Characteristics and management of pyogenic liver abscess: A European experience

Utility of Contrast-Enhanced Ultrasound in Optimizing Hepatic Abscess Treatment and Monitoring

Background/Objectives: Untreated hepatic abscesses (HAs) have an 80% mortality rate and can be caused by bacteria and fungi. Previously managed with surgery, current treatments now utilize interventional radiology and antibiotics, reducing complications to 2.5%. This study evaluates contrast-enhanced ultrasound (CEUS) for better drainage placement and monitoring, overcoming conventional ultrasound's limitations in detecting the HA liquefied portion. Methods: We conducted a retrospective study of 50 patients with HAs confirmed via computed tomography (CT) scans. Inclusion criteria comprised specific clinical symptoms and laboratory parameters. Both B-mode and CEUS were utilized for initial and follow-up imaging. Results: In the CEUS studies, the mean size of HAs was 6.26 cm, with pus displaying significantly lower echogenicity compared to the HA pouch and liver parenchyma in all phases. Classification by size (>6 cm, <6 cm) and volume (>113 mL, <113 mL) revealed differences in the assessment of fluid volume between CEUS and B-mode. Conclusions: CEUS is valuable for diagnosing, performing therapeutic procedures, and monitoring HA. It provides precise real-time assessment of HA morphology, including dimensions and volume. If the liquefied volume of an HA exceeds 113 mL, it may qualify for drainage placement. CEUS can replace CT as an effective, less harmful, and cheaper method, eliminating the need for multiple radiological departments. While CEUS is a safer, cost-effective alternative to CT for HA evaluation and monitoring, comprehensive clinical evaluation remains essential. Therefore, CEUS should be part of a broader diagnostic and monitoring strategy, not a stand-alone solution.

Pyogenic liver abscess in pediatric populations in beijing (2008-2023)

BACKGROUND

Data on pyogenic liver abscess (PLA) of children in China have been limited. We aimed to summarize the clinical feather, microbiological characteristics, management, and outcome of PLA in children.

METHOD

We retrospectively reviewed PLA cases from January 2008 to June 2023 at Beijing Children's Hospital. Clinical characteristics, pathogens and management were analyzed.

RESULTS

We diagnosed 57 PLA patients in our center. The median onset age was 4.5 years and the male-to-female ratio was 1.6:1. The median diagnostic time was nine days and the median length of stay was 22 days. Twenty-eight patients (49.1%) had predisposing factors, around 71.4% of the patients had malignant hematology and primary immunodeficiency disease. Patients with underlying factors were more likely to have extrahepatic organ involvement (p = 0.024), anemia (p < 0.001), single abscess (p = 0.042), unilateral involvement (p = 0.039), and small size of the abscess (p = 0.008). Twenty-four patients (42.1%) had extrahepatic organ involvement. Pathogens were identified in 17 patients (29.8%), the most common pathogens were Klebsiella pneumoniae and Staphylococcus aureus. The positive rate of metagenomic next-generation sequencing (mNGS) was 87.5% (7/8). On multivariable analysis, the extrahepatic organ involved (p = 0.029) and hepatomegaly (p = 0.025) were two independent factors associated with poor outcomes.

CONCLUSIONS

PLA is usually seen in children with predisposing factors. Malignant hematology and primary immunodeficiency disease were the most common underlying diseases. Extrahepatic organ involvement and hepatomegaly are associated with poor prognosis. Increased use of mNGS could be beneficial for identifying pathogens.

Clinical management, pathogen spectrum and outcomes in patients with pyogenic liver abscess in a German tertiary-care hospital

Pyogenic liver abscesses (PLA) are life-threatening disorders and require immediate treatment, but structured evidence is sparse and treatment guidelines are not established. In a retrospective observational study of 221 adult PLA patients (mean age 63 years, 63% men) treated between 2013 and 2019 at the Leipzig University Medical Center, we characterized pathogen spectrum, clinical management and outcomes. Biliary malignancies (33%), cholelithiasis (23%) and ischemic biliary tract disease (16%) were most common causes of PLA. Comorbidities included malignancies (40%) and diabetes mellitus (35%). Abdominal ultrasound was the preferred initial imaging modality (58%). Enterobacterales (58%), enterococci (42%) and streptococci (18%) were identified as most frequent pathogens. 97% of patients were treated with antibiotics and 75% of patients underwent an invasive treatment procedure. The 30-day mortality was almost identical in patients with and without underlying malignancy (14.6% vs. 14.4%, p = 0.96), while the one-year outcome differed significantly (58.4% vs. 29.6%, p < 0.001). Positive blood cultures (OR 4.78, 95% CI 1.39 to 22.5, p = 0.023) and detection of Enterobacterales (OR 3.55, 95% CI 1.40 to 9.97, p = 0.010) were associated with increased 30-day-mortality. We conclude that ultrasound, extensive microbiologic diagnosis, adequate anti-infective therapy and early intervention are crucial for the management of PLA.

