Pyogenic Liver Abscess

Emphysematous hepatitis--a fatal infection in diabetic patients: case report

Emphysematous hepatitis is a rare fatal rapidly progressive fulminant infection of hepatic parenchyma seen in the setting of diabetes characterised by replacement of hepatic parenchyma with gas collection. There is paucity of literature with regard to pathogenesis, implicated organisms, imaging appearance and management of this condition. We report a case with extensive segmental replacement of liver parenchyma with gas. The fatality of this condition warrants awareness of this entity amongst radiologists and clinicians alike for early diagnosis and aggressive management.

Percutaneous needle aspiration of multiple pyogenic abscesses of the liver: 13-year single-center experience

OBJECTIVE

The aim of this study was to report 13 years of experience in the management of multiple pyogenic liver abscesses with only percutaneous needle aspiration of the abscess cavities under sonographic guidance.

MATERIALS AND METHODS

From December 1991 to October 2004, 39 consecutively registered patients (29 men and 10 women; age range, 37-82 years; mean age, 64 years) with 118 pyogenic liver abscesses were treated with sonographically guided percutaneous needle aspiration at our institution. The number of pyogenic liver abscesses per patient ranged from two to 15 (mean, 3.0).

RESULTS

Eighty-seven percutaneous needle aspirations were performed on 39 patients with 118 pyogenic liver abscesses (range, 1-4 aspirations per patient; mean, 2.2 aspirations per patient). Because they were close to another aspirated abscess in the right lobe of the liver, 31 (26.3%) of 118 abscesses were aspirated without removal of the needle from the liver. Thirty-six (92.3%) of 39 patients were treated with a single aspiration of an abscess in a single session. The other three patients needed two aspiration sessions. No patient needed imaging-guided percutaneous catheter drainage or open surgical drainage. Complete reconstitution of liver parenchyma occurred within a maximum of 80 days. No abscesses recurred during the follow-up period, which ranged from 7 to 42 months (mean, 18 months).

CONCLUSION

Percutaneous needle aspiration of multiple pyogenic abscesses under sonographic guidance is a safe, effective, and low-cost procedure. In our experience, percutaneous needle aspiration was acceptable to patients. Our data suggest that a trial of percutaneous needle aspiration should always be undertaken before catheter drainage or surgery.

Pyogenic Liver Abscess

Pyogenic liver abscess is an important and often life-threatening disorder. It is commonly caused by underlying disease of the biliary system, but more frequently, no predisposing disorder can be identified. Its diagnosis requires a high index of suspicion and imaging of the liver. The optimal treatment of pyogenic liver abscess is percutaneous drainage and intravenous broad-spectrum antibiotics with activity against enteric aerobic and anaerobic bacteria. Blood and abscess cultures should be obtained and amebic liver abscess carefully eliminated when the diagnosis is in doubt. Surgical drainage, preferably laparoscopic, is reserved for patients with complicated abscesses or after failure of response to initial medical therapy. Possible primary predisposing conditions to pyogenic liver abscess, such as biliary tract disorders, should be sought and managed accordingly. Intravenous antibiotics should be administered for a period of 2 weeks, followed by a more prolonged course of oral antibiotics. The choice and duration of antibiotic therapy, and the need for further intervention are determined by microbiologic data, the patient's clinical response, and repeated imaging studies.

Malignant liver tumors treated with MR imaging-guided laser-induced thermotherapy: experience with complications in 899 patients (2,520 lesions)

PURPOSE

To evaluate the complications from laser-induced thermotherapy (LITT) of malignant liver tumors and demonstrate that LITT is safe as an outpatient procedure.

MATERIALS AND METHODS

During 8 years, 899 patients with malignant liver tumors were treated with magnetic resonance (MR) imaging-guided LITT. A total of 2,132 LITT procedures were performed to treat 2,520 lesions. To account for the technical evolution of LITT during this time and the change from performing the procedure on an inpatient basis to performing it on an outpatient basis, patients were assigned to four groups. Overall complication rates and major and minor complications in the inpatient versus outpatient groups were evaluated. Multidimensional contingency table analysis with the chi(2) test was performed.

RESULTS

On the basis of a total of 2,132 LITT procedures performed, complications were divided into major and minor categories and detected at clinical or imaging studies. Major complications included three deaths (0.1%) within 30 days after LITT, pleural effusion requiring thoracentesis in 16 (0.8%) cases, hepatic abscess requiring drainage in 15 (0.7%) cases, bile duct injury in four (0.2%) cases, segmental infarction in three (0.1%) cases, and hemorrhage requiring transfusion in one (0.05%) case. Minor complications included postprocedural fever in 710 (33.3%), pleural effusion not requiring thoracentesis in 155 (7.3%), subcapsular hematoma in 69 (3.2%), subcutaneous hematoma in 24 (1.1%), pneumothorax in seven (0.3%), and hemorrhage in two (0.1%) cases. Outpatient management did not significantly affect pleural effusion (P =.96) or subcapsular hematoma (P =.33) rate.

CONCLUSION

MR imaging-guided LITT with local anesthesia is safe and yields an acceptably low rate of major complications.

Hepatobiliary infections

The major hepatobiliary infections (excluding the viral hepatitides) include amebic and pyogenic liver abscess and cholangitis. Little new information has been published in the area of cholangitis during the last several years. In contrast, the clinical presentation and management of liver abscess have evolved considerably, not only in the last several years but also during a more extended period spanning the last two decades. In the United States, amebic liver abscess occurs largely in individuals from endemic areas or in those traveling to endemic areas. Recent data suggest that patients with human immunodeficiency virus (HIV) infection are at an increased incidence of amebic liver abscess. New serologic tests and molecular techniques are being added to the diagnostic armamentarium for amebic liver abscess. In most cases, amebic liver abscess is associated with an excellent prognosis (up to 100% survival) if properly managed. Pyogenic liver abscess, although commonly occurring in patients with known biliary tract disease, is often cryptogenic in origin (ie, no clear causal factor can be identified) or often is caused by underlying medical disorders. An emerging population of patients with pyogenic liver abscess includes those with complications of aggressive interventions (hepatic chemoembolization, cryoablation, liver transplantation). Pyogenic liver abscess was predominantly managed by surgical methods up until the early 1980s, but almost entirely has changed to being managed by interventional techniques; in 2000, this trend has continued. In contrast to amebic liver abscess, pyogenic liver abscess is associated with greater morbidity and mortality, ostensibly caused by the severity of the underlying disease in many patients. However, it should be emphasized that the prognosis of patients with pyogenic liver abscess, who do not have underlying comorbid conditions, is excellent.