Diferencia entre revisiones de «Hepatic abscess»
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==Background== | ==Background== | ||
[[File:Biliary system multilingual.png|thumb|Bile duct and pancreas anatomy. 1. Bile ducts: 2. Intrahepatic bile ducts; 3. Left and right hepatic ducts; 4. Common hepatic duct; 5. Cystic duct; 6. Common bile duct; 7. Sphincter of Oddi; 8. Major duodenal papilla; 9. Gallbladder; 10-11. Right and left lobes of liver; 12. Spleen; 13. Esophagus; 14. Stomach; 15. Pancreas: 16. Accessory pancreatic duct; 17. Pancreatic duct; 18. Small intestine; 19. Duodenum; 20. Jejunum; 21-22: Right and left kidneys.]] | |||
[[File:Sobo 1906 389.png|thumb|Inferior view of the liver with surface showing lobes and impressions.]] | |||
[[File:Liver vascular anatomy.png|thumb|Liver vascular anatomy.]] | |||
*Uncommon overall - usually occurs in right liver lobe | *Uncommon overall - usually occurs in right liver lobe | ||
**More abscesses → more severe disease | **More abscesses → more severe disease | ||
*History of camping is common | *History of camping is common | ||
**Endemic of Midwest | **Endemic of Midwest | ||
===Types=== | ===Types=== | ||
*Pyogenic (80%) | *Pyogenic (80%) | ||
**Most common cause | **Most common cause | ||
**Associated with biliary tract obstruction (most common), [[cholangitis]], [[diverticulitis]], pancreatic abscess, [[appendicitis]] and [[inflammatory bowel disease]]. | **Associated with biliary tract obstruction (most common), [[Special:MyLanguage/cholangitis|cholangitis]], [[Special:MyLanguage/diverticulitis|diverticulitis]], pancreatic abscess, [[Special:MyLanguage/appendicitis|appendicitis]] and [[Special:MyLanguage/inflammatory bowel disease|inflammatory bowel disease]]. | ||
**Possible arterial hematogenous seeding: [[sepsis]], direct [[trauma]] or instrumentation | **Possible arterial hematogenous seeding: [[Special:MyLanguage/sepsis|sepsis]], direct [[Special:MyLanguage/trauma|trauma]] or instrumentation | ||
**Usually polymicrobial | **Usually polymicrobial | ||
*[[amebiasis|Amebic]] (10%) | *[[Special:MyLanguage/amebiasis|Amebic]] (10%) | ||
**E. histolytica most common | **E. histolytica most common | ||
**Usually not septic and sick, rarely needs drainage | **Usually not septic and sick, rarely needs drainage | ||
*[[fungal infections|Fungal]] (<10%), [[candida|candidal]] | *[[Special:MyLanguage/fungal infections|Fungal]] (<10%), [[Special:MyLanguage/candida|candidal]] | ||
*Hydatid cyst ([[echinococcosis]]) | *Hydatid cyst ([[Special:MyLanguage/echinococcosis|echinococcosis]]) | ||
**Associated with sheep farmers | **Associated with sheep farmers | ||
==Clinical Features== | ==Clinical Features== | ||
*[[RUQ pain]] | |||
*High [[fever]] | *[[Special:MyLanguage/RUQ pain|RUQ pain]] | ||
*[[Nausea]], [[vomiting]], anorexia | *High [[Special:MyLanguage/fever|fever]] | ||
*[[Special:MyLanguage/Nausea|Nausea]], [[Special:MyLanguage/vomiting|vomiting]], anorexia | |||
*Clay-colored stool | *Clay-colored stool | ||
*Dark urine | *Dark urine | ||
*[[Jaundice]] - seen with pyogenic, as opposed to amebic<ref>Oyama LC. Disorders of the Liver and Biliary Tract, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2013, (Ch) 90: p 1186-1205.</ref> | *[[Special:MyLanguage/Jaundice|Jaundice]] - seen with pyogenic, as opposed to amebic<ref>Oyama LC. Disorders of the Liver and Biliary Tract, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2013, (Ch) 90: p 1186-1205.</ref> | ||
*Often with right [[pleural effusions]] | *Often with right [[Special:MyLanguage/pleural effusions|pleural effusions]] | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
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{{Liver abscess DDX}} | {{Liver abscess DDX}} | ||
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{{DDX RUQ}} | {{DDX RUQ}} | ||
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==Evaluation== | ==Evaluation== | ||
[[File:Leberabszess - CT axial PV.jpg|thumb|Liver abscess on axial CT image: a hypodense lesion in the liver with peripherally enhancement.]] | |||
[[File:LargeHepaticAbscessMark.png|thumb|A large pyogenic liver abscess.]] | |||
===Work-up=== | ===Work-up=== | ||
*CBC - Elevated white blood count (70-80%) | *CBC - Elevated white blood count (70-80%) | ||
*BMP | *BMP | ||