Efficacy of empirical Ciprofloxacin or Cefixime plus Metronidazole therapy for the treatment of liver abscess: a randomized control clinical trial

Liver abscess is a potentially life-threatening medical emergency. Prompt empirical antimicrobial with or without percutaneous aspiration or drainage is therapeutic. The rational for using empirical intravenous broad-spectrum antimicrobials upfront instead of oral Fluoroquinolone or Cephalosporin is contentious. In this double blind randomized control clinical trial 69 participants received Ciprofloxacin (500 mg q 12 hourly) and 71 participants received Cefixime (200 mg q 12 hourly) orally for 2 weeks. Both the group received oral Metronidazole (800 mg q 8 hourly) for 2 weeks and percutaneous drainage or aspiration of the abscess was done as per indication and followed-up for 8 weeks. Out of 140 participants, 89.3% (N = 125) achieved clinical cure, 59 (85.5%) in Ciprofloxacin group and 66 (93%) in Cefixime group (p = 0.154). Mean duration of antimicrobial therapy was 16.2 ± 4.3 days, 15.1 ± 4.5 days in Ciprofloxacin group and 16.0 ± 4.2 days in Cefixime group (p = 0.223). Total 15 (10.7%) participants had treatment failure, 10 (14.5%) in Ciprofloxacin group and 5 (7.0%) in Cefixime group (p = 0.154). The most common reason for treatment failure was need of prolong (> 4 weeks) antimicrobial therapy due to persistent hepatic collection requiring drainage, which was significantly (p = 0.036) higher in Ciprofloxacin (14.5%, N = 10) group, compared to the Cefixime (4.2%, N = 3) group. In conclusion, both, the Ciprofloxacin or Cefixime plus Metronidazole for duration of 2-3 weeks were efficacious as empirical oral antimicrobial regimen along with prompt percutaneous drainage or aspiration for the treatment of uncomplicated liver abscess with similar efficacy. Oral Cefixime was better than Ciprofloxacin in term of lesser chance of treatment failure due to persistent collection which is required to be investigated further in larger clinical trial.Trial registration: clinicaltrials.gov PRS ID: NCT03969758, 31/05/2019.

Liver abscess after drug-eluting bead transarterial chemoembolization for hepatic malignant tumors: Clinical features, pathogenesis, and management

AIM

The study aimed to investigate the clinical features, incidence, pathogenesis, and management of liver abscess after drug-eluting bead transarterial chemoembolization (DEB-TACE) for primary and metastatic hepatic malignant tumors.

METHODS

From June 2019 to June 2021, patients with liver abscess after DEB-TACE for primary and metastatic hepatic malignant tumors were reviewed and evaluated at our hospital. Demographic and clinical data, radiological findings, management approaches, and prognosis were retrospectively analyzed.

RESULTS

In total, 419 DEB-TACE procedures were carried out in 314 patients with primary and metastatic liver tumors at our medical center. Twelve patients were confirmed to have liver abscesses after DEB-TACE through clinical manifestations, laboratory investigations, and imaging. In this study, the incidence of liver abscess was 3.82% per patient and 2.86% per DEB-TACE procedure. After percutaneous drainage and anti-inflammatory treatments, 10 patients recovered, and the remaining 2 patients died due to direct complications of liver abscess, such as sepsis and multiple organ failure. The mortality rate of liver abscesses after DEB-TACE was 16.7% (2/12).

CONCLUSION

The incidence of liver abscess after DEB-TACE is relatively high and can have serious consequences, including death. Potential risk factors could include large tumor size, history of bile duct or tumor resection, history of diabetes, small DEB size (100-300 μm). Sensitive antibiotics therapy and percutaneous abscess aspiration/drainage are effective treatments for liver abscess after DEB-TACE.

