Therapy of Liver Abscesses

Abstract

Background: Liver abscess (LA) is an uncommon but potentially life-threatening disease with significant morbidity and mortality.

Methods: This review comprehensively describes epidemiology, pathogenesis, diagnosis, and treatment of LA, with a strong focus on antimicrobial treatment choices and the impact of multidrug-resistant pathogens.

Results: In industrialized areas, pyogenic liver abscess (PLA) accounts for over 80% of the cases, whereas Entamoeba histolyticais responsible for up to 10% of the cases, with a higher incidence in tropical areas. Highly virulent strains of Klebsiella pneumoniaehave emerged as a predominant cause of PLA in Asian countries and tend to spread to the USA, Australia, and European countries, therefore requiring special alertness. Most common symptoms of LA are fever, chills, and right upper quadrant abdominal pain, although a broad spectrum of non-specific symptoms may also occur.

Conclusion: Imaging studies (ultrasound, computed tomography scan) and microbiological findings play a crucial role in the diagnosis of LA. The treatment of choice for PLA is a multimodal approach combining broad-spectrum antibiotics and aspiration or drainage of larger abscess cavities. Amebic LA can be cured by metronidazole therapy without drainage.

Keywords: Amebic liver abscess; Antibiotics; Aspiration; Drainage; Entamoeba histolytica; Klebsiella pneumoniae; Liver abscess; Multidrug-resistant pathogens; Pyogenic liver abscess.

Fig. 1

CT imaging of a large amebic LA in the right lobe of the liver.

Fig. 2

Ultrasound morphology of LA (B mode): PLA frequently show an inhomogeneous hypoechoic pattern (A) with a thickened, edematous wall (B, arrow). Blurred, irregular borders (C) and septa (D) can also be observed. Morphology cannot discriminate between pyogenic (A, B, D) and amebic (C) abscesses.

Fig. 3

Creamy brownish aspiration fluid of a PLA, together with small traces of blood (A, B).

Fig. 4

Pink-colored aspiration fluid from a large amebic LA in a 46-year-old patient returning from an 8-week backpacking trip to India (courtesy Prof. Stefan Schubert, Leipzig University Hospital, Germany).

Fig. 5

Repeated ultrasound imaging shows successful treatment of a PLA in the right lobe of the liver in a 54-year-old male patient: Under combined treatment with needle aspiration and antibiotics a ‘meltdown’ (A-D) of the abscess (initial size: 4.0 × 2.9 cm) could be demonstrated within 4 weeks.

Fig. 6

Material for interventional therapy of LA: For drainage, a pigtail catheter (2) is placed into the abscess cavity using a guide needle (3). An adaptor (1) connects the catheter with a drainage bag (7). Alternatively, different fine needle types (4-6) can be used for aspiration of liquid abscess content.