앖 앫 serum bilirubin 앖

앫 cholinesterase, Quick’s value 앗 앫 bile acids 앖

Tab. 27.4: Laboratory parameters in liver abscess(es) depending on the respective degree of severity and course of disease and on the involvement of the biliary tract

5.4 Aspiration material

Diagnosis is reached by means of needle aspiration of

the abscess guided by ultrasonography or computer

tomography and subsequent examination of the abscess

Liver abscess

contents. In pyogenic abscesses, it is possible to detect one or several pathogens in 62 ⫺95% of cases. ^{(quot. 70;}

85) Gram-negative aerobic bacteria are found in approx.

60% and gram-positive aerobic pathogens in 15 ⫺20%

of cases. In order to detect anaerobic bacteria (approx.

20% of cases), utmost care is required when collecting the anaerobic cultures; so-called sterile cultures are often due to mistakes made during the process of collec- tion or are attributable to preceding antibiotic therapy.

The aspiration material should also be tested by selec- tive culture, since mixed infections resulting from both bacteria and fungi may be present. In individual cases, microscopic examination can make it possible to dif- ferentiate between tumorous and mycotic material. The respective results determine therapy requirements; with the help of targeted treatment, greater efficacy can be achieved.

6 Localization

The right lobe of liver, especially the dorsal segments, is most frequently involved (60 ⫺70%). In 20⫺30% of cases, both lobes are affected. Solitary abscesses are localized in the right lobe of liver in 80 ⫺90% of cases.

Multiple abscesses can be observed in approx. 40% of patients. Subhepatic localization of an abscess was observed following the perforation of a gastric ulcer (11)

and conventional cholecystectomy. (111)

7 Complications

With pyogenic abscesses, the most frequent complica- tion is septicaemia and its deleterious sequelae. The abscess can, however, also penetrate the biliary tract or the intrahepatic vascular system (59) , or rupture into the abdominal cavity and subphrenic space. (22) Sometimes, thrombosis of the portal vein develops. Penetration through the diaphragm into the pleural cavity and the pulmonary parenchyma is likewise to be feared. Pyo- genic or mycotic sepsis can also give rise to end- ophthalmitis, particularly in patients suffering from dia- betes mellitus. (23, 100) Initial signs of eye symptoms in the presence of a liver abscess call for immediate examination by the ophthalmologist and, if necessary, appropriate treatment. • Gas-forming pyogenic abscess:

Numerous pathogens are capable of gas formation, especially klebsiella pneumoniae. Such gas reveales four major constituents: nitrogen, oxygen, carbon dioxide and hydrogen. This composition implicates mixed acid fermentation of glucose as the mechanism of gas forma- tion.

8 Therapy

8.1 Conservative treatment

1. Multiple, small and minute abscesses are not access- ible to invasive or surgical treatment. Hence it is import-

ant to sanitize any focus of infection to prevent it from spreading and to combat the infectious toxic process by suitable therapeutic measures. A bacteriological analysis must be obtained as early as possible by aspiration of the abscess area using a thin needle. Until the patho- genic result is available, a combination of antibiotics should be administered which covers the aerobic as well as the anaerobic spectrum of the most frequent patho- gens (e. g. E. coli, Proteus, Klebsiella, Bacteroides frag- ilis, aerobic and anaerobic streptococci, staphylococci).

A suitable combination is cephalosporin ⫹ metronida- zole ⫹ aminoglycoside. The combination of aminogly- coside ⫹ clindamycine has also proved helpful. ⁽⁴⁸⁾ Once the bacteriological result is available, the antibiotic combination is altered in line with the antibiogram, pos- sibly supplemented in the individual case by a fungi- static agent. The duration of parenteral administration is 10 ⫺14 (⫺21) days with subsequent oral treatment for about 3 to 4 weeks. Prior to cessation of the antibiotic therapy, a check-up should be carried out by ultrasono- graphy and/or computer tomography. In the case of suc- cessful treatment, the abscess is either obliterated or at least significantly reduced. (36, 48)

2. It is probable that antibiotics will reach the interior of those abscesses which are still relatively small and have only existed for a short period of time. In these cases, too, the spectrum of aerobic and anaerobic bac- teria should initially be covered non-specifically by the above-mentioned combination of antibiotics. At the same time, the presence of an amoebic abscess or echi- nococcosis should be ruled out serologically (as quickly as possible) and aspirated material collected for bacte- rial and mycotic testing. Depending on the results, the respective antibiotic (and possibly fungistatic) therapy is effected. After 2 ⫺3 (⫺4) days, the efficacy of this targeted treatment is reviewed clinically and biochemi- cally as well as ultrasonographically. If the treatment is considered to have been effective, it is continued until obliteration of the abscess foci is achieved. (12, 29, 53, 60, 64, 74, 91, 97, 113)

8.2 Aspiration treatment

1. Should initial antibiotic therapy fail to show any suc- cess within the limited period of 2 ⫺4 days (persistence of fever, leucocytosis, bacteriaemia), percutaneous as- piration of the abscess contents, if necessary repeated several times during the next few days, usually proves successful. Antibiotic therapy is continued during the course of percutaneous aspiration treatment.