Clinical characteristics, diagnosis, treatment, and outcome of patients with liver abscess due to Aspergillus spp: a systematic review of published cases

BACKGROUND

Aspergillus spp liver abscess is a relatively rare entity and thus far no systematic review has been performed examining patients' demographics, clinical manifestations, diagnosis, management, and outcome.

METHODS

We performed a systematic review of the literature using MEDLINE and LILACS databases. We searched for articles published in the period from January 1990 to December 24, 2022, to identify patients who developed liver abscesses due to Aspergillus spp.

RESULTS

Our search yielded 21 patients all of whom had invasive aspergillosis confirmed on liver biopsy. Of these patients 81% were adults, and 60% were males. The majority (86%) of patients were immunocompromised and 95% had symptomatic disease at the time of diagnosis. The most common symptoms were fever (79%), abdominal pain (47%), and constitutional symptoms (weight loss, chills, night sweats, fatigue) (38%). Liver enzymes were elevated in 50%, serum galactomannan was positive in 57%, and fungal blood cultures were positive in only 11%. Co-infection with other pathogens preceded development of apsergillosis in one-third of patients, and the majority of the abscesses (43%) were cryptogenic. In the remaining patients with known source, 28% of patients developed liver abscess through dissemination from the lungs, 19% through the portal vein system, and in 10% liver abscess developed through contiguous spread. The most common imaging modality was abdominal computerized tomography done in 86% of patients. Solitary abscess was present in 52% of patients while 48% had multiple abscesses. Inadequate initial empiric therapy was prescribed in 60% of patients and in 44% of patients definite treatment included combination therapy with two or more antifungal agents. Percutaneous drainage of the abscesses was done in 40% of patients, while 20% required liver resection for the treatment of the abscess. Overall mortality was very high at 38%.

CONCLUSION

Further studies are urgently needed for a better understanding of pathophysiology of liver aspergillosis and for developement of newer blood markers in order to expedite diagnosis and decrease mortality.

A case report and treatment considerations for pyogenic liver abscess with biliary fistula

INTRODUCTION AND IMPORTANCE

Pyogenic liver abscess (PLA) is a potentially life-threatening condition characterized by the formation of space-occupying lesions within the liver parenchyma. Despite advancements in diagnostic imaging and antibiotic therapies, complications such as biliary fistula formation can arise, posing challenges in management.

CASE PRESENTATION

This case study presents a 23-year-old male patient with PLA complicated by a biliary fistula. Diagnostic imaging via CT scan and MRI confirmed a liver abscess and biliary dilation. The patient underwent a second drainage for ascitic fluid following the initial percutaneous liver catheter drainage.

CLINICAL DISCUSSION

The patient responded positively to the treatment, with reduced abscess size and fistula resolution. While endoscopic interventions offer promising results, their limited availability necessitates alternative treatment strategies, such as percutaneous drainage and appropriate antibiotics.

CONCLUSION

This case emphasises the importance of individualized management approaches for PLA complicated by biliary fistulas. Despite the challenges, successful outcomes can be achieved through careful management and appropriate treatment strategies.

Symptoms and Management of Aseptic Liver Abscesses

Aseptic liver abscesses occur very rarely. Clinical guidelines on the management of the disease do not exist, and the diagnosis is challenging.We screen MEDLINE and PUBMED databases for relevant case reports from inception to November 2022. Information on patient age, sex, initial symptoms, the extent of abscess formation, further diagnoses, treatment, and course of the disease is analyzed.Thirty cases with sterile hepatic abscess formation are identified. In most patients (n=18), the spleen is affected as well. Patients typically present with fever, abdominal pain, and increased inflammatory values. Comorbidity with inflammatory bowel disease is very common (n=18) and is associated with a significantly younger age at the time of hepatic abscess development. In addition, many patients show autoimmune-mediated cutaneous, ocular, or arthritic rheumatoid manifestations. Histological examination of abscess material reveals neutrophilic infiltration. The majority of patients initially receive corticosteroid therapy. Furthermore, response to azathioprine, anti-TNF-α antibodies, and other immunomodulatory drugs is reported. Ten out of fourteen patients with a long-term follow-up (≥ 36 months) have at least one relapse of hepatic abscess formation.Aseptic hepatic abscesses should be considered in the case of sterile punctures and non-response to antibiotics. Patients with aseptic liver abscesses have a high risk of recurrence warranting immunomodulatory maintenance therapy.

