Should colonoscopy be performed in patients with cryptogenic liver abscess?

Management of Pyogenic Liver Abscesses: Contemporary Strategies and Challenges

Pyogenic liver abscesses (PLAs) are a suppurative infection of the hepatic parenchyma responsible for significant morbidity and mortality. PLAs are categorized into a variety of mechanisms: (1) via the portal vein, (2) through the biliary tract, (3) via the hepatic artery, (4) from trauma, (5) contiguously via direct extension, and (6) cryptogenically. The pathogenesis of PLA, which informs treatment, can often be discerned based on host factors, clinical presentation, and causative microorganisms. The Streptococcus anginosus group, hypervirulent Klebsiella pneumoniae , and multidrug-resistant gram-negative pathogens have emerged as microbiologically challenging organisms to treat. The identification of hypervirulent K. pneumoniae should prompt for assessment for metastatic spread and consideration of prolonged antimicrobial treatment. Abdominal imaging is indispensable in characterizing PLAs and facilitating source control interventions. Source control remains the most critical aspect of PLA management, followed by antimicrobial therapy. Empiric antibiotics for PLAs are informed by the suspected etiology of PLA formation. Duration of antimicrobial therapy is individualized and dependent on multiple components, including the success of achieving source control, host factors, mechanism of PLA development, and the illness course of the individual-factoring in clinical, biochemical, and radiographic parameters.

Occult colon cancer with liver abscess and pancreatitis as the first manifestations: A case report

INTRODUCTION

Klebsiella pneumoniae-induced liver abscess (KP-PLA) is a common type of pyogenic liver abscess, severe acute pancreatitis (SAP) has high mortality, and poor prognosis in advanced colon cancer. There have been no report of SAP complicated with colon cancer after KP-PLA as so far. In this study, we reported a case of SAP secondary to KP-PLA with colon cancer for the first time, so as to provide reference for clinical diagnosis and treatment of these diseases.

PATIENT CONCERNS AND DIAGNOSIS

A 64-year-old woman with a history of diabetes visited our hospital with abdominal pain for 5 + days. He was diagnosed with KP-PLA a month ago, which had not healed when he was admitted. He was diagnosed with SAP, and histological examination of colonic biopsy confirmed the diagnosis of moderately differentiated adenocarcinoma.

INTERVENTIONS AND OUTCOMES

He was treated with intravenous antibiotics and underwent modified endoscopic mucosal resection under colonoscopy. We conducted a 2-month follow-up, and there was no recurrence of liver abscess and pancreatitis.

CONCLUSION

Screening for intestinal tumors is necessary in patients with cryptogenic liver abscess, especially KP-PLA with diabetes.

Therapy of pyogenic liver abscess with a primarily unknown cause

Purpose

Pyogenic liver abscess (PLA) is a collection of pus in the liver, often without a known direct cause. There is discord on the best diagnostic and therapeutic strategy. We aimed to examine these questions in our patient cohort.

Methods

A total of 66 out of 309 patients with PLA at our tertiary referral center between 2012 and 2020 had a primarily unknown cause. We analyzed PLA configuration, comorbidities, and whether an underlying cause could be found later. Therapy was sorted by antibiotics alone, percutaneous drainage, and primary surgery. Success was assessed by a change of initial therapy, in-hospital mortality, and mean hospital stay.

Results

Overall mortality was 18%; in 55%, a causative condition could be found. CRP, GGT, size, and multiple localization go along with higher mortality. Antibiotics alone had a failure rate of 82%. Percutaneous drainage was successful in 70% of cases. Surgery was mainly reserved for failed previous non-surgical treatment and had in-hospital mortality of 12%.

Conclusions

PLA goes along with high mortality. In the majority of all patients, a causative condition can be identified by detailed diagnostics. Percutaneous drainage together with antibiotics is the therapy of choice and is successful in 70% of cases. If drainage is insufficient or impossible, surgery is an effective alternative.

Cardiac tamponade due to perforation of a Roseomonas mucosa pyogenic hepatic abscess as initial presentation of hepatoid carcinoma

Hepatic abscesses can rarely cause pericardial disease by erosion into the pericardial space and present with haemodynamic instability due cardiac tamponade. While rare, these dramatic presentations are more often due to amoebic abscesses than bacterial abscesses. Importantly, a cause must be found for any cryptogenic hepatic abscess regardless of presentation, as there is a high association with underlying malignancy. We report a previously healthy man in his 30s who presented with cardiac tamponade from perforation of a Roseomonas mucosa pyogenic hepatic abscess into the pericardium in the absence of bacteremia and biliary disease. One year later, he was found to have diffusely metastatic hepatoid carcinoma.

Prevalence of colorectal cancer in cryptogenic pyogenic liver abscess patients. Do they need screening colonoscopy? A systematic review and meta-analysis

BACKGROUND

Cryptogenic pyogenic liver abscess (PLA) could result due to compromised colonic mucosal barrier in patients with colorectal cancer (CRC). Association of PLA and CRC is unclear. Evidence is weak and limited to small sized studies. As a result, the need for colonoscopy in PLA patients is debatable.