2. In an extremely large abscess, percutaneous aspiration

of the focus with evacuation of the pus is carried out as

an initial measure. Generally, several punctures have to

be performed with respective aspiration of the focal

contents until the abscess cavity is gradually obliterated

under the impact of specific antibiotics. The outcome of

this form of treatment is considered to be more favour- able and the concomitant complications (e. g. intraperi- toneal contamination, bleeding) are less numerous than with percutaneous drainage. (4, 12, 13, 24, 35, 40, 42, 53, 81, 85, 92, 97, 99, 113, 115)

8.3 Percutaneous drainage

䉴 Percutaneous drainage was initially attempted by ^{A. F. S M} ac- F adzen et al. in 1953. It was later introduced into clinical routine by J. R. H aaga et al. (1976) (s. tab. 7.2) using the CT-guided method. An improved technique was applied by S. G. G erzof et al. (1981) and proved very successful in the treatment of liver abscesses.

Puncture is effected using a teflon-coated 18 (or 20) gauge needle. After aspiration of the contents, a pigtail catheter (7 or 8 Charrie`re scale) is placed in the cavity of the abscess by means of a guidewire. Subsequently, the position of the catheter and the abscess cavity itself are checked by computer tomography to ensure that there is no septation and that the abscess cavity is com- pletely drained. Once the catheter has been placed in an optimal position, the pus is totally evacuated and the cavity rinsed clean with a physiological NaCl solution.

The original catheter may be replaced later, if necessary, by one with a wider lumen (14 ⫺16 Charrie`re scale). • Simultaneous antibiotic therapy is readjusted according to the bacteriological results and the antibiogram. Add- itional injection of antibiotics into the abscess cavity can further improve the efficacy of the parenteral and subse- quent oral antibiotic treatment.

The drainage can be removed if ultrasonography or computer tomography show the abscess cavity to be completely (or extensively) obliterated, if no more fluid can be detected and if the white blood cell count has dropped to below 10,000/mm

³

. This method of treat- ment of liver abscesses has proved its worth; success rates are of 70 ⫺90%. (8, 24, 25, 30, 34, 40, 42, 53, 54, 56, 66, 72, 77, 81, 83, 85, 99, 111, 112, 113)

8.4 Surgical drainage

Percutaneous drainage may be limited by antelocated intestinal loops or by abscesses that are difficult to reach. Similarly, surgery is indicated following unsuc- cessful percutaneous drainage, in extensive cavernous or multifocal abscesses, tissue sequestration, formation of enteral fistula and viscous abscess contents as well as local recurrences. • With abscess perforation or the exis- tence of other purulent foci in the abdomen, surgical intervention is called for immediately.

The surgical approach depends on the location of the abscess, any abdominal investigation that may be required, and possible sanitization of a focus. • The respective access routes are: (1.) transperitoneal, (2.) extraperitoneal, (3.) in special cases also retroperitoneal or infrapleural, and (4.) transpleural as well as transdia-

phragmatic. Evidence of biliary genesis calls for opera- tive or endoscopic sanitization of the biliary tracts and safeguarding of the biliary flow, possibly via a T drain in the choledochus. (8, 24, 42, 53, 54, 72, 78, 85, 99, 113)

Laparoscopic drainage: An alternative to the open surgi- cal drainage of abscesses can be found in laparoscopic drainage. This method is deemed to be safe and success- ful. In a group of 20 patients, there were no intraopera- tive or postoperative complications. (103) Consequently, before deciding on open surgery, the possibility of lapa- roscopic abscess drainage should be considered.

8.5 Liver resection

Liver resection as treatment of a liver abscess is still reserved for exceptional circumstances. Nevertheless, the advantages are definitive sanitization of the abscess, an insignificant degree or indeed absence of peritoneal con- tamination, short-term postoperative antibiotic therapy and the possibility of histological clarification in the event of suspected superinfected malignant tumours.

Moreover, the quality of life is nowhere near as limited as with the various operative drainage procedures, nor is the treatment as drawn-out and burdensome. A pre- requisite for resection is the fundamental operability of the patient and a residual liver parenchyma that is still intact. • The indications concerning liver resection are as follows: large abscess cavities without any tendency to regression but possibly with rigid walls and septation, multifocal abscess systems, abscesses of unresolved status of benignancy/malignancy as well as necrotized and superinfected malignant tumours. Usually, low- complication postoperative courses without mortality have been reported. (51, 78, 80) In some cases, the liver parenchyma completely regenerates along the edge of the abscission scar. (80)

9 Prognosis

Prior to the introduction of liver scintigraphy, a mere 20% of liver abscesses were diagnosed antemortem; the mortality rate was correspondingly 80 ⫺100%. Follow- ing the introduction of scintigraphy in 1965, approx.

80% of all liver abscesses could be diagnosed, so that

the mortality rate dropped to 28%. • Early diagnosis

and the correct choice of aspiration or drainage treat-

ment procedures have further reduced the mortality rate

to below 20%; the rate for solitary abscesses is now

below 10%, sometimes even as low as 3%. • Risk factors

include: advanced age, impairment of the body’s defence

system, sepsis, considerable prior liver damage, increas-

ing hepatic and renal insufficiency, multiple and/or

cavernous abscesses, biliary causes of infection, gas-

forming abscesses ⫺ all depending on the situation in

the respective case. (20, 32, 48, 91, 113) • For this reason,

each liver abscess calls for individual therapy planning

discussed at an interdisciplinary level!

Liver abscess

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