Gastrointestinal Variant of Lemierre Syndrome due to Fusobacterium nucleatum: A Case Report

Introduction

Pyogenic liver abscess is a noteworthy health concern in North America, characterized by a mortality rate ranging from 2 to 12%. This condition is often polymicrobial, with Streptococcus species and Escherichia coli as the predominant causal pathogens in Western countries. Fusobacterium species, typically commensals of gastrointestinal, genital, and oral flora, have been implicated in the rare formation of tonsillar abscesses and Lemierre syndrome, including its gastrointestinal variant known as pylephlebitis.

Case Presentation

We present the case of an immunocompetent male with a 2-week history of abdominal distention and pain. Abdominal magnetic resonance imaging revealed multiseptated cystic hepatic masses and portal vein thrombosis. A subsequent liver biopsy confirmed Fusobacterium nucleatum etiology. The patient was initiated on intravenous cefepime and oral metronidazole antibiotics. Unfortunately, the patient succumbed to cardiac arrest before a final diagnosis could be established.

Conclusion

Fusobacterium species-associated liver abscess, coupled with the rare gastrointestinal variant of Lemierre syndrome (pylephlebitis), poses a significant mortality risk. This case underscores the rarity and clinical challenges associated with these conditions. Increased awareness among clinicians is crucial for early diagnosis and prompt intervention, potentially improving outcomes in such cases.

Genetic and immune determinants of E. coli liver abscess formation

Systemic infections can yield distinct outcomes in different tissues. In mice, intravenous inoculation of Escherichia coli leads to bacterial replication within liver abscesses, while other organs such as the spleen clear the pathogen. Abscesses are macroscopic necrotic regions that comprise the vast majority of the bacterial burden in the animal, yet little is known about the processes underlying their formation. Here, we characterize E. coli liver abscesses and identify host determinants of abscess susceptibility. Spatial transcriptomics revealed that liver abscesses are associated with heterogenous immune cell clusters comprised of macrophages, neutrophils, dendritic cells, innate lymphoid cells, and T-cells that surround necrotic regions of the liver. Abscess susceptibility is heightened in the C57BL lineage, particularly in C57BL/6N females. Backcross analyses demonstrated that abscess susceptibility is a polygenic trait inherited in a sex-dependent manner without direct linkage to sex chromosomes. As early as 1 d post infection, the magnitude of E. coli replication in the liver distinguishes abscess-susceptible and abscess-resistant strains of mice, suggesting that the immune pathways that regulate abscess formation are induced within hours. We characterized the early hepatic response with single-cell RNA sequencing and found that mice with reduced activation of early inflammatory responses, such as those lacking the LPS receptor TLR4 (Toll-like receptor 4), are resistant to abscess formation. Experiments with barcoded E. coli revealed that TLR4 mediates a tradeoff between abscess formation and bacterial clearance. Together, our findings define hallmarks of E. coli liver abscess formation and suggest that hyperactivation of the hepatic innate immune response drives liver abscess susceptibility.

Analysis of 15 cases from a monocentric cohort of 307 liver abscesses

BACKGROUND

Out of the context of haematological patients, Candida sp. is rarely retrieved from pyogenic liver abscesses (PLA).

OBJECTIVES

Our objective was to assess the risk factors for occurrence, and clinical, microbiological characteristics, management and outcome of Candida pyogenic liver abscesses (C-PLA).

PATIENTS/METHODS

We retrospectively analysed C-PLA cases and compared them to pyogenic liver abscesses exclusively due to bacteria (B-PLA) included in our monocentric database on liver abscesses. Unfavourable course was defined as the occurrence of a primary treatment failure (PTF), recurrence after an initial cure, or death within 3 months after diagnosis.

RESULTS

Between 2010 and 2018, 15 C-PLA and 292 B-PLA were included. All C-PLA had a biliary origin and were polymicrobial. All patients with C-PLA had at least one comorbidity at risk for Candida infection and 7 (53.3%) presented with sepsis requiring an admission in intensive care unit. Median duration of antifungal treatment was 42 days [24-55]. In multivariate analysis, compared with B-PLA, a medical history of malignancy (OR 4.16; 95%CI 1.15-18.72) or liver abscess (OR 7.39; 95%CI 2.10-26.62), and sepsis with severity criteria (OR 3.52; 95%CI 1.07-11.90) were independently associated with the occurrence of C-PLA. In multivariate analysis, C-PLA was associated with a higher risk of recurrence (HR 3.08; 95%CI 1.38-11.22).

