Abcès à pyogènes du foie. Diagnostic et prise en charge

Pyogenic liver abscess: contrast-enhanced ultrasound allows morpho-evolutive classification and guides personalized management

Aim: The aim of this study is to propose a contrast-enhanced ultrasound (CEUS)-based morphologic classification of pyogenic liver abscess (PLA) reflecting different evolutive stages and to assess the added value of CEUS in the management of PLA. Methods: Forty-four PLAs of different etiologies in 44 patients (male/female = 24/20; mean age 66 ± 14.7 years) were evaluated with ultrasound (US) B-mode and CEUS (using SonoVue). PLAs were mainly located in the right lobe (n = 28, 63.6%) with a mean diameter of 6.8 cm [standard deviation (SD) ± 3.2, range 1.7–15 cm]. Conventional US findings were categorized as the presence and extension of liquified areas, echogenicity and echostructure of the index lesion. Peripheral hyperenhancing rim, transient segmental enhancement, hyperenhancing septa and “honeycomb” aspect were considered PLA hallmarks in the arterial phase after contrast agent injection. CEUS results were judged as clinically relevant if they modified the approach to percutaneous treatment in comparison with pre-operative US B-mode findings. Results: CEUS was superior to US B-mode as to depiction of PLA internal echostructure and enabled identification of 4 evolutive stages of PLA: type I (tumor-like), type II (“honeycomb”), type III (multiloculated with incomplete septa), and type IV (cystic-like). In 22 cases (67.4%) out of 34 who underwent percutaneous treatment, the operator tailored percutaneous approach according to PLA internal echostructure observed during CEUS exam. Conclusions: CEUS depicts the internal structure of PLA so allowing a morpho-evolutive classification of PLA and provides invaluable information for immediately tailoring the management to the single case. By showing the structure of PLA more precisely, CEUS allows a morpho-evolutive PLA classification and guides tailored management in the single case.

Infected hepatic cyst complicating urinary sepsis

Congenital hepatic cysts are a common disorder. Usually they are asymptomatic and do not have to be treated. However, some serious complications can occur. We report here the case of an 86-year old patient who has been treated by a percutaneous drainage for an infected solitary hepatic cyst due to urinary sepsis. She was admitted to the Department of Internal Medicine for epigastric pain with fever and chills. The patient was treated for a urinary tract infection 3 weeks ago by her General Practitioner. On admission, blood tests showed 21 620 neutrophils per microliter with a C-reactive protein level at 443.7 mg/L, procalcitonin > 200 ng/mL, total bilirubin at 1.43 mg/dL, lactate dehydrogenase at 666 U/L and alanine aminotransferase at 227 U/L. Urinalysis and hemocultures highlighted the presence of Escherichia coli and Streptococcus constellatus. The abdominal tomodensitometry indicated the presence of a left hepatic biliary cyst with banal appearance. She was first treated with intravenous amoxicillin clavulanic acid. After a few days, another abdominal tomodensitometry with contrast pinpointed a large abscess of 11 centimeters in diameter extending to liver segments II and IV with a similar small lesion in segments IV and V. clindamycin per os was added to the treatment because of its good diffusion in tissues. Percutaneous drain was inserted under tomodensitometric control and stayed in place until the follow-up at three weeks. Bacteriologic culture on the fluid sample demonstrated the presence of Escherichia coli and Streptococcus constellatus. The abscess completely regressed after 6 weeks of treatment and the biologic abnormalities resolved at the same time.

Clinical Characteristics and Treatment Outcomes in Human Immunodeficiency Virus (HIV)-Infected Patients with Liver Abscess: A Retrospective Study of 53 Patients

