The geriatric nutritional risk index independently predicts adverse outcomes in patients with pyogenic liver abscess

Background

Geriatric nutritional risk index (GNRI) is a simple and useful nutritional marker for predictor of adverse outcomes in patients undergoing a variety of conditions. This study explored the relationship between GNRI and adverse outcomes of Pyogenic Liver Abscess (PLA) patients and assessed GNRI predictive value.

Methods

This was one retrospective study involving 240 PLA patients. According to one GNRI cutoff value of 90, the patients were divided into two groups. Besides, demographic, laboratory, adverse outcomes were compared between the two groups. Multivariate logistic regression analyses and receiver-operating characteristic (ROC) curve analysis were performed.

Results

Compared with high GNRI patients, those with low GNRI had a higher risk of mortality (13.4% vs. 2.0%, P = 0.002), metastatic infection (17.7% vs. 8.2%, P = 0.050), acute hepatic failure (6.8% vs. 1.0%, P = 0.036), acute respiratory failure (7.4% vs. 1.0%, P = 0.024), upper gastrointestinal (UGI) bleeding (11.9% vs. 2.1%, P = 0.006) and empyema (20.1% vs. 10.2%, P = 0.047). Multivariate logistic regression analysis demonstrated GNRI (< 90) as one independent factor in death prediction (odds ratio (OR) = 5.36, 95% of confidence interval (CI) = 1.17–24.48), and adverse outcomes (OR = 2.04, 95% CI = 1.05–3.98). GNRI had the largest area under receiver operating characteristic (ROC) curve than albumin, BMI, platelet, prothrombin time and hemoglobin in death prediction (area under ROC curves (AUC) = 0.771, cutoff value = 79.45, P < 0.01) and all adverse outcomes (AUC = 0.656, cutoff value = 87.43, P < 0.01).

Conclusions

Lower levels of GNRI are an independent risk factor for poor PLA prognosis. Physicians should consider GNRI for PLA outcomes and consider more careful resuscitation and timely and appropriate treatment, especially in those with GNRI< 87.43.

A comparison of pyogenic liver abscess in patients with or without diabetes: a retrospective study of 246 cases

Background

Pyogenic liver abscess(PLA) has become common in patients with diabetes mellitus (DM), but it is unclear whether differences exist between patients with and without DM. A retrospective study was performed to identify these differences, summarize the clinical experience, and improve the diagnosis and treatment of PLA.

Methods

The patients were enrolled in a teaching hospital from January 2012 to December 2016. The patients were separated into two groups based on comorbidity with diabetes mellitus (DM). The DM group was further separated into two subgroups according to the HbA1C concentration to investigate whether glycaemic control affected the clinical characteristics of PLA patients with DM. Chi-square, Fisher’s exact test, and t-tests were used to analyse and evaluate differences between the two groups.

Results

Two hundred and forty-six PLA patients were identified and 90 (36.6%) had comorbid DM. Patients with DM were older, had higher levels of alkaline phosphatase and γ-glutamyl transferase, hypertension, a loss of body weight, a single abscess, and combined antibiotic therapy with the use of carbapenems and Klebsiella pneumoniae in their blood cultures but a less frequent history of abdominal surgery and Escherichia coli in their pus cultures. When DM patients were compared to non-DM patients, each of these differences was significant (P < 0.05). Diabetic PLA patients with poor glycaemic control had a significantly higher proportion of fever and both lobes abscess(P < 0.05).

Conclusion

PLA patients with diabetes are older, have more serious complications, a higher prevalence of cardiovascular disease, an increased use of combined antibiotic therapy with carbapenem, and K. pneumoniae as the predominant pathogen, but these patients had fewer abdominal surgeries and fewer E. coli infections. In addition, poorly controlled glycaemia in diabetic PLA patients is associated with high incidence of fever and both lobes abscess.

Atherosclerosis of the right posterior hepatic artery in a patient with hilar cholangiocarcinoma undergoing left trisectionectomy: a case report of a therapeutic pitfall

BACKGROUND

We experienced a rare case of benign arterial stricture of the right posterior hepatic artery (RPHA) caused by atherosclerosis in a patient with hilar cholangiocarcinoma.

CASE PRESENTATION

A 75-year-old man was referred to our hospital for the detailed investigation of serum hepatobiliary enzyme elevation. The patient had a history of hypertension, type 2 diabetes mellitus, and an operative history of coronary artery bypass grafting 10 years before. Endoscopic retrograde cholangiography found strictures of the right and left hepatic ducts with involvement of right anterior and posterior bile ducts. Adenocarcinoma was evident by brush cytology. We diagnosed these findings as hilar cholangiocarcinoma and planned left trisectionectomy including bile duct reconstruction. Although the tumor and RPHA were not adjacent, preoperative multidetector computed tomography revealed a stricture of the RPHA that was 5.6 mm in length. We suspected that atherosclerosis caused the stricture, and we performed digital subtraction angiography and intravascular ultrasonography that showed stricture of the RPHA accompanied by thick plaques in the arterial wall. We placed a bare-metal stent in the RPHA and then performed left trisectionectomy. Since this patient developed bile leakage postoperatively, percutaneous drainage was performed. The bile leakage was successfully controlled, and the patient was discharged 3 months after surgery. Unfortunately, 4 months after hepatectomy, he was re-hospitalized with multiple pyogenic liver abscesses. We performed intensive multimodal treatment for the liver abscesses and stabilized the disease; however, we eventually lost this patient due to liver failure 14 months after surgery.

CONCLUSION

To the best of our knowledge, there is no previous literature on atherosclerosis of the RPHA, which was evident preoperatively in our case. Because arterial complications may lead to critical biliary complications in patients who undergo left trisectionectomy, we first performed prophylactic arterial stent placement. We speculate that existing chronic microscopic injury of the peribiliary plexus might have caused the liver abscesses. We successfully diagnosed atherosclerosis of the RPHA preoperatively. However, further investigation of patients is warranted to determine if left trisectionectomy is contraindicated in these patients.

Hepatic Abscess Secondary to Stomach Perforation by a Fish Bone: a Rare Cause of Hepatic Abscess

Gastrointestinal foreign bodies are commonly encountered in clinical practice. However, although perforation of the gastrointestinal tract by a foreign body is not unusual, the formation of a hepatic abscess as a result of the migration of a foreign body is extremely rare. Patients usually present with atypical symptoms, and the treatment of such pyogenic liver abscesses presents a challenge. Here we report a case of hepatic abscess secondary to stomach perforation by a fish bone.

Bilateral osteomyelitis and liver abscess caused by hypervirulent Klebsiella pneumoniae- a rare clinical manifestation (case report)

Background

Hypervirulent strains of Klebsiella pneumoniae are a recognized cause of a distinct invasive syndrome that results in pyogenic liver abscesses and metastatic complications, particularly in the Asia Pacific region. Reports of hypervirulent K.pneumoniae in Europe, the Americas and Australia indicate worldwide spread. We present a case of multi-focal osteomyelitis, a rarely described complication of hypervirulent K.pneumoniae in the medical literature. The prevalence of this condition in countries outside Asia may be expected to rise with increasing travel.

Case presentation

A 20-year-old Chinese man residing in Australia for 2 years presented with a 2-week history of gradually worsening leg pain preceded by 2 weeks of constitutional symptoms. Imaging with computerized axial tomography (CT) and other modalities revealed bilateral tibial lesions described as lattice-like linear lucencies involving the cortices with scalloping of the outer involved cortex. Cultures of tissue from a left tibial bone biopsy were positive cultures for K.pneumoniae. Whole-genome sequencing identified the isolate as K1 serotype ST23, a well-recognized hyper virulent strain capable of causing invasive disease. An abdominal CT revealed a 27x22mm liver abscess. The patient had no other metastatic manifestations of the disease, and responded to 6 weeks of intravenous ceftriaxone followed by 3 months of oral Ciprofloxacin.