CONCLUSION

Candida liver abscesses in non-neutropenic is a rare and severe disease. The high rate of recurrence should lead to discuss a more intensive treatment.

Antibiotic treatment durations for pyogenic liver abscesses: A systematic review

Background

We sought to systematically review the existing research on pyogenic liver abscesses to determine what data exist on antibiotic treatment durations.

Methods

We conducted a systematic review and meta-analysis of contemporary medical literature from 2000 to 2020, searching for studies of pyogenic liver abscesses. The primary outcome of interest was mean antibiotic treatment duration, which we pooled by random-effects meta-analysis. Meta-regression was performed to examine characteristics influencing antibiotic durations.

Results

Sixteen studies (of 3,933 patients) provided sufficient data on antibiotic durations for pooling in meta-analysis. Mean antibiotic durations were highly variable across studies, from 8.4 (SD 5.3) to 68.9 (SD 30.3) days. The pooled mean treatment duration was 32.7 days (95% CI 24.9 to 40.6), but heterogeneity was very high (I2 = 100%). In meta-regression, there was a non-significant trend towards decreased mean antibiotic treatment durations over later study years (-1.14 days/study year [95% CI -2.74 to 0.45], p = 0.16). Mean treatment duration was not associated with mean age of participants, percentage of infections caused by Klebsiella spp, percentage of patients with abscesses over 5 cm in diameter, percentage of patients with multiple abscesses, and percentage of patients receiving medical management. No randomized trials have compared treatment durations for pyogenic liver abscess, and no observational studies have reported outcomes according to treatment duration.

Conclusions

Among studies reporting on antibiotic durations for pyogenic liver abscess, treatment practices are highly variable. This variability does not seem to be explained by differences in patient, pathogen, abscess, or management characteristics. Future RCTs are needed to guide optimal treatment duration for patients with this complex infection.

Hepato-Biliary Imaging in an Acute Setting: Is There a Role for Nuclear Medicine?

Nuclear medicine (NM) is not commonly considered as a first-line imaging modality in hepato-biliary (HB) emergencies. The aim of this review is to provide an update on the potential of NM for the imaging of HB emergencies. 99mTc-HIDA scintigraphy showed high diagnostic accuracy for acute cholecystitis, thus being particularly useful in patients at high-risk for surgery due to comorbidities and with no clear findings at US or CT. Although limitedly explored, White blood cell (WBC) scan might have a role in case of acute pancreatitis, especially for the imaging of pancreatic leukocyte infiltration and the prediction of pancreatic necrosis. Scientific literature on 18F-FDG-PET/CT in HB acute disease mainly consists of case reports or case series, describing incidental findings in oncological PET/CT scans. In patients with obstructive jaundice, PET/CT has been proposed to disclose and characterize occult tumoral etiology. Further studies are needed to evaluate the clinical usefulness of the various NM approaches in HB acute settings, particularly with respect to the emerging new technologies (eg, PET/MRI) and radiopharmaceuticals.

Profile of Amoebic vs Pyogenic Liver Abscess and Comparison of Demographical, Clinical, and Laboratory Profiles of these Patients From a Tertiary Care Center in Northern India

Background and objective

Amoebic liver abscess (ALA) and pyogenic liver abscesses (PLA) are the most common causes of liver abscess in developing and developed countries, respectively. Although incidence of liver abscess is low, but mortality is high amongst the patients due to delayed diagnosis. The study was done to find out the prevalence of amoebic and PLA among patients of liver abscess. The clinical, personal, and demographical details were also evaluated to find out the risk factor(s) associated with ALA and PLA, respectively.

Method

A retrospective study was conducted to find the prevalence of amoebic and PLA. Clinical, demographic, personal details were evaluated from hospital records. Laboratory parameters such as total leucocyte count, platelets, bilirubin, ESR (Erythrocyte Sedimentation Rate), hemoglobin, glycosylated hemoglobin (HbA1c), alkaline phosphate (ALP), Aspartate aminotransferase (SGOT/AST), Alanine aminotransferase (SGPT/ALT), serum albumin, bilirubin levels, and procalcitonin were recorded. The Ultrasonography (USG) findings regarding the size, location, volume, and number of abscesses were also analyzed.

