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An Increasing Prominent Disease of Klebsiella pneumoniae Liver Abscess: Etiology, Diagnosis, and Treatment. Gastroenterol Res Pract 2013; 2013:258514. [PMID: 24194749 PMCID: PMC3806164 DOI: 10.1155/2013/258514] [Citation(s) in RCA: 61] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/03/2013] [Accepted: 07/15/2013] [Indexed: 02/07/2023] Open
Abstract
Background. During the past two decades, Klebsiella pneumoniae (K. pneumoniae) had surpassed Escherichia coli (E. coli) as the predominant isolate from patients with pyogenic liver abscess (PLA) in Asian countries, the United States, and Europe, and it tended to spread globally. Since the clinical symptom is atypical, the accurate and effective diagnosis and treatment of K. pneumoniae liver abscesses (KLAs) are very necessary. Methods. Here, we have comprehensively clarified the epidemiology and pathogenesis of KLA, put emphases on the clinical presentations especially the characteristic radiographic findings of KLA, and thoroughly elucidated the most effective antibiotic strategy of KLA. Results. K1 serotype is strongly associated with KLA especially in diabetic patients. Computed tomography (CT) and ultrasound (US) were two main diagnostic methods of KLA in the past. Most of KLAs have solitary, septal lobular abscesses in the right lobe of liver, and they are mainly monomicrobial. Broad-spectrum antibiotics combined with the US-guided percutaneous drainage of liver abscesses can increase their survival rates, but surgical intervention still has its irreplaceable position. Conclusion. The imaging features contribute to the early diagnosis, and the percutaneous intervention combined with an aminoglycoside plus either an extended-spectrum betalactam or a second- or third-generation cephalosporin is a timely and effective treatment of KLA.
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An unusual cause of acute abdomen-Gas-forming liver abscess due to Salmonella enteritidis. Asian J Surg 2013; 40:66-69. [PMID: 23978428 DOI: 10.1016/j.asjsur.2013.07.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2013] [Revised: 03/25/2013] [Accepted: 07/09/2013] [Indexed: 01/10/2023] Open
Abstract
Gas-forming pyogenic liver abscess (GFPLA) is considered to be a very severe form of PLA and carries a high mortality. Klebsiella pneumoniae is the most common pathogen responsible for the disease, whereas cases where Salmonella is cited as the cause are very uncommon. We report the first case of a 53-year-old lady suffering from GFPLA due to Salmonella, who was successfully treated with surgical drainage. To the best of our knowledge, this is the first case of GFPLA caused by Salmonella enteritidis to be reported in the English literature.
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Kuo SH, Lee YT, Li CR, Tseng CJ, Chao WN, Wang PH, Wong RH, Chen CC, Chen SC, Lee MC. Mortality in Emergency Department Sepsis score as a prognostic indicator in patients with pyogenic liver abscess. Am J Emerg Med 2013; 31:916-21. [PMID: 23623237 DOI: 10.1016/j.ajem.2013.02.045] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2012] [Revised: 02/28/2013] [Accepted: 02/28/2013] [Indexed: 01/12/2023] Open
Abstract
OBJECTIVES The purpose of this study was to explore the predictor index of mortality in patients with pyogenic liver abscess (PLA). METHODS We performed a retrospective review that enrolled 431 patients 18 years and older hospitalized due to PLA between January 2005 and December 2010. Clinical characteristics, laboratory results, treatments, and outcomes retrieved from medical records were analyzed. Multiple logistic regression and receiver operating characteristic curve analyses were performed. RESULTS The mean age of the 431 patients identified with PLA was 56.9 ± 15.0 years. The mean Mortality in Emergency Department Sepsis (MEDS) score on admission was 4.8 ± 4.1 (range, 0-17). During hospitalization, 94 patients (22%) required intensive care. Of the 431 patients, 63 died, yielding a 15% case fatality rate. Multivariate analysis revealed that higher MEDS scores on admission (P < .0001) and the presence of underlying malignancy (P = .006), multiple abscesses (P = .001), anaerobic infections (P < .0001), hyperbilirubinemia (P < .0001), and higher serum creatinine levels (P < .0001) were significantly associated with PLA mortality. The estimated area under the receiver operating characteristic curve for MEDS in predicting PLA mortality was 0.829 (95% confidence interval, 0.791-0.864; P < .0001). The optimal cutoff MEDS value of 7 or higher had a sensitivity of 76% sensitivity and a specificity of 81%, with a 10.7-fold PLA mortality risk (P < .0001) and a 26.2-fold intensive care unit admission risk (P < .0001). CONCLUSIONS The MEDS scores on admission represent a significant prognostic indicator for patients with PLA.