Conclusions

Increased awareness of the manifestations and subsequent management of hyper virulent strains of K.pneumoniae by clinicians is important to assist early recognition and help minimize serious sequelae. Cases with overseas links, such as previous residence in the Asia Pacific area, are at higher risk for infection with the hyper virulent strain. This case highlights the need for clinicians to be able to recognize this important disease, especially in patients with the right epidemiological links, and to investigate and treat appropriately to prevent severe metastatic complications.

Pyogenic liver abscess after laparoscopic sleeve gastrectomy

An infected material in the gastrosplenic area after laparoscopic sleeve gastrectomy (LSG) due to hematoma or staple line leak has the potential to spread of the bacterial content to the liver which can result in pyogenic liver abscess. Presently described is a thirty-seven-year-old female patient with unilocular pyogenic liver abscess two weeks after LSG. The abscess resolved by Ultrasound guided percutaneous drainage plus intravenous antibiotic treatment. Review of the literature regarding 3 other cases with liver abscess after LSG is also presented.

Liver Abscess due to Streptococcus constellatus in an Immunocompetent Adult: A Less Known Entity

BACKGROUND

Pyogenic liver abscesses (PLAs) are an uncommon, but potentially life threatening infection. We report a case of PLA due to Streptococcus constellatus, a member of the Streptococcus anginosus group (SAG) bacteria, commonly found as commensals of the oropharyngeal, gastrointestinal and genitourinary flora.

CASE

The patient, a 42-year-old man with no premorbidities, non-smoker and non-alcoholic, presented to our hospital with high-grade fever associated with chills and rigors and right upper quadrant pain of one month duration. Culture of the ultrasound-guided liver aspirate yielded a pure growth of S. constellatus subspecies constellatus identified by conventional biochemical tests. In a standard antimicrobial disk-diffusion test, the isolate was susceptible to cefepime, cefotaxime, ceftriaxone, vancomcyin, levofloxacin, clindamycin and linezolid. Treatment with parenteral ceftriaxone alongwith appropriate surgical management led to resolution of the abscess with no recurrence of infection at three months follow-up.

CONCLUSIONS

The pathogenic potential of SAG has generally been disregarded because of the commensal nature of these microorganisms; however, streptococci belonging to this group have been increasingly reported as relevant pathogens in abscesses and blood cultures. An underlying condition, such as diabetes, cirrhosis or cancer or some medical manipulation, such as dental extraction, acupuncture, or hemorrhoidectomy is associated with the majority of patients with SAG abscess. However, the present case highlights the need to include S. constellatus and other members of the SAG while investigating for etiology of PLA, even in immunocompetent adults.

Clostridium paraputrificum septicemia and liver abscess

We report the first case of a healthy 23-year-old female who underwent an interventional radiology-guided embolization of a hepatic adenoma, which resulted in a gas forming hepatic liver abscess and septicemia by Clostridium paraputrificum. A retrospective review of Clostridial liver abscesses was performed using a PubMed literature search, and we found 57 clostridial hepatic abscess cases. The two most commonly reported clostridial species are C. perfringens and C. septicum (64.9% and 17.5% respectively). C. perfringens cases carried a mortality of 67.6% with median survival of 11 h, and 70.2% of the C. perfringens cases experienced hemolysis. All C. septicum cases were found to have underlying liver malignancy at the time of the presentation with a mortality of only 30%. The remaining cases were caused by various Clostridium species, and this cohort’s clinical course was significantly milder when compared to the above C. perfringens and C. septicum cohorts.

Neutrophil-to-lymphocyte ratio as a feasible prognostic marker for pyogenic liver abscess in the emergency department

PURPOSE

The neutrophil-to-lymphocyte ratio (NLR) is an effective predictor of mortality in patients with for various conditions. To date, there are no previous studies on NLR as a prognostic marker for pyogenic liver abscess (PLA), especially on admission to the emergency department (ED).

METHODS

From January 2013 to December 2015, 102 patients diagnosed with PLA in the ED were included. Clinico-radiological and laboratory results, including NLR, were evaluated as variables. NLR was calculated as absolute neutrophil count/absolute lymphocyte count. To evaluate the prognosis of PLA, data on hospital mortality, intensive care unit (ICU) admission, and development of septic shock were obtained. Multivariate logistic regression analyses and receiver-operating characteristic (ROC) curve analysis were performed.

RESULTS

Among 102 patients, 10 (9.8%) died, 14 (13.7%) were admitted to the ICU, and 15 (14.7%) developed septic shock during hospitalization. Multivariate logistic regression analysis revealed NLR as an independent factor in predicting death [odds ratio (OR), 1.4; p = 0.020], ICU admission (OR, 1.4; p = 0.021), and development of septic shock (OR, 1.6; p = 0.041). NLR showed an excellent predictive performance for death (areas under the ROC curves [AUC], 0.941; cut-off value, 19.7; p < 0.001), ICU admission (AUC, 0.946; cut-off value, 16.9; p < 0.001), and development of septic shock (AUC, 0.927; cut-off value, 16.9; p < 0.001).

CONCLUSION

NLR was positively associated with poor prognosis of PLA; elevated NLR could predictor of high risk of death, ICU admission, and development of septic shock. Emergency physicians should consider NLR for the prognosis of PLA and early aggressive treatment, especially in patients with NLR > 16.9.

Increased risk of pyogenic liver abscess in patients with alcohol intoxication: A population-based retrospective cohort study

We designed a population-based retrospective cohort study to investigate the association between the event of alcohol intoxication and the risk of pyogenic liver abscess. The present study enrolled 245,076 patients with a history of alcohol intoxication from 2000 to 2010 and matched each of them with four comparison patients, with similar mean age and sex ratios. We determined the cumulative incidences and adjusted hazard ratios (aHRs) of liver abscess. A significant association was observed between alcohol intoxication and liver abscess. The incidence density rate of liver abscess was 3.47-fold greater in the alcohol intoxication (AI) cohort than in the non-AI cohort (12.2 vs. 3.43 per 10,000 person-years), with an adjusted HR (aHR) of 2.64 (95% CI = 2.26 to 3.08). This population-based study positively associated the event of alcohol intoxication with increased risk of liver abscess. Our findings warrant further large-scale and in-depth investigations in this area.

Fusobacterium nucleatum detected simultaneously in a pyogenic liver abscess and advanced sigmoid colon cancer

Fusobacterium nucleatum is an invasive, adherent, and pro-inflammatory anaerobic bacterium involved in various infections and colorectal cancer. We report a case with pyogenic liver abscess, diagnosed with advanced sigmoid colon cancer, in whom F. nucleatum was simultaneously detected. In this patient, F. nucleatum was systematically analyzed using the molecular biological techniques of metagenome analysis, conventional PCR, and microbial fluorescence in situ hybridization.

Are our endoscopy patients at risk for pyogenic liver abscess?

This is an editorial comment on a recent publication reporting an increased rate of pyogenic liver abscesses (PLAs) after upper gastrointestinal panendoscopy. Its aim is to critically highlight the findings, limitations and potential clinical implications of this study. Issues of the mucosal barrier, the microbial flora, administration of antibiotics and underlying diseases are discussed. The probability of PLAs after endoscopies is not exactly known and the length of the “incubation period” remains unclear, but a possible causality should already suffice to make us think how to avoid them. Especially in patients with risk factors such as diabetes mellitus, end-stage renal disease, liver cirrhosis, biliary tract infection, and malignancies, the potential risk for PLAs should be considered. Unnecessary insufflation during endoscopy (causing mucosal stretching and microscopic tears) as well as mucosal damage (by direct abrasion with the scope) should be avoided in order to limit the invasiveness of the procedure as much as possible. And, in everyday routine, it should be kept in mind that in patients after endoscopy, especially in those with a breach of the mucosal barrier and significant comorbidities, PLAs can potentially develop and require timely administration of antibiotics as well as further diagnostic and therapeutic steps.

The prevalence of rectal carriage of Klebsiella pneumoniae amongst diabetic patients and their clinical relevance in Taiwan: A five-year prospective study

BACKGROUND/PURPOSE

Pyogenic liver abscess (PLA) and bacteremia caused by Klebsiella pneumoniae is a common complication among patients with diabetes mellitus (DM). The aim of this study is to investigate the prevalence of rectal carriage and serotype distribution of K. pneumoniae amongst DM patients and their clinical relevance.