METHODS

We conducted a comprehensive search of multiple electronic databases and conference proceedings (from inception through January 2019) to identify studies that reported on the prevalence of CRC in PLA patients. Our goals were to evaluate the pooled rate of CRC in patients with cryptogenic PLA.

RESULTS

12 studies were included in the analysis. 18,607 patients were diagnosed with PLA in study group and 60,130 patients were in control group. 63% were males in the age range of 56-94 years. 90.5% of the colonic lesions were left sided and 93.1% were positive for Klebsiella pneumoniae. The pooled rate of prevalence of CRC was 7.9% (95% CI (confidence interval) 5-12.1, I² = 92.4, relative risk = 6.6) in patients with PLA, as compared to 1.2% (95% CI 0.3-5.7, I² = 93.4) in control, with statistical significance (p = 0.001 respectively).

CONCLUSION

Our study, albeit limited by heterogeneity, demonstrates that patients with cryptogenic PLA are at a 7-fold risk of having CRC. A screening colonoscopy may be considered in population with cryptogenic PLA, especially if positive for K. pneumoniae. Well-conducted studies are needed to answer this question.

Klebsiella Pneumoniae Liver Abscess: A Case Series of Six Asian Patients

BACKGROUND Liver abscesses represent a serious infection of hepatic parenchyma and are associated with significant morbidity and mortality. The emergence of a new hypervirulent variant of Klebsiella pneumoniae, which can cause serious infections in the Asian population, is under investigation. We report a case series of six Asian patients hospitalized at our institution from January 2013 to November 2015 for liver abscess due to Klebsiella pneumoniae. CASE REPORT Charts of six Asian patients were retrospectively reviewed. Four patients were male and two were female. The mean age was 53 years (range: 35-64 years). All patients had no known past medical history of immunodeficiency. Three patients had multiple liver abscesses at the time of initial presentation. In five patients, the source of entry of the pathogenic microorganism was unknown and in one patient the suspected source of entry was the gastrointestinal tract. In three patients there was also concomitant Klebsiella pneumoniae bacteremia. The mean duration of antibiotic treatment was seven weeks and the mean duration of hospital stay was 13.5 days. CONCLUSIONS Liver abscess should always be included in the differential diagnosis in cases of sepsis without obvious source and/or in the clinical scenarios of fever, abdominal pain, and liver lesions.

Asymptomatic pyogenic liver abscesses secondary to Fusobacterium nucleatum and Streptococcus vestibularis in an immunocompetent patient

A 66-year-old male patient presented with symptoms and signs of L4/5 radiculopathy. He was found to be anaemic with elevated inflammatory markers and deranged hepatic enzymes. Imaging revealed lumbar canal stenosis and the presence of pyogenic liver abscesses from which Fusobacterium nucleatum and Streptococcus vestibularis were isolated. The hepatic abscesses were attributed to asymptomatic diverticular perforation. Multiple coexisting incidental infections were discovered, including oesophageal candidiasis, Helicobacter pylori, stool cultures positive for Strongyloides stercoralis, and sputum cultures positive for Enterobacter cloacae, Escherichia coli and Mycobacterium avium Extensive investigations for possible underlying immunosuppression were negative.

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.

The Prevalence of Colonic Neoplasm in Cryptogenic Pyogenic Liver Abscess: A Prospectively Enrolled Cross-sectional Study

Background/Aims

Several studies suggest that pyogenic liver abscess (PLA) is associated with colon neoplasm. A colonoscopic exam for cryptogenic PLA might detect a hidden colon neoplasm, through which intestinal flora can be transmitted into the liver. However, there are no prospectively enrolled cross-sectional data for colonic neoplasm in cryptogenic PLA.

Methods

Patients with PLA were prospectively enrolled from two university hospitals. Among them, all the patients with cryptogenic PLA were recommended for colonoscopic exam to check for colonic neoplasm.

Results

One hundred eighty-three patients with PLA were enrolled in the study for 22 months. One hundred and one (55.2%) patients did not have a definite cause of liver abscess at initial evaluation. The median diameter of the largest lesion was 5.7 cm (1.0-14.0 cm), and 74.3% of the patients were treated by percutaneous abscess drainage. Ninety-one percent of the patients who had an identified pathogen yielded Klebsiella. Sixty-two patients underwent colonoscopic exams, and no one had a colonic cancer, one had an adenomatous polyp with high grade dysplasia (1.6%), and 27 had adenomatous polyps with low grade dysplasia (43.5%; 41.0% in male and 43.5% in female). Of fifty patients who underwent an esophagogastroduodenoscopic exam, nine had gastric ulcers, one had an esophageal ulcer, and one had hemorrhagic gastritis.

Conclusions

The prevalence of colonic neoplasm among the patients with cryptogenic PLA was not as high as that in previous studies. Further well-designed, large-scale studies are required to assess the association of the colon neoplasm and cryptogenic PLA.

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.