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Affiliation(s)
- Sheng-Hung Kuo
- Institute of Medicine, Chung Shan Medical University, Taichung 40201, Taiwan
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Laparoscopic drainage of cryptogenic liver abscess. Surg Endosc 2013; 27:3308-14. [PMID: 23494514 DOI: 10.1007/s00464-013-2910-y] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2012] [Accepted: 02/15/2013] [Indexed: 12/14/2022]
Abstract
BACKGROUND To retrospectively compare the outcomes of percutaneously drained and laparoscopically drained liver abscesses. METHODS Eight-five consecutive patients with radiological evidence of liver abscess were treated at National University Hospital of Singapore from 2005 to 2011. Multivariable logistic regression was used to identify failures of intervention. This was defined as persistent objective signs of sepsis. Complications, length of antibiotic therapy, and hospital stay were recorded but not used as indicators for failure of intervention. A propensity score analysis was used to adjust for possible confounders. RESULTS Twenty-seven (40.3%) patients in the percutaneous group did not respond to primary intervention compared to 2 patients (11.1%) in the laparoscopic group (p = 0.020). Two patients within the percutaneous group died from progression of sepsis despite intervention. In the multivariate model with propensity score, laparoscopic drainage had a protective effect against failure compared to percutaneous drainage of liver abscess (odds ratio [OR], 0.03; 95% confidence interval [CI], [0-0.4]; p = 0.008). There were no differences in complications related to the intervention (p = 0.108). Mean duration of antibiotics (p = 0.437) and hospital stay (p = 0.175) between the groups was similar. CONCLUSIONS Laparoscopic drainage of cryptogenic liver abscesses should be considered as an option for drainage of liver abscess.
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Togashi J, Sugawara Y, Akamatsu N, Aoki T, Ijichi M, Tanabe M, Kusaka K, Shibazaki M, Tadami T, Sakou M, Takazoe M, Bandai Y, Kokudo N. Resection of a methicillin-resistant Staphylococcus aureus liver abscess in a patient with Crohn's disease under infliximab treatment: a case report. J Med Case Rep 2013; 7:36. [PMID: 23374532 PMCID: PMC3565913 DOI: 10.1186/1752-1947-7-36] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2012] [Accepted: 12/19/2012] [Indexed: 11/10/2022] Open
Abstract
Introduction A liver abscess in Crohn’s disease is a rare but important entity that is associated with a poor prognosis and high mortality when treatment is delayed. We report a case of successful liver segmentectomy for a methicillin-resistant Staphylococcus aureus liver abscess in a patient with Crohn’s disease under infliximab treatment. Case presentation A 31-year-old Japanese man, who had been treated with infliximab infusions for Crohn’s disease, was referred to our hospital presenting with an abrupt onset of high fever and an elevated white blood cell count and serum C-reactive protein level. Computed tomography revealed a liver abscess occupying segment 8. The limited effect of percutaneous transhepatic abscess drainage and antibiotics led us to perform radical resection of the abscess. The patient recovered quickly after surgery and the postoperative course was uneventful. Conclusion The present case suggests that surgical removal of an abscess should be considered for patients under immunosuppression or refractory to conventional treatment.
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Affiliation(s)
- Junichi Togashi
- Department of Surgery, Artificial Organ and Transplantation Surgery Division, University of Tokyo, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan.