BACKGROUND Although episodes of liver abscess (LA) have been reported in patients infected with the human immunodeficiency virus (HIV), specific symptoms in these patients remain unclear. MATERIAL AND METHODS The clinical characteristics, laboratory findings, treatments, and final clinical outcomes of LA in 53 HIV-infected patients were analyzed. RESULTS The most common clinical manifestations were fever (92.5%), chills (41.5%), and abdominal pain (37.7%). The mean CD4⁺ T cell count in these HIV-infected patients at admission was 328.09±236.192 cells/µL. LA and blood cultures were positive in six (17.6%) and two (5.4%) patients, respectively. Thirteen strains of pathogens, including Staphylococcus, Corynebacterium, and Candida, were detected in LA cultures. Forty-four (95.7%) of 46 patients were successfully treated with antibiotics plus image-guided percutaneous aspiration, drainage, or surgery, whereas four (57.1%) of the remaining seven patients were successfully treated with antibiotics alone. Septic shock [odds ratio (OR)=8.970; 95% confidence interval (CI)=0.840-92.110; p=0.014] and ascites (OR=7.057; 95% CI=0.683-72.957; p=0.016) were found to be independent risk factors for poor prognosis. The clinical characteristics of LA in HIV-infected patients were nonspecific, with bacteria being the primary pathogens. CONCLUSIONS Antibiotics plus image-guided percutaneous drainage can effectively improve treatment outcomes in HIV-infected patients with LA.

Pyogenic liver abscess in liver transplant recipient: A warning signal for the risk of recurrence and retransplantation

BACKGROUND

Pyogenic liver abscesses in liver transplant recipients (PLA-LTR) are a rare disease whose specificities compared with PLA in non-transplanted patients (PLA-C) are unknown.

METHODS

A retrospective case-control study was conducted in a French academic hospital from January 1, 2010, to December 31, 2014.

RESULTS

Among 176 patients diagnosed with PLA, 14 were LTR; each case was matched with 3 PLA-C controls by date of PLA diagnosis and pathophysiological mechanism of PLA. Median time from liver transplantation to PLA diagnosis was 34.5 months. Among 14 PLA-LTR, 8/14 (57.1%) had bacteremia and 10/14 (71.4%) had positive PLA cultures. Most commonly isolated bacteria were Enterobacteriaceae (9/14; 64.3%), Enterococcus spp. (4/14; 28.6%), and anaerobic bacteria (3/14; 21.4%). Clinical, radiological, and microbiological characteristics did not significantly differ between PLA-LTR and PLA-C but there was a tendency toward more diabetic patients and a less acute presentation. All but one PLA-LTR were associated with ischemic cholangitis, whereas this was a rare cause among PLA-C (13/14 vs 3/42, respectively, P < .001) among patients with PLA-LTR. In contrast, hepatobiliary neoplasia was rare in PLA-LTR but frequent in PLA-C (1/14 vs 24/42, P = .001). No significant difference was found between PLA-LTR and PLA-C in terms of duration of antibiotic therapy (6.5 and 6 weeks, respectively), PLA drainage rates (10/14 and 26/42, respectively), or mortality at 12 months after PLA diagnosis (2/14 and 5/42, respectively). Recurrence rates within the first year were observed in 6/14 patients (42.9%), and retransplantation was needed in 5/14 (35.7%).

CONCLUSIONS

Occurrence of PLA in LTR is a severe event leading to high risk of recurrence and retransplantation.

[Liver abscess]

Liver abscess is a rare and severe infection. Incidence increases because of aging of population, advances in liver and biliary surgery including liver transplantation, and immunodeficiency factors. Diagnosis depends mainly on imaging and needle aspiration for microbiological identification. Treatment is based on antibiotics, percutaneous or surgical drainage, and control of the primary source.

