Liver abscesses and hydatid disease

doi:10.1136/bmj.322.7285.537

Search all BMJ education articles:

From

Limit by

The BMJ iPad app brings you the best of print and online, including live links to the latest news, blogs, video, and podcasts. Get the BMJ iPad app.
You can use bmj.com to help you with your continuing medical education. Find out about CME/CPD credits for BMJ articles
Rapid responses are electronic letters to the editor and new ones are published each day. Read latest responses.

Access to the full text of this article requires a subscription or payment. Please log in or subscribe below.

J E J Krige,
I J Beckingham

Liver abscesses are caused by bacterial, parasitic, or fungal infection. Pyogenic abscesses account for three quarters of hepatic abscess in developed countries. Elsewhere, amoebic abscesses are more common, and, worldwide, amoebae are the commonest cause.

Pyogenic liver abscesses

Aetiology

Most pyogenic liver abscesses are secondary to infection originating in the abdomen. Cholangitis due to stones or strictures is the commonest cause, followed by abdominal infection due to diverticulitis or appendicitis. In 15% of cases no cause can be found (cryptogenic abscesses). Compromised host defences have been implicated in the development of cryptogenic abscess and may have a role in the aetiology of most hepatic abscesses. Diabetes mellitus has been noted in 15% of adults with liver abscesses.

Typical features of pyogenic liver abscess

Right upper quadrant pain and tenderness
Nocturnal fevers and sweats
Anorexia and weight loss
Raised right hemidiaphragm in chest radiograph
Raised white cell count and erythrocyte sedimentation rate with mild anaemia

Origins and causes of pyogenic liver abscess

Biliary tract

Gall stones

Cholangiocarcinoma

Strictures
Portal vein

Appendicitis

Diverticulitis

Crohn's disease
Hepatic artery

Dental infection

Bacterial endocarditis
Direct extension of:

Gall bladder empyema

Perforated peptic ulcer

Subphrenic abscess
Trauma
Iatrogenic

Liver biopsy

Blocked biliary stent
Cryptogenic
Secondary infection of liver cyst

Microbiology

Most patients presenting with pyogenic liver abscesses have a polymicrobial infection usually with Gram negative aerobic and anaerobic organisms. Most organisms are of bowel origin, with Escherichia coli, Klebsiella pneumoniae, bacteroides, enterococci, anaerobic streptococci, and microaerophilic streptococci being most common. Staphylococci, haemolytic streptococci, and Streptococcus milleri are usually present if the primary infection is bacterial endocarditis or dental sepsis. Immunosuppression as a result of AIDS, intensive chemotherapy, and transplantation has increased the number of abscesses due to fungal or opportunistic organisms.

Clinical features

The classic presentation is with abdominal pain, swinging fever, and nocturnal sweating, vomiting, anorexia, malaise, and weight loss. The onset may be insidious or occult in elderly people, and patients may present …