Results

Total of 107 patients of liver abscess were evaluated, and 61.6% of patients were of amoebic etiology, and 25.3% were of pyogenic etiology. Males of 20-60 years of age were predominantly affected with right upper quadrant pain and fever as the most common presentations. ALA patients were found to have solitary abscess in the right lobe involving 6th and 7th segments, with decreased hemoglobin, hyperbilirubinemia, elevated ALP and SGOT, with normal SGPT, and addiction to alcohol. PLA patients had increased HbA1c, increased PCT values, low serum albumin levels, and low platelet-to-white blood cell values. The most common bacteria causing PLA was Escherichia coli (n = 8) followed by Enterobacter cloacae (n = 5). Mortality was seen in 6 patients.

Conclusion

Liver abscess is found to have relatively high mortality and morbidity. Therefore, early diagnosis is the only method to prevent mortality and morbidity in these patients. Since the presentation is very nonspecific, evaluation of certain risk factors and laboratory parameters can aid in the diagnosis.

Hepatic abscessation in dogs: A multicenter study of 56 cases (2010-2019)

OBJECTIVE

To investigate the clinical findings, treatment strategies, and outcomes in dogs with confirmed hepatic abscessation.

DESIGN

Retrospective cohort study from 2010 to 2019.

SETTING

Multicenter study.

ANIMALS

Fifty-six client-owned dogs with hepatic abscessation confirmed by culture, cytology, or histopathology.

MEASUREMENTS AND MAIN RESULTS

Dogs were presented for lethargy (39/56), hyporexia (31/56), and vomiting (26/56). Abnormal physical examination findings included increased temperature (41/56) and abdominal pain (22/54). CBCs revealed neutrophilia (31/49), toxic changes (25/49), anemia (28/49), and thrombocytopenia (23/49). Biochemical analyses revealed increased alkaline phosphatase (45/50), increased alanine aminotransferase (40/50), hypoalbuminemia (25/48), and hyperbilirubinemia (19/49). Hypoglycemia was found in 13 of 49 dogs. Hepatic abscesses ranging from 0.5 to 15 cm in diameter were identified ultrasonographically in 37 of 48 dogs; 19 of 37 had solitary abscesses, and 18 of 37 had multifocal abscessation. Escherichia coli was the most commonly cultured organism, isolated in 18 of 42 cases. Histopathology revealed underlying hepatic neoplasia in 10 of 47 dogs. Surgical management was performed in 41 of 49 dogs, and 35 of 41 survived to discharge. Medical management was performed in 8 of 49 dogs, and 5 of 8 survived to discharge. With univariate analysis, hypoglycemia and multifocal abscessation were associated with decreased odds of survival (odds ratio [OR]: 0.2, 95% confidence interval [CI]: 0.03-0.9, P = 0.04; OR: 0.07, 95% CI: 0.01-0.6, P = 0.02, respectively). With multivariate analysis, only multifocal abscessation was associated with decreased odds of survival (OR: 0.09, 95% CI: 0.01-0.87, P = 0.04).

CONCLUSIONS

Hepatic abscessation, although rare, should remain a differential diagnosis for dogs presenting with nonspecific clinical signs and increase liver enzyme activities, especially with concurrent increased temperature and neutrophilia. Rate of survival to discharge for dogs in this study was consistent with previously reported survival rates, with 40 of 56 (71%) of the total population surviving to discharge. No variables assessed were able to predict survival to discharge; however, hypoglycemia and multifocal abscessation should be assessed in larger populations to determine prognostic significance.

Hepatic Abscess in Inflammatory Bowel Disease: A Systematic Scoping Review of an Overlooked Entity

Background

Liver abscess is one of the hepatobiliary manifestations of inflammatory bowel disease (IBD) that has been scarcely described in the literature.

Objectives

To conduct a scoping review to provide a detailed description of the occurrence of hepatic abscess in patients with IBD and summarize the observed clinical features.

Methodology

Searches were carried out using relevant keywords in Medline (via PubMed) and Web of Science from inception until June 13, 2022. Only articles that reported the occurrence of hepatic abscess in patients with IBD were included.

Results

Forty-eight publications (40 case reports and 8 case series) were included, representing 73 patients with IBD who were radiologically or intraoperatively diagnosed with hepatic abscess. Patients with Crohn's disease were more predisposed to developing hepatic abscess than patients with ulcerative colitis (79.5% vs. 20.5%, respectively). Furthermore, pyogenic liver abscess was found to be more prevalent (57.9%) compared with aseptic (38.7%) and amebic (3.2%) abscesses. No clear relation was found between death or prolonged hospital stay in terms of the clinical presentation or management plan, as mortality was reported in different age groups with different managements.