METHODS

We prospectively collected rectal swabs for K. pneumoniae culture in asymptomatic DM patients from March 2008 to June 2009. Seven capsular serotypes that were commonly associated with PLA were determined by capsular polysaccharide synthesis (cps) genotyping. Microbiologically confirmed bacterial infections were evaluated 1 and 5 years after initial enrolment of the patients.

RESULTS

A total of 100 male and 62 female patients (mean age, 56.6 years) were enrolled. Of these, 77 (47.5%) had rectal K. pneumoniae colonization. Colonizers were older than non-colonizers (p = 0.03). Sex, fasting blood glucose, and initial HbA1C were not statistically different (p = 0.26, 0.18, and 0.31, respectively). Among the 65 available isolates, 22 (33.8%) belonged to the seven main serotypes. During the 5-year's follow-up, 21 patients developed microbiologically documented bacterial infections but none of them developed PLA and bacteremia. Risk factors for bacterial infection within 5 years included initial glycosylated hemoglobin (HbA1C) > 10% or first-year average HbA1C > 10%.

CONCLUSION

Although nearly half of asymptomatic DM patients had rectal carriage of K. pneumoniae and one-third of them colonized by isolates belonging to the seven serotypes related to PLA, none of them subsequently developed PLA and colonized patients did not have higher risk of microbiologically confirmed bacterial infections.

and multidrug-resistant bacteria causing pyogenic liver abscesses

Background

Pyogenic liver abscesses (PLA) remain a significant clinical problem. Unfortunately, little is known about current bacterial susceptibility profiles and the incidence of multidrug resistant organisms (MDROs) causing PLA in Western countries. Yet, this crucial information is pivotal to guide empirical antibiotic therapy. Aim of this study was to provide detailed characteristics of PLA with a special focus on underlying bacterial pathogens and their susceptibility to antibiotics.

Methods

A retrospective study of patients diagnosed with PLA from 2009 to 2015 in a large tertiary reference center in Germany was performed in order to characterize PLA and antimicrobial susceptibility profiles of causative bacterial species.

Results

Overall, 86 patients were included. The most common causes of PLA were bile duct stenosis/obstruction (31.4%) and leakage of biliary anastomosis (15.1%). Frequent predisposing diseases were malignancies (34.9%), diabetes (24.4%) and the presence of liver cirrhosis (16.3%). Of note, Enterococcus spp. were the most frequently cultured bacterial isolates (28.9%), and in 1/3 of cases vancomycin resistance was observed. In addition, a relevant frequency of gram-negative MDROs was identified. In particular, an alarming 10% and 20% of gram-negative bacteria were resistant to carbapenems and tigecycline, respectively. Of note, MDRO status did not predict ICU stay or survival in multivariate regression analysis. The mortality rate in our series was 16.3%.

Conclusion

Our study demonstrates an as yet underreported role of Enterococcus spp., often associated with vancomycin resistance, as well as of gram-negative MDROs causing PLA.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-017-2543-1) contains supplementary material, which is available to authorized users.

Predictors of septic shock in initially stable patients with pyogenic liver abscess

OBJECTIVES

The incidence of pyogenic liver abscess (PLA), a life-threatening condition, is increasing worldwide. This study was designed to evaluate clinical features and outcomes in initially stable patients with PLA and to determine the predictors of septic shock.

METHODS

The medical records of all adult patients who were hemodynamically stable and diagnosed with PLA in the emergency department from January 2010 to December 2014, inclusive, were reviewed. The primary outcome was septic shock.

RESULTS

A review of medical records identified 453 patients (66.7% male), of mean age 61.4 years, diagnosed with PLA. Of these patients, 73 (16.1%) had septic shock and 10 (2.2%) died in-hospital. Of the 73 patients with septic shock, nine (12.3%) died in-hospital. The most common symptom was fever (79.5%), and the most common infectious agent was Klebsiella pneumoniae. Septic shock was significantly associated with age ≥60 years [odds ratio (OR): 2.99, 95% confidence interval (CI): 1.38-6.48], malignancy (OR: 2.11, 95% CI: 1.08-4.09), systolic blood pressure <100 mmHg (OR: 3.63, 95% CI: 1.43-9.21), respiratory rate ≥24/min (OR: 3.15, 95% CI: 1.20-8.28) and lactate concentration ≥2 mmol/L (OR: 4.92, 95% CI: 2.51-9.64). Septic shock also tended to be associated with procalcitonin concentration, but this was not statistically significant (OR: 3.42, 95% CI: 0.96-12.18).

CONCLUSIONS

Septic shock was frequent in initially stable patients with PLA and was associated with older age, malignancy, low blood pressure, tachypnea and elevated lactate concentration.

Recent upper gastrointestinal panendoscopy increases the risk of pyogenic liver abscess

AIM

To investigate the association between a recent gastrointestinal (GI) endoscopy and the subsequent risk of pyogenic liver abscess (PLA).

METHODS

We designed a nested case control study. Using the Taiwan National Health Insurance Research Database, 2135 patients with a first diagnosis of PLA were identified from 1998 to 2011. Another 10675 patients without PLA matched by age and sex were selected as reference controls. We identified and compared the possible risk factors for PLA and GI endoscopies performed before the index date (when PLA was diagnosed) between the two cohorts. Multivariate analysis was conducted to examine the risk of PLA within the 90 d after the GI endoscopies.

RESULTS

Patients with a history of diabetes [adjusted odds ratio (aOR) = 4.92, 95%CI: 1.78-13.61], end-stage renal disease (aOR = 3.98, 95%CI: 1.45-10.91), biliary tract infection (aOR = 2.68, 95%CI: 2.11-3.40), liver cirrhosis (aOR = 2.19, 95%CI: 1.39-3.46), GI malignancies (aOR = 5.68, 95%CI: 4.23-7.64), appendicitis (aOR = 3.16, 95%CI: 2.27-4.41), diverticulitis (aOR = 1.64, 95%CI: 1.01-2.64), and recent endoscopic retrograde cholangiopancreatography (aOR = 27.04, 95%CI: 11.65-62.72) were significantly associated with an increased risk of PLA. After adjusting for the above risk factors and the frequency of outpatient department visits and abdominal ultrasounds during 90 d before the index date, an upper GI panendoscopy (aOR = 2.75, 95%CI: 2.05-3.69) but not a lower GI endoscopy (aOR = 1.07, 95%CI: 0.62-1.86) was significantly associated with PLA.

CONCLUSION

An upper GI panendoscopy performed before 90 d may increase the risk of PLA.

Correlation between proton pump inhibitors and risk of pyogenic liver abscess. Eur J Clin Pharmacol. 2017;73:1019-1025. [PMID: 28434021 DOI: 10.1007/s00228-017-2256-9]

BACKGROUND/OBJECTIVE

Little is known about the relationship between proton pump inhibitors use and pyogenic liver abscess. The objective of this study was to evaluate the correlation between proton pump inhibitors use and pyogenic liver abscess in Taiwan.

METHODS

This was a population-based case-control study using the database of the Taiwan National Health Insurance Program since 2000 to 2011. Subjects aged 20 to 84 who experienced their first episode of pyogenic liver abscess were enrolled as the case group (n = 1372). Randomly selected subjects aged 20 to 84 without pyogenic liver abscess were enrolled as the control group (n = 1372). Current use, early use, and late use of proton pump inhibitors was defined as subjects whose last one tablet for proton pump inhibitors was noted ≤30 days, between 31 to 90 days and ≥91 days before the date of admission for pyogenic liver abscess. Subjects who never received a prescription for proton pump inhibitors were defined as nonusers of proton pump inhibitors. A multivariable unconditional logistic regression model was used to measure the odds ratio and 95% confidence interval to evaluate the correlation between proton pump inhibitors use and pyogenic liver abscess.

RESULTS

After adjusting for confounders, the adjusted odds ratio of pyogenic liver abscess was 7.59 for subjects with current use of proton pump inhibitors (95% confidence interval 5.05, 11.4), when compared with nonusers.