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Lai KC, Cheng KS, Jeng LB, Huang CC, Lee YT, Chang HR, Chen CC, Chen SC, Lee MC. Factors associated with treatment failure of percutaneous catheter drainage for pyogenic liver abscess in patients with hepatobiliary-pancreatic cancer. Am J Surg 2012; 205:52-7. [PMID: 22794706 DOI: 10.1016/j.amjsurg.2012.03.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2011] [Revised: 03/04/2012] [Accepted: 03/04/2012] [Indexed: 12/19/2022]
Abstract
BACKGROUND The aim of this study was to identify predictors of treatment failure of percutaneous catheter drainage (PCD) in patients with hepatobiliary-pancreatic cancer with pyogenic liver abscess (PLA). METHODS Medical records of 44 patients with PLA with underlying hepatobiliary-pancreatic cancer who underwent PCD under computed tomographic guidance as primary treatment between January 2001 and December 2010 were collected and reviewed. Included patients were diagnosed with cholangiocarcinoma (n = 16), hepatocellular carcinoma (n = 12), pancreatic carcinoma (n = 9), carcinoma of the ampulla of Vater (n = 6), and gallbladder cancer (n = 1). The clinical factors related to failure of PCD were determined using logistic regression. RESULTS The median age of the 44 patients with PLA was 68 years, and 48% were men. PCD failed in 15 patients (34%). Of the 15 patients with PCD failure, 12 subsequently required surgical intervention because of either clinical deterioration or imaging that demonstrated failure of abscess resolution with PCD. Three of these patients died with the initial drain in place before resolution of the abscess. In patients requiring surgery after PCD failure, the frequency of cure or abscess resolution reached 67%. Fourteen patients (32%) died during hospitalization. Multivariate analysis identified that multiloculated abscesses (P = .005) and abscesses with biliary communication (P = .036) were associated with failure of PCD. CONCLUSIONS Multiloculated abscesses and lesions with biliary communication pose a greater likelihood of failure of PCD in patients with hepatobiliary-pancreatic cancer with PLA. Early surgical intervention after PCD failure should be considered for these patients.
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Affiliation(s)
- Kuang-Chi Lai
- Department of Surgery, China Medical University Beigang Hospital, Yunlin 65152, Taiwan
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Glick WA, Simo KA, Swan RZ, Sindram D, Iannitti DA, Martinie JB. Pyogenic hepatic abscess secondary to endolumenal perforation of an ingested foreign body. J Gastrointest Surg 2012; 16:885-7. [PMID: 21989581 DOI: 10.1007/s11605-011-1711-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2011] [Accepted: 09/20/2011] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Pyogenic hepatic abscess induced by foreign body perforation of the gastrointestinal tract is an increasing phenomenon. Pyogenic liver abscess in itself is a challenge to treat without the complication of a foreign body. METHODS A case of a patient who developed a pyogenic hepatic abscess after unknown ingestion of a toothpick that subsequently perforated the duodenum is presented, and a literature review of pyogenic hepatic abscesses secondary to ingestion of foreign bodies and their causes, diagnosis, and treatment was performed. DISCUSSION Even with a thorough workup, often the diagnosis of a pyogenic hepatic abscess secondary to an endolumenal foreign body perforation is not obtained until the time of operation.
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Affiliation(s)
- Wesley A Glick
- Hepato-Pacreato-Biliary Surgery, Department of General Surgery, Carolinas Medical Center, 1025 Morehead Medical Drive, Suite 300, Charlotte, NC 28204, USA
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Chen SC, Lee YT, Tsai SJ, Lai KC, Huang CC, Wang PH, Chen CC, Lee MC. Clinical outcomes and prognostic factors of cancer patients with pyogenic liver abscess. J Gastrointest Surg 2011; 15:2036-43. [PMID: 21826544 DOI: 10.1007/s11605-011-1650-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2011] [Accepted: 07/26/2011] [Indexed: 01/31/2023]
Abstract
PURPOSE Pyogenic liver abscess (PLA) of cancer patients often has a poor prognosis, but corresponding prognostic factors are less investigated. This study aimed to identify predictors of mortality in cancer patients with PLA. PATIENTS AND METHODS Medical records of 85 consecutive cancer patients (46 with hepatobiliary pancreatic cancer, 14 with gastrointestinal cancer, and 25 with non-digestive system cancer) having PLA who were admitted to two university hospitals were retrospectively reviewed. The predictors of mortality were determined using Cox regression model. RESULTS The overall case fatality rate was 33%. In multivariate analysis, the greater Acute Physiology and Chronic Health Evaluation II score (P = 0.028), multiloculated abscess (P = 0.025), and polymicrobial infection (P = 0.003) were associated with mortality. In subgroup analysis of the 25 patients with multiloculated abscess undergoing percutaneous catheter drainage as primary treatment, the case fatality rates of patients with a solitary smaller abscess (size < 5 cm), those with a solitary larger abscess (size > 5 cm), and those with larger multiple abscesses were 0%, 36%, and 85%, respectively (P = 0.002; using χ (2) for trend). CONCLUSIONS The advanced disease stage, multiloculated abscess, and polymicrobial infection posed a greater mortality risk in cancer patients with PLA. Moreover, an early surgical approach should be considered for cancer patients having large, multiloculated complex PLAs.