*[[LFTs]] - Elevated alkaline phosphatase levels (90%) | *[[Special:MyLanguage/LFTs|LFTs]] - Elevated alkaline phosphatase levels (90%) | ||
*Coags | *Coags | ||
*[[Blood cultures]] | *[[Special:MyLanguage/Blood cultures|Blood cultures]] | ||
*Amebic and echinococcal serologies | *Amebic and echinococcal serologies | ||
*[[RUQ ultrasound|Ultrasound]] (80-100% sensitivity) | *[[Special:MyLanguage/RUQ ultrasound|Ultrasound]] (80-100% sensitivity) | ||
*CT abd/pelvis ('''Imaging study of choice''') | *CT abd/pelvis ('''Imaging study of choice''') | ||
**Triphasic CT scan to define the proximity of the [[abscess]] to the major branches of the portal and hepatic veins | **Triphasic CT scan to define the proximity of the [[Special:MyLanguage/abscess|abscess]] to the major branches of the portal and hepatic veins | ||
===Evaluation=== | ===Evaluation=== | ||
*Diagnosis usually made on imaging studies | *Diagnosis usually made on imaging studies | ||
==Management== | ==Management== | ||
*IV antibiotics<ref>Guss DA, Oyama LA: Disorders of the Liver and Biliary Tract, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 7. St. Louis, Mosby, Inc., 2010, (Ch) 88: p 1153-1171.</ref> | *IV antibiotics<ref>Guss DA, Oyama LA: Disorders of the Liver and Biliary Tract, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 7. St. Louis, Mosby, Inc., 2010, (Ch) 88: p 1153-1171.</ref> | ||
**Two or more antibiotics | **Two or more antibiotics | ||
***[[Gram Negs]]: third or fourth generation [[cephalosporin]] ([[ceftriaxone]]) or [[aminoglycoside]] | ***[[Special:MyLanguage/Gram Negs|Gram Negs]]: third or fourth generation [[Special:MyLanguage/cephalosporin|cephalosporin]] ([[Special:MyLanguage/ceftriaxone|ceftriaxone]]) or [[Special:MyLanguage/aminoglycoside|aminoglycoside]] | ||
***[[Gram Pos]]: [[penicillin]] for [[streptococcal]] species ([[ampicillin]]) | ***[[Special:MyLanguage/Gram Pos|Gram Pos]]: [[Special:MyLanguage/penicillin|penicillin]] for [[Special:MyLanguage/streptococcal|streptococcal]] species ([[Special:MyLanguage/ampicillin|ampicillin]]) | ||
****For penicillin allergic, use [[fluoroquinolones]] | ****For penicillin allergic, use [[Special:MyLanguage/fluoroquinolones|fluoroquinolones]] | ||
***[[Anaerobes]]: [[metronidazole]] or [[clindamycin]] | ***[[Special:MyLanguage/Anaerobes|Anaerobes]]: [[Special:MyLanguage/metronidazole|metronidazole]] or [[Special:MyLanguage/clindamycin|clindamycin]] | ||
*Diagnostic aspiration and drainage of the [[abscess]] followed by placement of drainage catheter | *Diagnostic aspiration and drainage of the [[Special:MyLanguage/abscess|abscess]] followed by placement of drainage catheter | ||
**Sonographic guidance for small or superficial abscesses | **Sonographic guidance for small or superficial abscesses | ||
**CT guidance for deep or multiple abscesses | **CT guidance for deep or multiple abscesses | ||
| Línea 63: | Línea 90: | ||
**Failure of percutaneous aspiration and drainage | **Failure of percutaneous aspiration and drainage | ||
**Coexistence of inra-abdominal disease that requires surgical management | **Coexistence of inra-abdominal disease that requires surgical management | ||
==Disposition== | ==Disposition== | ||
*Admit for IV [[antibiotics]] and surgical drainage | |||
*Admit for IV [[Special:MyLanguage/antibiotics|antibiotics]] and surgical drainage | |||
==See Also== | ==See Also== | ||
*[[Right upper quadrant abdominal pain]] | |||
*[[Amebiasis]] | *[[Special:MyLanguage/Right upper quadrant abdominal pain|Right upper quadrant abdominal pain]] | ||
*[[Special:MyLanguage/Amebiasis|Amebiasis]] | |||
==References== | ==References== | ||
<references/> | <references/> | ||
[[Category:GI]] | [[Category:GI]] | ||
[[Category:ID]] | [[Category:ID]] | ||
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Revisión actual - 22:59 4 ene 2026
Background
Bile duct and pancreas anatomy. 1. Bile ducts: 2. Intrahepatic bile ducts; 3. Left and right hepatic ducts; 4. Common hepatic duct; 5. Cystic duct; 6. Common bile duct; 7. Sphincter of Oddi; 8. Major duodenal papilla; 9. Gallbladder; 10-11. Right and left lobes of liver; 12. Spleen; 13. Esophagus; 14. Stomach; 15. Pancreas: 16. Accessory pancreatic duct; 17. Pancreatic duct; 18. Small intestine; 19. Duodenum; 20. Jejunum; 21-22: Right and left kidneys.