CONCLUSIONS

Current use of proton pump inhibitors is associated with a greater risk of pyogenic liver abscess.

Predictors of Mortality in Korean Patients with Pyogenic Liver Abscess: A Single Center, Retrospective Study

BACKGROUND/AIMS

The mortality rate of pyogenic liver abscess (PLA) has decreased dramatically, but it remains a potentially life threatening disease. Most cases are cryptogenic or occur in elderly men with underlying biliary tract disease. Although several studies have addressed the characteristics and etiology of PLA, research on factors affecting PLA-associated mortality is lacking. This study intended to identify the clinical and radiological features, pathogens, complications, and predictors of mortality in Korean PLA patients.

METHODS

The medical records of 231 PLA patients diagnosed at Yeungnam University Medical Center between January 2010 and January 2014 were analyzed. A diagnosis of PLA was made based on imaging studies and blood and abscess cultures. The clinical, radiological, and laboratory findings of patients were analyzed.

RESULTS

The mean patient age was 64.0±12.9 years and the male to female ratio was 1.5:1. Klebsiella pneumoniae was the predominant organism isolated from hepatic abscesses (69.9%) and blood (74.2%). The most common complication was pleural effusion (35.8%) and most common co-infection was cholangitis (8.2%). The overa ll mortality rate of PLA was 6.9% (16/231), and was significantly higher in patients with a history of liver abscess (OR 5.970, 95% CI 1.207-29.529; p=0.028), bilirubinemia (>2 mg/dL) (OR 9.541, 95% CI 2.382-38.216; p=0.001), thrombocytopenia (< 140×10(3)/L) (OR 4.396, 95% CI 1.130-17.106; p=0.033), or anemia (< 12 g/dL) (OR 13.277, 95% CI 1.476-119.423; p=0.021).

CONCLUSIONS

The prognosis of PLA appears to be dependent on underlying pathologies and severity of condition. More aggressive treatment should be considered if a poor prognosis is expected.

Herpes zoster correlates with pyogenic liver abscesses in Taiwan

OBJECTIVE

The purpose of the paper was to explore the relationship between herpes zoster and pyogenic liver abscesses in Taiwan.

METHODS

This was a nationwide cohort study. Using the database of the Taiwan National Health Insurance Program, there were 33049 subjects aged 20-84 years who were newly diagnosed with herpes zoster from 1998 to 2010 that were selected for our study, and they were our herpes zoster group. 131707 randomly selected subjects without herpes zoster were our non-herpes zoster group. Both groups were matched by sex, age, other comorbidities, and the index year of their herpes zoster diagnosis. The incidence of pyogenic liver abscesses at the end of 2011 was then estimated. The multivariable Cox proportional hazard regression model was used to estimate the hazard ratio and 95% confidence interval for pyogenic liver abscesses associated with herpes zoster and other comorbidities.

RESULTS

The overall incidence rate was 1.38-fold higher in the herpes zoster group than in the non-herpes zoster group (4.47 vs. 3.25 per 10000 person-years, 95% confidence interval 1.32, 1.44). After controlling for potential confounding factors, the adjusted hazard ratio of pyogenic liver abscesses was 1.34 in the herpes zoster group (95% confidence interval 1.05, 1.72) when compared with the non-herpes zoster group. Sex (in this case male), age, presence of biliary stones, chronic kidney diseases, chronic liver diseases, cancers, and diabetes mellitus were also significantly associated with pyogenic liver abscesses.

CONCLUSIONS

Patients with herpes zoster are associated with an increased hazard of developing pyogenic liver abscesses.

Clostridium difficile: A rare cause of pyogenic liver abscess

Extra-intestinal infections due to Clostridium difficile have been reported rarely. Herein we report a case of pyogenic liver abscess from toxigenic C. difficile in an 80-year-old non-hospitalized woman with diabetes mellitus, cerebrovascular and cardiovascular diseases. The patient was admitted to the emergency department with fever and abdominal pain. There was no history of diarrhea or use of antibiotics. Laboratory parameters revealed signs of inflammation and elevated AST and ALT levels. Abdominal ultrasound and computer tomography showed multiple focal lesions in the bilateral liver lobes and hydropic gallbladder with stones. The patient underwent cholecystectomy and the liver abscesses were drained. Toxigenic C. difficile strains were isolated from the drained pus and also from the stool sample. According to repetitive-element PCR (rep-PCR) analyses both organisms were the same. The organisms were susceptible to antibiotics. Despite proper antibiotic therapy and surgical drainage, the patient succumbed to her illness.

Abdominal wall abscess secondary to spontaneous rupture of pyogenic liver abscess

INTRODUCTION

Pyogenic liver abscess is a rare cause of hospitalization, related to a mortality rate ranging between 15% and 19%. Treatment of choice is represented by image-guided percutaneous drainage in combination with antibiotic therapy but, in some selected cases, surgical treatment is necessary. In extremely rare cases, spontaneous rupture of liver abscess may occur, free in the peritoneal cavity or in neighboring organs, an event which is generally considered a surgical emergency.

PRESENTATION OF CASE

A 95-years-old woman was hospitalized with fever, upper abdominal pain, mild dyspepsia and massive swelling of the anterior abdominal wall. Computed tomography revealed an oval mass located in the abdominal wall of 12cm×14cm×7cm, in continuity with an abscess of the left hepatic lobe. Because Proteus mirabilis was detected in both the liver abscess and the abdominal wall abscess, the patient was diagnosed with a ruptured pyogenic liver abscess. After spontaneous drainage to the exterior of the hepato-parietal abscess, she was successfully treated with antibiotics alone.

CONCLUSION

Pyogenic liver abscess is a serious and life-threatening illness. Abscess rupture might occur. Many authors consider this complication a surgical emergency, but the site of abscess rupture changes the clinical history of the disease: in case of free rupture into the peritoneum, emergency surgery is mandatory, while a rupture localized in neighboring tissues or organs can be successfully treated by a combination of systemic antibiotics and fine needle aspiration and/or percutaneous drainage of the abscess.

Clinical Characteristics and Outcomes of Pyogenic Liver Abscess in Elderly Korean Patients

BACKGROUND/AIMS

Incidence of pyogenic liver abscess (PLA) has been increasing worldwide, especially in the elderly population. Therefore, the aim of this study is to elucidate the clinical features and outcomes of PLA in elderly patients.

METHODS

A total of 602 patients diagnosed with PLA from January 2003 to January 2013 were analyzed retrospectively. The patients were divided according to two age groups;≥ 65 years (n=296) and <65 years (n=306).

RESULTS

The mean age was 73.59 ± 5.98 (range, 65-93) years in the elderly group. Significantly higher incidence of females (52.4% vs. 29.1%, p<0.001), hepatobiliary disease (41.2% vs. 24.8%, p<0.001), hepatobiliary procedure (29.4% vs. 13.7%, p<0.001), underlying malignancy (18.2% vs. 4.6%, p<0.001), culture positivity of resistant organism (20.6% vs. 14.4%, p=0.047), occurrence of complication (19.6% vs. 12.8%, p=0.026), and higher white blood cell (13.44 ± 6.56 vs. 12.26 ± 5.89, p=0.021), but lower rates of right lobe abscess (67.2% vs. 80.4%, p<0.001), fever (68.6% vs. 79.3%, p=0.003), and lower CRP (16.79 ± 9.67 vs. 18.80 ± 9.86, p=0.012) was observed in elderly PLA patients, compared to younger patients. Regarding complications, elderly patients had higher incidence of septic shock (8.1% vs. 2.3%, p=0.001) and cardiovascular disease (2% vs. 0%, p=0.014).

CONCLUSIONS

More atypical presentations and complications tend to occur in elderly PLA patients compared with younger patients. Clinicians should be aware of these age-related differences in PLA and devise management strategies accordingly.