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Affiliation(s)
- Shiuan-Chih Chen
- Institute of Medicine, Chung Shan Medical University, Taichung, 40201, Taiwan
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61
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Heneghan HM, Healy NA, Martin ST, Ryan RS, Nolan N, Traynor O, Waldron R. Modern management of pyogenic hepatic abscess: a case series and review of the literature. BMC Res Notes 2011; 4:80. [PMID: 21435221 PMCID: PMC3073909 DOI: 10.1186/1756-0500-4-80] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2010] [Accepted: 03/24/2011] [Indexed: 11/20/2022] Open
Abstract
Background Pyogenic hepatic abscesses are relatively rare, though untreated are uniformly fatal. A recent paradigm shift in the management of liver abscesses, facilitated by advances in diagnostic and interventional radiology, has decreased mortality rates. The aim of this study was to review our experience in managing pyogenic liver abscess, review the literature in this field, and propose guidelines to aid in the current management of this complex disease. Methods Demographic and clinical details of all patients admitted to a single institution with liver abscess over a 5 year period were reviewed. Clinical presentation, aetiology, diagnostic work-up, treatment, morbidity and mortality data were collated. Results Over a 5 year period 11 patients presented to a single institution with pyogenic hepatic abscess (55% males, mean age 60.3 years). Common clinical features at presentation were non-specific constitutional symptoms and signs. Aetiology was predominantly gallstones (45%) or diverticular disease (27%). In addition to empiric antimicrobial therapy, all patients underwent radiologically guided percutaneous drainage of the liver abscess at diagnosis and only 2 patients required surgical intervention, including one 16-year old female who underwent hemi-hepatectomy for a complex and rare Actinomycotic abscess. There were no mortalities after minimum follow-up of one year. Conclusions Pyogenic liver abscesses are uncommon, and mortality has decreased over the last two decades. Antimicrobial therapy and radiological intervention form the mainstay of modern treatment. Surgical intervention should be considered for patients with large, complex, septated or multiple abscesses, underlying disease or in whom percutaneous drainage has failed.
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Affiliation(s)
- Helen M Heneghan
- Department of Surgery, Mayo General Hospital, Castlebar, Mayo, Ireland.
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Su YJ, Lai YC, Lin YC, Yeh YH. Treatment and prognosis of pyogenic liver abscess. Int J Emerg Med 2010; 3:381-4. [PMID: 21373309 PMCID: PMC3047832 DOI: 10.1007/s12245-010-0232-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2009] [Accepted: 08/24/2010] [Indexed: 02/07/2023] Open
Abstract
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.
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Affiliation(s)
- Yu-Jang Su
- Department of Emergency Medicine, Mackay Memorial Hospital, No.92, Sec 2 Chung-Shan North Rd, Taipei, 10449 Taiwan
- Mackay Medicine, Nursing and Management College, No.92, Shengjing Rd.,Beitou District, Taipei, 112 Taiwan
| | - Yen-Chun Lai
- Department of Anesthesiology, Wan Fang Hospital, Taipei Medical University, Taipei, 116 Taiwan
| | - Yu-Chia Lin
- Department of Family Medicine, Mackay Memorial Hospital, No.92, Sec 2,Chung-Shan North Rd, Taipei, 10449 Taiwan
| | - Yu-Hang Yeh
- Department of Emergency Medicine, Mackay Memorial Hospital, No.92, Sec 2 Chung-Shan North Rd, Taipei, 10449 Taiwan
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Abstract
Benign pathologies of the liver often include several cystic diseases, such as simple cysts, autosomal dominant polycystic liver disease, and Caroli's disease. The differential of hepatic cysts also includes infectious pathologies, such as pyogenic liver abscess, hydatid cysts, and parasitic infections if the appropriate clinic setting. Understanding of the various causes, clinical presentation, and treatment options is required to ensure the appropriate surgical management of these patients.