Conclusion

To date, there is no consensus regarding the appropriate management of hepatic abscess as an extraintestinal manifestation of IBD. However, the condition shares several features with liver abscess diagnosed among the general population.

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.

[Clinical and radiological differences between amoebic and pyogenic liver abscess: A case-control study]

INTRODUCTION

Amoebic liver abscess (ALA) is the fourth cause of mortality by parasitic infection. This study aimed to assess clinical, radiological and therapeutic characteristics of patients admitted for amoebic liver abscess compared to pyogenic abscess in a French digestive tertiary care-centre.

MATERIAL AND METHOD

The charts of patients hospitalized for a liver abscess between 2010 and 2020 were retrospectively assessed then separated in two groups: amoebic liver abscess and pyogenic liver abscess from portal underlying cause. Clinical and radiological data were collected for univariate comparison.

RESULTS

Twenty-one patients were hospitalized during the time of the study for ALA, and 21 patients for pyogenic liver abscess with a portal mechanism. All patients hospitalized for ALA lived in and/or had travelled recently in an endemic area. In comparison with patients hospitalized for pyogenic abscess, patients admitted for ALA were younger (44years old vs. 63years old, P<0.001), had less comorbidities (5% vs. 43% of patients with at least one comorbidity, P<0.01), a longer median duration of symptoms (10days vs. 3days, P=0.015), abdominal pain (86% vs. 52%, P=0.019), and a slighter leucocytosis (9600G/L vs. 15,500G/L, P=0.041) were more frequent. On the abdominal tomodensitometry, density of ALA was higher (34 vs. 25 UH, P<0.01), associated with a focal intra-hepatic biliary dilatation and less often multiloculated.

CONCLUSION

While rare in western countries, amoebic liver abscess care should not be underestimated. The presence of a solitary liver abscess of intermediate density on computed tomography, occurring on a patient returning from an endemic zone should lead the physician to a possible diagnosis of ALA.

A Population-Based Study of Unfavorable Prognostic Factors Associated With Pyogenic Liver Abscess

Background

Pyogenic liver abscess (PLA) is a rare entity that is associated with substantial mortality and morbidity. Our objective was to investigate variables associated with mortality and subsequent PLA in patients diagnosed with PLA in southern Sweden.

Methods

We conducted a population-based observational study comprising all episodes of PLA that occurred between 2011 and 2020 in the county of Skåne, southern Sweden. The primary outcome was defined as all-cause 90-day mortality and the secondary outcome was defined as the occurrence of a subsequent PLA.

Results

A total of 452 episodes of PLA occurred in 360 patients during the study period. The 90-day mortality rate was 16% (n = 58) and the subsequent PLA rate was 20% (n = 92). In a multivariable logistic regression model, female sex (odds ratio [OR], 2.0 [95% confidence interval {CI}, 1.1-3.9]), malignancy (OR, 3.7 [95% CI, 1.9-7.1]), liver failure (OR, 6.3 [95% CI, 2.7-14.5]), and polymicrobial findings (OR, 3.8 [95% CI, 2.2-6.9]) were associated with death within 90 days (P < .05). Male sex (OR, 2.1 [95% CI, 1.2-3.6]), malignancy (OR, 2.1 [95% CI, 1.3-3.6]), age (64-74 years: OR, 2.5 [95% CI, 1.3-4.8]), and chronic liver disease (OR, 3.0 [95% CI, 1.4-6.5]) were associated with the risk of subsequent PLA (P ≤ .01).

Conclusions

Identifying different clinical variables associated with an unfavorable outcome may improve the management and treatment of patients with PLA and thus prevent the risk of death and subsequent PLA.

The New Changes of Epidemiology, Etiology, and Clinical Characteristics of Pyogenic Liver Abscesses: A Retrospective Study in a Hospital in Northern China

Purpose

To investigate the epidemiology, etiology, and clinical characteristics of patients with pyogenic liver abscesses (PLA) and provide guidance for clinical treatments.