Klebsiella pneumoniae invasive liver abscess syndrome with purulent meningitis and septic shock: A case from mainland China

We present a rare case of invasive liver abscess syndrome due to Klebsiella pneumoniae (K. pneumoniae) with metastatic meningitis and septic shock. A previously healthy, 55-year-old female patient developed fever, liver abscess, septic shock, purulent meningitis and metastatic hydrocephalus. Upon admission, the clinical manifestations, laboratory and imaging examinations were compatible with a diagnosis of K. pneumoniae primary liver abscess. Her distal metastasis infection involved meningitis and hydrocephalus, which could flare abruptly and be life threatening. Even with early adequate drainage and antibiotic therapy, the patient’s condition deteriorated and she ultimately died. To the best of our knowledge, this is the first case of K. pneumoniae invasive liver abscess syndrome with septic meningitis reported in mainland China. Our findings reflect the need for a better understanding of the epidemiology, risk factors, complications, comorbid medical conditions and treatment of this disease.

Percutaneous drainage for giant pyogenic liver abscess--is it safe and sufficient?

BACKGROUND

Large size is a predictor of failure of percutaneous drainage (PD) for pyogenic liver abscess (PLA). This article serves to establish the safety and sufficiency of PD in giant PLA (GPLA).

METHODS

A retrospective review of all GPLA patients treated at a tertiary care academic hospital from 2001 to 2011 was performed. A GPLA is defined as an abscess greater than or equal to 10 cm size based on imaging.

RESULTS

Forty patients (24 men, 60%) were treated for GPLA. All but 1 patient (98%) was managed with PD and the mean duration of drainage was 9 days (range 1 to 23 days). One patient underwent operative drainage. Three patients (7.7%) needed secondary procedures after the initial PD. One patient (2.6%) failed PD and subsequently underwent operative drainage. Among the patients who underwent PD, the overall morbidity was 25%; the median length of hospital stay was 13 days (range 5 to 31 days) and 1 (2.6%) mortality.

CONCLUSIONS

Large size itself is not a contraindication for PD. PD is safe and sufficient even in GPLA patients.

Risk factors, management, and prognosis for liver abscess after radical resection of hilar cholangiocarcinoma

OBJECTIVES

Pyogenic liver abscess (PLA) is a rare but potentially lethal infectious complication after radical surgical resection of hilar cholangiocarcinoma (HC), this study is aimed to identify the risk factors, management and prognosis of PLA after curative surgical resection of HC.

METHODS

Between January 2003 and October 2013, 95 patients who underwent surgical resection of HC at a tertiary center were included in this study. The risk factors pertaining to PLA formation were identified by exact logistic regression.

RESULTS

PLA developed in 8 of 95 patients. The median duration of PLA formation following surgical procedure was 145 days (range, 16-295 days) and the most commonly isolated microorganism was Escherichia coli (4/8). Though most patients who developed PLA after surgery were successfully managed with antibiotics and invasive therapy, the overall survival was statistically poorer than those without PLA formation (median, 16.9 vs. 34.2 months, P=0.048). Univariate analysis revealed that coexisting biliary disorders (37.5% vs. 8.0%, P=0.036), vascular reconstruction (37.5% vs. 9.2%, P=0.041) and margin status (62.5% vs. 21.8%, P=0.023) were associated with PLA formation, whereas only vascular reconstruction (odds ratio (OR), 10.31; 95% confidence interval (CI), 1.03-142.73; P=0.047) and margin status (OR, 8.45; 95% CI, 1.13-109.38; P=0.035) were identified as independent risk factors by multivariate analysis.

CONCLUSIONS

Intraoperative vascular reconstruction and positive margin status pose greater risks for PLA formation after radical resection of HC. For patients with high risk factors, careful follow-up is needed for early detection and management of this infrequent complication.

Two cases of Klebsiella pneumoniae liver abscess necessitating liver resection for effective treatment

We report two British cases of liver abscess, due to Klebsiella pneumoniae and associated with synchronous infection elsewhere, which required liver resection for definitive treatment. They illustrate the geographic spread of aggressive K pneumoniae liver infection and demonstrate the importance of early aggressive treatment.

Inferior vena caval thrombosis complicating pyogenic liver abscess after pancreatoduodenectomy: a case report

Pyogenic liver abscess (PLA) complicated by inferior vena caval (IVC) thrombosis is rare but life-threatening. We experienced a case of PLA complicated by an IVC thrombus close to the right atrium after pancreatoduodenectomy. A 75-year-old man had undergone pancreatoduodenectomy with modified-Child reconstruction for pancreatic cancer 3 years prior, and no recurrence was noted on follow-up. He was admitted to our hospital owing to fever and general fatigue. PLA and septic shock were diagnosed, and conservative therapy with antibiotics was initiated. His general condition gradually improved, but a thrombus in the middle hepatic vein and IVC was noted on follow-up computed tomography on hospital day 8. Although anticoagulant therapy using heparin was started, the thrombus size increase and extended to the right atrium. Considering the risk of pulmonary embolism, we planned a surgical intervention with a cardiovascular surgeon to remove the thrombus. During surgery, we made an incision in the right atrium and removed the thrombus using extracorporeal circulation. After removal, we dissected the middle hepatic vein using an automated suturing device to prevent the thrombus from extending into the IVC. The patient was discharged 10 weeks after surgery. Eighteen months post-intervention, there was no recurrence of either PLA or thrombi. Our experience suggests that physicians should consider the existence of a middle hepatic vein and IVC thrombi when examining PLA patients and that surgical intervention can be applied successfully in such cases.

Therapy of Liver Abscesses

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.

Fusobacterium nucleatum: a rare cause of pyogenic liver abscess

While pyogenic liver abscesses are uncommon, they are associated with significant mortality and morbidity. Most pyogenic liver abscesses are polymicrobial and are caused by enteric bacteria and anaerobes. Rarely, mono-microbial infections may occur, typically in immunocompromised individuals. We report the unusual case of a 69 year-old immunocompetent female who developed a pyogenic liver abscess due to Fusobacterium nucleatum infection, likely from a dental source. Poor oropharyngeal hygiene seems to have a major role in infection from this organism and therefore F. nucleatum should be considered as a differential for causes of pyogenic liver abscess in such patients. Drainage of the abscess and antibiotic therapy are the mainstays of therapy.

Contrast-enhanced ultrasound in different stages of pyogenic liver abscess

To enable sonographic classification of different stages of pyogenic liver abscesses, sonographic findings in 86 patients with 113 pyogenic liver abscesses were retrospectively analyzed and compared with established pathomorphologic descriptions of the disease. The typical findings in contrast-enhanced ultrasound were sub-segmental hyperemia (93/113, 82%) and necrosis with a hyperemic margin (109/113, 96%) in the arterial phase and a washout of liver tissue surrounding necrosis in the late phase (101/113, 89%). Four different sonomorphologic stages of pyogenic liver abscess were identified. Stage I was defined by focal inflammation without necrosis (n = 2); stage II by focal clusters of micro-abscesses appearing to coalesce (n = 41); and stage III by a single cavity with or without capsule (n = 64). Stage IV was defined as numerous small abscesses scattered all over the liver (n = 6). The results indicate that contrast-enhanced ultrasound is suitable for classifying different stages of pyogenic liver abscesses. Knowledge of the described morphologic patterns influences therapeutic decisions and helps distinguish abscesses from other liver masses.

Analysis of clinical and CT characteristics of patients with Klebsiella pneumoniae liver abscesses: an insight into risk factors of metastatic infection

PURPOSE

To compare the clinical and CT characteristics of patients with Klebsiella pneumoniae liver abscess (KPLA), with or without metastatic infection.

MATERIALS AND METHODS

Clinical information (age, sex, clinical symptoms, underlying disease, hematological parameters, abscess-related mortality) and CT characteristics of abscesses were analyzed to investigate associations with metastatic infection. Metastatic infections were divided into septic pulmonary embolism (SPE) and extra-pulmonary metastatic infection (EMI).