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Affiliation(s)
- Kaye M Reid-Lombardo
- Division of Gastroenterologic and General Surgery, Mayo Clinic, 200 First Street South West, Rochester, MN 55905, USA.
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64
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McKenzie TJ, Lillegard JB, Grotz TE, Moir CR, Ishitani MB. Pyogenic liver abscess secondary to Streptococcus anginosus in an adolescent. J Pediatr Surg 2010; 45:e15-7. [PMID: 20438908 DOI: 10.1016/j.jpedsurg.2010.02.044] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2009] [Revised: 02/09/2010] [Accepted: 02/10/2010] [Indexed: 10/19/2022]
Abstract
Pyogenic liver abscess in the pediatric population is a rare entity and can be difficult to manage. Surgical infections caused by Streptococcus anginosus are exceedingly rare. Here we present a case of pyogenic liver abscess caused by S anginosus in an adolescent presenting with fever, nausea, emesis, and right upper quadrant abdominal discomfort.
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Affiliation(s)
- Travis J McKenzie
- Department of Pediatric Surgery, Mayo Clinic, Rochester, MN 55905, USA.
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Leggieri N, Marques-Vidal P, Cerwenka H, Denys A, Dorta G, Moutardier V, Raoult D. Migrated foreign body liver abscess: illustrative case report, systematic review, and proposed diagnostic algorithm. Medicine (Baltimore) 2010; 89:85-95. [PMID: 20517180 DOI: 10.1097/md.0b013e3181d41c38] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Pyogenic liver abscess is a severe condition and a therapeutic challenge. Treatment failure may be due to an unrecognized ingested foreign body that migrated from the gastrointestinal tract. There has recently been a marked increase in the number of reported cases of this condition, but initial misdiagnosis as cryptogenic liver abscess still occurs in the majority of cases. We conducted the current study to characterize this entity and provide a diagnostic strategy applicable worldwide. To this end, data were collected from our case and from a systematic review that identified 59 well-described cases. Another systematic review identified series of cryptogenic-and Asian Klebsiella-liver abscess; these data were pooled and compared with the data from the cases of migrated foreign body liver abscess. The review points out the low diagnostic accuracy of history taking, modern imaging, and even surgical exploration. A fistula found through imaging procedures or endoscopy warrants surgical exploration. Findings suggestive of foreign body migration are symptoms of gastrointestinal perforation, computed tomography demonstration of a thickened gastrointestinal wall in continuity with the abscess, and adhesions seen during surgery. Treatment failure, left lobe location, unique location (that is, only 1 abscess location within the liver), and absence of underlying conditions also point to the diagnosis, as shown by comparison with the cryptogenic liver abscess series. This study demonstrates that migrated foreign body liver abscess is a specific entity, increasingly reported. It usually is not cured when unrecognized, and diagnosis is mainly delayed. This study provides what we consider the best available evidence for timely diagnosis with worldwide applicability. Increased awareness is required to treat this underestimated condition effectively, and further studies are needed.
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Affiliation(s)
- Nicola Leggieri
- From Service de Maladies Infectieuses et Laboratoire Central de Bactériologie (NL), Hôpitaux Universitaires de Genève, Geneva, Switzerland; Institut Universitaire de Médecine Sociale et Préventive (PMV), Service deRadiologie (AD), Service de Gastroentérologie et d'Hépatologie (GD), Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland; Department of Surgery (HC), Medical University of Graz, Graz, Austria; Service de Chirurgie Viscérale (VM), Hôpital Nord, Marseille, France; and Unité des Rickettsies (DR), Centre Nationale de Recherche Scientifique, Unité Mixte de Recherche, Marseille, France
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Clinical Guideline for the Diagnosis and Treatment of Gastrointestinal Infections. Infect Chemother 2010. [DOI: 10.3947/ic.2010.42.6.323] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
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Guiteau JJ, Fisher M, Cotton RT, Goss JA. Intrahepatic gallbladder. J Am Coll Surg 2009; 209:672. [PMID: 19854411 DOI: 10.1016/j.jamcollsurg.2009.03.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2009] [Revised: 03/19/2009] [Accepted: 03/27/2009] [Indexed: 10/20/2022]
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