Hepatic abscess: Diagnosis and management

Microbial contamination of the liver parenchyma leading to hepatic abscess (HA) can occur via the bile ducts or vessels (arterial or portal) or directly, by contiguity. Infection is usually bacterial, sometimes parasitic, or very rarely fungal. In the Western world, bacterial (pyogenic) HA is most prevalent; the mortality is high approaching 15%, due mostly to patient debilitation and persistence of the underlying cause. In South-East Asia and Africa, amebic infection is the most frequent cause. The etiologies of HA are multiple including lithiasic biliary disease (cholecystitis, cholangitis), intra-abdominal collections (appendicitis, sigmoid diverticulitis, Crohn's disease), and bile duct ischemia secondary to pancreatoduodenectomy, liver transplantation, interventional techniques (radio-frequency ablation, intra-arterial chemo-embolization), and/or liver trauma. More rarely, HA occurs in the wake of septicemia either on healthy or preexisting liver diseases (biliary cysts, hydatid cyst, cystic or necrotic metastases). The incidence of HA secondary to Klebsiella pneumoniae is increasing and can give rise to other distant septic metastases. The diagnosis of HA depends mainly on imaging (sonography and/or CT scan), with confirmation by needle aspiration for bacteriology studies. The therapeutic strategy consists of bactericidal antibiotics, adapted to the germs, sometimes in combination with percutaneous or surgical drainage, and control of the primary source. The presence of bile in the aspirate or drainage fluid attests to communication with the biliary tree and calls for biliary MRI looking for obstruction. When faced with HA, the attending physician should seek advice from a multi-specialty team including an interventional radiologist, a hepatobiliary surgeon and an infectious disease specialist. This should help to determine the origin and mechanisms responsible for the abscess, and to then propose the best appropriate treatment. The presence of chronic enteric biliary contamination (i.e., sphincterotomy, bilio-enterostomy) should be determined before performing radio-frequency ablation and/or chemo-embolization; substantial stenosis of the celiac trunk should be detected before performing pancreatoduodenectomy to help avoid iatrogenic HA.

Appendiceal actinomycosis complicated by multiple hepatic abscesses

We report the case of a patient with appendicitis due to actinomycosis, complicated by multiple liver abscesses. Definitive diagnosis was based on histopathologic examination of the resected appendix. Accurate identification of the pathogen led to curative antibiotic therapy of the liver abscesses.

Abscess after a laparoscopic appendectomy presenting as low back pain in a professional athlete

A professional baseball player presented to the orthopaedic clinic for a preseason assessment because of continued lumbar spine and flank pain. He had a laparoscopic appendectomy for a perforated appendix 8 months before his presentation. He was able to finish the previous season with only mild limitation. He presented with back pain that limited his activity. His examination was nonlocalizing, but subsequent computed tomography revealed a hepatic abscess. The abscess was drained; he was treated with intravenous antibiotics; and his symptoms resolved.

Are pyogenic liver abscesses still a surgical concern? A Western experience

Backgrounds. Pyogenic liver abscess is a rare disease whose management has shifted toward greater use of percutaneous drainage. Surgery still plays a role in treatment, but its indications are not clear. Method. We conducted a retrospective study of pyogenic abscess cases admitted to our university hospital between 1999 and 2010 and assessed the factors potentially associated with surgical treatment versus medical treatment alone. Results. In total, 103 liver abscess patients were treated at our center. The mortality was 9%. The main symptoms were fever and abdominal pain. All of the patients had CRP > 6 g/dL. Sixty-nine patients had a unique abscess. Seventeen patients were treated with antibiotics alone and 57 with percutaneous drainage and antibiotics. Twenty-seven patients who were treated with percutaneous techniques required surgery, and 29 patients initially received it. Eventually, 43 patients underwent abscess surgery. The factors associated with failed medical treatment were gas-forming abscess (P = 0.006) and septic shock at the initial presentation (P = 0.008). Conclusion. Medical and percutaneous treatment constitute the standard management of liver abscess cases. Surgery remains necessary after failure of the initial treatment but should also be considered as an early intervention for cases presenting with gas-forming abscesses and septic shock and when treatment of the underlying cause is immediately required.

Superinfection of focal liver lesions after bile duct procedures

OBJECTIVES

Pyogenic liver abscess is a rare condition in the general population. The source of infection is most often biliary, and more rarely gastrointestinal via the portal tract, or even hematogenic. Other than in special contexts (scarring after radiofrequency ablation), focal liver lesions are not a usual risk factor for hepatic abscesses in patients with a history of bile duct procedures (sphincterotomy, biliary stenting, biliary enteric anastomosis). MATERIALS AND METHOD - RESULTS: We report four cases of focal liver lesions (two patients with benign lesions of the biliary cyst type and two other patients with lesions due to pancreatic cancer) complicated by a superinfection in patients with a history of bile duct procedures. There were no predisposing factors other than a context of cancer or diabetes.

CONCLUSION

Superinfection of a focal liver lesion should be considered when there is a suggestive clinical picture and a change in the appearance of the lesion in patients with a history of bile duct procedures in a context of cancer or diabetes.