RESULTS

We identified 66 consecutive patients with KPLA. Metastatic infection occurred in 22/66 patients (33.3%); 8/66 (12.1%) patients had SPE, 6/66 (9.09%) patients had EMI; and 8/66 (12.1%) patients had both SPE and EMI. Patients with SPE were younger than patients without SPE (47.7±13.7 y vs.55.6±12.0 y; p=0.03). Unilocular abscess was significantly more common in patients with SPE than the non-SPE group (43.75% vs 18.0%, p=0.036). The mean maximal diameter of EMI was 56.5±21.3 mm and was significantly smaller than that of the non-EMI which was 79.9±31.4 (p=0.011). SPE was significantly associated with development of EMI (50% vs 17.3%, p=0.011).

CONCLUSION

Unilocular liver abscess is associated with SPE, and SPE is strongly associated with EMI among patients with KPLA. A maximal diameter of KPLA<55 mm can be used as a predictor of EMI.

Epidemiology and clinical outcome of pyogenic liver abscess: an analysis from the National Health Insurance Research Database of Taiwan, 2000-2011

BACKGROUND

The epidemiology of pyogenic liver abscess continues to change and the issue of antimicrobial therapy is controversial. This study investigated the epidemiology and clinical outcomes of antimicrobial therapy.

METHODS

The annual incidence rates, demographic data, underlying diseases, complications, length of stay, mortality rates, and antimicrobial therapy were analyzed using the data retrieved from the Longitudinal Health Insurance Database 2000, Taiwan, from 2000 to 2011.

RESULTS

The annual incidence of pyogenic liver abscess for all age groups increased gradually in Taiwan from 10.83 per 100,000 person-years in 2000 to 15.45 per 100,000 person-years in 2011. Pyogenic liver abscess occurred more commonly in patients with male sex, of older age (>50 years), and lower family income. Among the 1522 adult patients with pyogenic liver abscess, 537 (35.3%) patients had diabetes mellitus, 165 (10.8%) patients had complications, 234 (15.4%) patients received mechanical ventilation, and 361 (23.7%) patients had a stay in intensive care; the mortality rate was 8.2% (125/1522). There were 426 (28%) patients treated with cefazolin and 158 (10.4%) patients treated with extended-spectrum cephalosporins. There were no statistically significant differences in the length of stay and mortality rates between these two groups (20.2 days vs. 23.1 days; and 7.5% vs. 10.1%, respectively).

CONCLUSION

The clinical outcomes of pyogenic liver abscess treated with cefazolin were comparable to those treated by extended-spectrum cephalosporins. Extended-spectrum cephalosporins should be used for severe complications, such as meningitis and endophthalmitis. Further surveillance of epidemiology and cohort analysis of antimicrobial therapy are important.

Pyogenic liver abscess in end-stage renal disease patients: a nationwide longitudinal study

End-stage renal disease (ESRD) patients are more prone to infectious disease because of their immunocompromised status. However, the association between pyogenic liver abscess (PLA) and ESRD remains not clear. The aim of our study is to evaluate the incidence, risk factors, and outcomes of PLA in ESRD patients. We recruited all incident ESRD patients from the Taiwan National Health Insurance database from 1998 to 2006. The incidence rate of PLA in ESRD patients was compared with that of a randomly selected non-ESRD control group matched for age, sex gender, Charlson comorbidity score, diabetes mellitus, and cirrhosis. Among the 57,761 incident dialysis patients, there were 538 cases of PLA. The incidence rate of PLA was 18.20 per 10,000 person-years in the ESRD cohort and 6.34 per 10,000 person-years in matched control cohort. The rate of PLA was significantly higher in the ESRD cohort (hazard ratio 3.63, 95% confidence interval 2.83-4.65, P < 0.001). The mortality rates of PLA were higher in the ESRD cohort than those in matched control cohort. Diabetes mellitus was an independent risk factor for mortality of PLA. Compared with non-ESRD patients, ESRD patients have a higher risk of PLA and poorer outcomes.

Liver abscess due to Klebsiella pneumoniae in a healthy 12-year-old boy

Pyogenic liver abscess (PLA) is rare in healthy children. We report a case of PLA in an immunocompetent 12-year-old boy. Percutaneous catheter drainage was performed for the abscess. In addition, parenteral antibiotics were administered for 3 weeks. Klebsiella pneumoniae was detected in the culture of blood and drained fluid. Here, we present this case and a brief review of the literature on this subject.

Liver Abscess following Hematogenous Transmission due to Rectal Foreign Body Perforation

Liver abscess caused by hematogenous transmission from a gastrointestinal perforation by a foreign body is a rare but life-threatening condition. We present the case of a 57-year-old male with a pyogenic liver abscess generated on the basis of a foreign body perforation of the rectum. This has not been reported previously. During the examination of the patient, computed tomography scan showed not only the liver abscess but also an inflammatory presacral process, which communicated with the rectum through a 6.5-cm-long foreign body. Subsequent sigmoidoscopy showed a toothpick placed transmurally in the rectum; the toothpick was removed endoscopically. We discuss the importance of computed tomography scans and colonoscopies in relation to liver abscesses of unknown etiology, including the importance of detecting possible perforation caused by possible foreign bodies, polyps or cancer.

Pyogenic liver abscess: An analysis of 58 cases

AIM: To analyze the clinical features of pyogenic liver abscess (PLA) to provide the basis for early diagnosis and treatment of this disease.

METHODS: The clinical data for 58 patients with PLA who were treated in the Second Affiliated Hospital of Nanjing Medical University from June 2000 to December 2011 were retrospectively analyzed to determine the clinical features, and laboratory, imaging, and microbiologic findings as well as the treatment outcome.

RESULTS: Fever and chills (94.8%) were the most common clinical manifestations, followed by right upper quadrant pain (58.6%). Twenty-seven cases (46.5%) had diabetes mellitus. The most common laboratory abnormality was increased alkaline phosphatase (ALP) (77.6%), followed by increased white blood cell (WBC) count (70.7%) and fibrinogen (FIB) (60%). The most commonly identified organism was Klebsiella pneumoniae (17.2%). The majority of patients had solitary liver abscess (86.2%), and most of liver abscesses were found in the right hepatic lobe with an average diameter of 7.1 cm ± 4.0 cm (1-24 cm). All patients underwent combined antibiotic treatment. Ultrasound or CT-guided needle aspiration or continuous drainage after needle aspiration of pyogenic liver abscess was performed in 26 patients (44.8%). Surgery was required in 3 patients (5.2%). One patient (1.7%) died due to septic shock after admission.

CONCLUSION: Patients who have fever, chills, and right upper quadrant pain should be considered of pyogenic liver abscess, especially in patients with diabetes, biliary tract disease, or cancer. Elevated ALP, WBC and FIB were more commonly seen than positive bacterial culture in PLA patients, which may have suggestive significance in clinical diagnosis. Antibiotics combined with needle aspiration or continuous drainage after needle aspiration are safe and effective treatments.

A middle-aged lady with a pyogenic liver abscess caused by Clostridium perfringens

The pyogenic liver abscess caused by Clostridium perfringens (C. perfringens) is a rare, but rapidly fatal infection. It is usually associated with malignancy and immunosuppression. We report the case of 50-year-old lady with the secondary liver metastases from rectal cancer presented with fever and epigastric pain. The identification of Gram-positive bacilli septicaemia, the presence of gas-forming liver abscess and massive intravascular hemolysis should lead to the suspicion of C. perfringens infection. Here we review twenty cases published since 1990 and their clinical features are discussed. The importance of "an aggressive treatment policy" with multidisciplinary team approach is emphasized.

Pyogenic liver abscesses associated with nonmetastatic colorectal cancers: An increasing problem in Eastern Asia

AIM: To elaborate the clinicopathologic features of colorectal cancer-related pyogenic liver abscess (PLA).

METHODS: Reported cases of colorectal cancer-related PLAs were collected from the literature published up to October 2011 and evaluated for their clinicopathologic features. Data of collected cases included demographics, clinical presentation, microbial findings and treatment. Categorical variables were compared by χ² analysis and continuous variables were evaluated using Student’s t test.