- Uncommon overall - usually occurs in right liver lobe
- More abscesses → more severe disease
- History of camping is common
- Endemic of Midwest
Types
- Pyogenic (80%)
- Most common cause
- Associated with biliary tract obstruction (most common), cholangitis, diverticulitis, pancreatic abscess, appendicitis and inflammatory bowel disease.
- Possible arterial hematogenous seeding: sepsis, direct trauma or instrumentation
- Usually polymicrobial
- Amebic (10%)
- E. histolytica most common
- Usually not septic and sick, rarely needs drainage
- Fungal (<10%), candidal
- Hydatid cyst (echinococcosis)
- Associated with sheep farmers
Clinical Features
- RUQ pain
- High fever
- Nausea, vomiting, anorexia
- Clay-colored stool
- Dark urine
- Jaundice - seen with pyogenic, as opposed to amebic[1]
- Often with right pleural effusions
Differential Diagnosis
Hepatic abscess
- Pyogenic abscess
- Aerobic: Escherichia coli, Klebsiella, Pseudomonas
- Anaerobic: Enterococcus, bacteroides, anaerobic streptococci
- Echinococcosis
- Amebiasis
- Benign cysts/malignancy
- Tuberculosis
- Mycosis
RUQ Pain
- Gallbladder disease
- Pancreatitis
- Acute hepatitis
- Pancreatitis
- GERD
- Appendicitis (retrocecal)
- Pyogenic liver abscess
- Bowel obstruction
- Cirrhosis
- Budd-Chiari syndrome
- GU
- Other
- Hepatomegaly due to CHF
- Peptic ulcer disease with or without perforation
- Pneumonia
- Herpes zoster
- Myocardial ischemia
- Pulmonary embolism
- Abdominal aortic aneurysm
Evaluation
Work-up
- CBC - Elevated white blood count (70-80%)
- BMP
- LFTs - Elevated alkaline phosphatase levels (90%)
- Coags
- Blood cultures
- Amebic and echinococcal serologies
- Ultrasound (80-100% sensitivity)
- CT abd/pelvis (Imaging study of choice)
- Triphasic CT scan to define the proximity of the abscess to the major branches of the portal and hepatic veins
Evaluation
- Diagnosis usually made on imaging studies
Management
- IV antibiotics[2]
- Two or more antibiotics
- Gram Negs: third or fourth generation cephalosporin (ceftriaxone) or aminoglycoside
- Gram Pos: penicillin for streptococcal species (ampicillin)
- For penicillin allergic, use fluoroquinolones
- Anaerobes: metronidazole or clindamycin
- Two or more antibiotics
- Diagnostic aspiration and drainage of the abscess followed by placement of drainage catheter
- Sonographic guidance for small or superficial abscesses
- CT guidance for deep or multiple abscesses
- Surgical drainage
- Abscesses > 5cm
- Abscesses not amenable to percutaneous drainage due to location
- Failure of percutaneous aspiration and drainage
- Coexistence of inra-abdominal disease that requires surgical management
Disposition
- Admit for IV antibiotics and surgical drainage
See Also
References
- ↑ Oyama LC. Disorders of the Liver and Biliary Tract, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 8. St. Louis, Mosby, Inc., 2013, (Ch) 90: p 1186-1205.
- ↑ Guss DA, Oyama LA: Disorders of the Liver and Biliary Tract, in Marx JA, Hockberger RS, Walls RM, et al (eds): Rosen’s Emergency Medicine: Concepts and Clinical Practice, ed 7. St. Louis, Mosby, Inc., 2010, (Ch) 88: p 1153-1171.