RESULTS: A total 96 cases of colorectal cancer-related PLA were collected from the previous literature. Most patients (60%) were male and 40% cases occurred in the age group of 61-70 years. Apart from some special types of PLA, there were significant differences in the microbiological spectrum between Eastern Asia and non-Eastern Asian countries, which implied different risk factors and courses of the disease. Gram negative bacteria especially Klebsiella pneumoniae (K. pneumoniae) PLA was predominant in Eastern Asia (80.0%) in contrast to non-Eastern Asian countries (P < 0.01). Meanwhile, most of the Eastern Asian patients exhibited smaller size of liver abscess and atypical presentation. Sigmoid colon and rectum (72.73%) were the main sites of tumor in Eastern Asian patients, whereas tumor sites were uneven among most of the non-Easter Asian PLA patients.

CONCLUSION: K. pneumoniae PLA was strongly associated with colorectal cancer, especially those occurring in sigmoid colon and rectum, in elderly Eastern Asian male patients.

Is hepatic neoplasm-related pyogenic liver abscess a distinct clinical entity?

AIM: To compare the clinical characteristics of pyogenic liver abscess (PLA) in patients with and without hepatic neoplasm (HN).

METHODS: Authors performed a retrospective analysis involving patients with PLA. The demographic, clinical features, laboratory and imaging findings, management and outcome of patients with and without HN were studied.

RESULTS: From January 2000 to December 2009 inclusive, 318 patients (35 with HN) had PLA, and mean age and comorbidity were comparable between the two groups. More patients with HN experienced right upper quadrant pain (68.6% vs 52.7%, P < 0.04), developed jaundice (14.3% vs 5.7%, P < 0.03) and hepatomegaly (17.1% vs 3.9%, P < 0.01), and had higher serum total bilirubin level (43.3 μmol/L vs 30.0 μmol/L, P = 0.05). Most patients in both groups had PLAs in the right hepatic lobe, and biliary tract disorder was the most common underlying cause (71.4% and 61.8%). However, more PLAs in the HN group were associated with thicker abscess wall (37.1% vs 19.4%, P < 0.01), septal lobulation (77.1% vs 58%, P < 0.02), gaseous cavitation (17% vs 7.8%, P = 0.03), portal thrombophlebitis (11.4% vs 1.8%, P < 0.01) and aerobilia (25.9% vs 5.5%, P < 0.01). Mixed bacterial growth (40% vs 15.2%, P < 0.01) and Gram-negative bacilli (22.8% vs 60.4%, P < 0.01) were dominant isolates in PLAs with and without HN, respectively. Although incidence of the complications was comparable between the two groups, patients with HN had a higher mortality rate than those without (71.4% vs 8.8%, P < 0.01). Multivariate logistic regression analysis revealed underlying active malignancy [odds ratio (OR): 40.45, 95% CI: 14.76-111.65], hypoalbuminemia (OR: 1.22, 95% CI: 1.14-1.38), disseminated intravascular coagulation (OR: 3.32, 95% CI: 1.19-9.69) and acute coronary syndrome (OR: 4.48, 95% CI: 1.08-17.8) were independent risk factors associated with mortality. However, several HN cases, presented concurrently with PLAs, were found to have curative resectable tumors and had good prognosis after surgery.

CONCLUSION: PLA associated with HN tends to form a distinct clinical syndrome with a different extent of clinical manifestations, radiological and microbiological features and complications.

A prospective series case study of pyogenic liver abscess: recent trands in etiology and management

Our study aims to review the literature on the management of pyogenic liver abscess, focusing on the choice of drainage. A case series of our experience with clinicopathological correlation is presented to highlight the indication and outcome of each modality of drainage. Intravenous antibiotic is the first line, and mainstay, of treatment. Drainage is necessary for large abscesses, equal to or larger than 5 cm in size, to facilitate resolution. While percutaneous drainage is appropriate as first-line surgical treatment in most cases, open surgical drainage is prudent in cases of rupture, multiloculation, associated biliary, or intra-abdominal pathology. Percutaneous drainage may help to optimize clinical condition prior to surgery. Nevertheless, in current good clinical practices, the choice of therapy needs to be individualized according to patient's clinical status and abscess factors. They are complementary in the management of liver abscesses.

A 10-year retrospective analysis of clinical profiles, laboratory characteristics and management of pyogenic liver abscesses in a chinese hospital

Background/Aims

Pyogenic liver abscess (PLA) is a serious, life threatening condition with a high mortality rate that represents a diagnostic and therapeutic challenge. The aim of this study was to collect demographic data and clinical, laboratory and microbiological characteristics of PLA patients treated between 2000 and 2010. We also aimed to collect information regarding our management experience of these cases.

Methods

As a retrospective review, 47 patients with PLA in a tertiary referral center were examined to determine their demographic characteristics, clinical features, and laboratory, imaging, and microbiologic findings as well as the treatment outcome.

Results

Cryptogenic PLA was the most frequently identified type of PLA, while benign biliary tract disease was the most frequently identifiable cause of PLA (18/47 patients; 38.3%). Leukocytosis and elevated alanine transaminase were common laboratory findings and were observed in 35 (74.5%) and 22 (46.8%) patients, respectively. Increased fibrinogen was also detected in 11 of 15 investigated cases (73.3%). Notably, infection-induced thrombocytopenia occurred in 8 patients (17%). Diabetes mellitus was associated with the occurrence of infection induced shock when compared to the non-diabetic group (p<0.05). Patients with two or more comorbid diseases had longer hospitalizations when compared to patients with one comorbid disease or those without comorbidities (p<0.001). The number of days needed to establish diagnosis was correlated with the length of hospitalization (p<0.001). The overall hospital mortality rate was 2.1% (1/47).

Conclusions

Characteristics of PLA patients from the past 10 years are presented. The number of days needed to establish a PLA diagnosis was correlated with the length of the hospital stay. The hospital stay of PLA patients can be further improved by early diagnosis and effective treatments during the early stages of PLA progression.

Pyogenic liver abscess: An audit of 10 years’ experience

AIM: To describe our own experience with pyogenic liver abscesses over the past 10 years and investigate the risk factors associated with failure of initial percutaneous therapy.

METHODS: A retrospective study of records of 63 PLA patients presenting between 1998 and 2008 to Australian tertiary referral centre, were reviewed. Amoebic and hydatid abscesses were excluded. Demographic, clinical, radiological, and microbiological characteristics, as well as surgical/radiological interventions, were recorded.

RESULTS: Sixty-three patients (42 males, 21 females) aged 65 (± 14) years [mean ± (SD)] had prodromal symptoms for a median (interquartile range; IQR) of 7 (5-14) d. Only 59% of patients were febrile at presentation; however, the serum C-reactive protein was elevated in all 47 in whom it was measured. Liver function tests were non-specifically abnormal. 67% of patients had a solitary abscess, while 32% had > 3 abscesses with a median (IQR) diameter of 6.3 (4-9) cm. Causative organisms were: Streptococcus milleri 25%, Klebsiella pneumoniae 21%, and Escherichia coli 16%. A presumptive cryptogenic cause was most common (34%). Four patients died in this series: one from sepsis, two from advanced cancer, and one from acute myocardial infarction. The initial procedure was radiological aspiration ± drainage in 54 and surgery in two patients. 17% underwent surgical management during their hospitalization. Serum hypoalbuminaemia [mean (95% CI): 32 (29-35) g/L vs 28 (25-31) g/L, P = 0.045] on presentation was found to be the only factor related to failure of initial percutaneous therapy on univariate analysis.

CONCLUSION: PLA is a diagnostic challenge, because the presentation of this condition is non-specific. Intravenous antibiotics and radiological drainage in the first instance allows resolution of most PLAs; However, a small proportion of patients still require surgical drainage.

Treatment and prognosis of pyogenic liver abscess

BACKGROUND

There are many combinations of treatments for pyogenic liver abscess (PLA). Different treatments are indicated for different clinical courses of PLA.

AIMS

To realize the current prevalence, clinical course, trend of treatment, and prognosis of pyogenic liver abscess (PLA) in Taiwan.

METHODS

We retrospectively reviewed the medical records of 126 patients with PLA. We divided them into four groups: M, MD, MS, and MDS, represented as parenteral antibiotic only, parenteral antibiotic with drainage, parenteral antibiotic with surgical intervention, and parenteral antibiotic with surgical drainage. We analyzed data by commercial statistical software (SPSS for Windows, version 11.0, SPSS Ltd., Chicago, IL). We used Student's t-test and χ(2) test for statistical analyses, and significance was set at a p value less than 0.05.

RESULTS

PLA patients who were treated only with parenteral antibiotics had early diagnosis of PLA with a mean fever period of 3.3 days (p = 0.043). Patients who needed surgical drainage were highly associated with shock presentation in the clinical course (35.7% versus 14.3%, p = 0.007).

CONCLUSION

The earlier we can diagnose PLA, the shorter the patient's hospital stay (20.6 days) will be. In PLA patients with shock, a higher rate of surgical intervention is mandatory to save their lives.

Treatment and prognosis of pyogenic liver abscess

BACKGROUND

There are many combinations of treatments for pyogenic liver abscess (PLA). Different treatments are indicated for different clinical courses of PLA.

AIMS

To realize the current prevalence, clinical course, trend of treatment, and prognosis of pyogenic liver abscess (PLA) in Taiwan.

METHODS

We retrospectively reviewed the medical records of 126 patients with PLA. We divided them into four groups: M, MD, MS, and MDS, represented as parenteral antibiotic only, parenteral antibiotic with drainage, parenteral antibiotic with surgical intervention, and parenteral antibiotic with surgical drainage. We analyzed data by commercial statistical software (SPSS for Windows, version 11.0, SPSS Ltd., Chicago, IL). We used Student's t-test and χ(2) test for statistical analyses, and significance was set at a p value less than 0.05.

RESULTS

PLA patients who were treated only with parenteral antibiotics had early diagnosis of PLA with a mean fever period of 3.3 days (p = 0.043). Patients who needed surgical drainage were highly associated with shock presentation in the clinical course (35.7% versus 14.3%, p = 0.007).

CONCLUSION

The earlier we can diagnose PLA, the shorter the patient's hospital stay (20.6 days) will be. In PLA patients with shock, a higher rate of surgical intervention is mandatory to save their lives.

Predictive factors for early aspiration in liver abscess

AIM: To determine the predictive factors for early aspiration in liver abscess.

METHODS: A retrospective analysis of all patients with liver abscess from 1995 to 2004 was performed. Abscess was diagnosed as amebic in 661 (68%) patients, pyogenic in 200 (21%), indeterminate in 73 (8%) and mixed in 32 (3%). Multiple logistic regression analysis was performed to determine predictive factors for aspiration of liver abscess.

RESULTS: A total of 966 patients, 738 (76%) male, mean age 43 ± 17 years, were evaluated: 540 patients responded to medical therapy while adjunctive percutaneous aspiration was performed in 426 patients. Predictive factors for aspiration of liver abscess were: age ≥ 55 years, size of abscess ≥ 5 cm, involvement of both lobes of the liver and duration of symptoms ≥ 7 d. Hospital stay in the aspiration group was relatively longer than in the non aspiration group. Twelve patients died in the aspiration group and this mortality was not statistically significant when compared to the non aspiration group.

CONCLUSION: Patients with advanced age, abscess size > 5 cm, both lobes of the liver involvement and duration of symptoms > 7 d were likely to undergo aspiration of the liver abscess, regardless of etiology.

Role and outcome of conventional surgery in the treatment of pyogenic liver abscess in the modern era of minimally invasive therapy

AIM: To evaluate the role and outcome of conventional surgery in the treatment of pyogenic liver abscess in the modern era of minimally invasive therapy.

METHODS: The medical records of thirteen patients with pyogenic liver abscess who underwent surgical treatment between January 1995 and December 2002 were retrospectively reviewed to determine the clinical presentation, indication and nature of surgery, and outcome of surgery.

RESULTS: The patients were predominantly women (10/13) with a mean age of 65 ± 17 years. Their main presenting symptoms were abdominal pain (100%) and fever (77%). The aetiologies included biliary (n = 6), cryptogenic (n = 3), portal (n = 2), and trauma (n = 2). Seven patients underwent percutaneous drainage as the initial treatment. Of these, three patients developed peritonitis secondary to peritoneal spillage. Another four patients failed to respond because of multiloculation. Salvage surgery was required in these patients. Six patients proceeded to straight laparotomy: two had marked sepsis and multiloculated abscess that precluded percutaneous drainage, and four presented with peritonitis of uncertain pathology. Surgical procedures included deroofment and drainage (n = 9), liver resection (n = 3), peritoneal lavage (n = 2), cholecystectomy (n = 4), and exploration of common bile duct (n = 2). One patient required reoperation because of bleeding. Three patients required further percutaneous drainage after surgery. The overall mortality was 46%. Four patients died of multiorgan failure and two patients died of pulmonary embolism.

CONCLUSION: Surgical treatment of pyogenic liver abscess is occasionally needed when percutaneous drainage has failed due to various reasons. Mortality rate in this group of patients has remained high.

Value of platelet count in the prognosis of patients with pyogenic liver abscess

AIM: To study the relationship between platelet count and the prognosis of patients with pyogenic liver abscess.

METHODS: A total of patients with pyogenic liver abscess were diagnosed by computed tomography (CT), magnetic resonance imaging (MRI) and liver punctures, and the average focus size was 6.54 cm in diameter. Blood routine examination was performed everyday, combined with B-ultrasonography every three days. The relationship between the dynamic changes of platelet count and the prognosis of pyogenic liver abscess patients was analyzed.

RESULTS: Within one week, 43 (38.39%) patients were found with maximal platelet count more than or equal to 400 × 10⁹/L, and 22 patients (19.64%) with platelet count less than 400 × 10⁹/L. More than one week, 29 patients (25.89%) were with maximal platelet count more than or equal to 400 × 10⁹/L, 18 patients (16.07%) with platelet count less than 400 × 10⁹/L. Thrombocytosis occurred quickly in the patients in hospital less than one week, whose maximal platelet count was more than or equal to 400 × 10⁹/L, and their clinical symptoms were improved remarkably as compared with those of patients in hospital more than one week, with maximal platelet count less than 400 × 10⁹/L (P < 0.05).

CONCLUSION: Pyogenic liver abscess patients, in whom thrombocytosis occurs in short time, have a favorable prognosis. Blood count is an important indicator for the prognosis of Pyogenic liver abscess.

Comparison between pyogenic liver abscess caused by Klebsiella pneumoniae and non-Klebsiella pneumoniae

AIM: To analyze the differences between pyogenic liver abscess caused by Klebsiella pneumoniae (Kp) and non-Klebsiella pneumoniae (NKp), and provide the evidence for early diagnosis and treatment.

METHODS: The clinical data of 162 patients with pyogenic liver abscess from January 2000 to January 2005 were collected, and statistical analysis was performed to compare the differences between the Kp and NKp patients in general characteristics, underlying diseases, clinical manifestations, laboratory features, and characteristics of liver abscess, treatments and outcomes.

RESULTS: Of the 162 patients, 112 (69.1%) were classified into Kp group, and 50 (30.9%) were NKp group. There was significant difference between the two groups in ages (P < 0.05). For underlying diseases, there were significant differences in diabetes (66.1% vs 38.0%, P < 0.01), biliary diseases (14.3% vs 28.0%, P < 0.05) and abdominal injury (5.4% vs 16.0%, P < 0.05) between two groups. For clinical manifestations and laboratory features, there were also significant differences in anemia between two groups (60.7% vs 78%, P < 0.05). For characteristics of liver abscess, solitary liver abscess and monomicrobial isolates were more frequent in the Kp group than those in the NKp group (75.9% vs 58%, P < 0.05; 85.7% vs 64%, P < 0.01). For treatment and outcome, there were significant differences in metastatic infection and mortality rate between two groups (20.5%vs 6%, P < 0.05; 8.9% vs 26.0%, P < 0.01).

CONCLUSION: In comparison with those in NKp patients, the age and mortality rate of Kp patients are lower, and the rate of diabetes and metastatic infection are higher. Monomicrobial isolates are mostly found in Kp patients.