Patients and Methods

A retrospective study was performed on a cohort of 402 hospitalized patients diagnosed with PLAs at the Affiliated Hospital of Chengde Medical College between January 2016 and December 2021. Patient demographics, drug sensitivity profiles, and microbiological culture results of drainage and blood samples were thoroughly analyzed to identify significant patterns or trends. Furthermore, clinical characteristics and treatments for patients with PLA were comprehensively assessed.

Results

Patients aged 50-69 years had the highest incidence of PLA, accounting for 59.9% of all cases, and 91.5% of them had a fever. Bacterial culture analysis of the 200 patients revealed that Klebsiella pneumoniae (K. pneumoniae) was the most predominant pathogen, detected in 70.5% of cases, exhibiting an upward trend. Escherichia coli (E. coli) was the second most frequently detected pathogen, identified in 14.5% of cases, showing a downward trend. Coexisting diabetes mellitus (DM) was found to be the most common comorbidity for PLA, occurring in most patients with the condition. Patients with a history of abdominal surgery and malignancy had an increased risk for PLA, while those with gallstones had a decreased risk. Drainage combined with antibiotic therapy was identified as the primary treatment of PLA. In addition, multivariate analysis demonstrated that coexisting DM and the presence of gas in the abscess cavity were independent risk factors for septic shock in patients with PLA.

Conclusion

This study reveals a shift in the proportions of pathogens and risk factors in patients with PLA, underscoring the necessity for improved diagnostic and therapeutic strategies.

Genetic and immune determinants of E. coli liver abscess formation

Systemic infections can yield distinct outcomes in different tissues. In mice, intravenous inoculation of E. coli leads to bacterial replication within liver abscesses while other organs such as the spleen largely clear the pathogen. Abscesses are macroscopic necrotic regions that comprise the vast majority of the bacterial burden in the animal, yet little is known about the processes underlying their formation. Here, we characterize E. coli liver abscesses and identify host determinants of abscess susceptibility. Spatial transcriptomics revealed that liver abscesses are associated with heterogenous immune cell clusters comprised of macrophages, neutrophils, dendritic cells, innate lymphoid cells, and T-cells that surround necrotic regions of the liver. Susceptibility to liver abscesses is heightened in the C57BL/6 lineage, particularly in C57BL/6N females. Backcross analyses demonstrated that abscess susceptibility is a polygenic trait inherited in a sex-dependent manner without direct linkage to sex chromosomes. As early as one day post infection, the magnitude of E. coli replication in the liver distinguishes abscess-susceptible and abscess-resistant strains of mice, suggesting that the immune pathways that regulate abscess formation are induced within hours. We characterized the early hepatic response with single-cell RNA sequencing and found that mice with reduced activation of early inflammatory responses, such as those lacking the LPS receptor TLR4, are resistant to abscess formation. Experiments with barcoded E. coli revealed that TLR4 mediates a tradeoff between abscess formation and bacterial clearance. Together, our findings define hallmarks of E. coli liver abscess formation and suggest that hyperactivation of the hepatic innate immune response drives liver abscess susceptibility.

Does Liver Resection Remain a Viable Option in Patients With Pyogenic Liver Abscess? A Single-Center Experience

Pyogenic liver abscesses (PLAs) are relatively rare but often fatal if left untreated. Antibiotic therapy combined with percutaneous procedures has replaced surgery as the cornerstone of treatment. However, open surgical drainage or liver resection may be a last resort. This study aimed to review our experience in treating PLA, with a focus on the conditions requiring partial liver resection as the last viable curative option. Medical records of patients with PLA admitted to Jordan Hospital between October 2014 through October 2020 were retrospectively reviewed. Medical and demographic data of all 43 patients admitted to our facility with a diagnosis of PLA were extracted. We reviewed these patients and extracted the cases that required surgical intervention. Four (three males and one female) of the 43 patients with PLA required surgical intervention. The underlying causes of liver abscesses were as follows: one traumatic due to shrapnel injury from an explosion, one following chemoembolization for hepatocellular carcinoma, and two patients with no apparent etiology. All patients were diagnosed with a computed tomography (CT) scan of the abdomen and pelvis with intravenous contrast. Two patients had negative cultures. All patients received broad-spectrum antibiotics, and all underwent CT- or ultrasound-guided percutaneous drainage or aspiration. All four patients required partial hepatic resection due to treatment failure or inaccessible percutaneous procedures with clinical improvement. Although antimicrobial and interventional therapy remains the primary treatment option in PLA, the surgical option with open surgical drainage or partial liver resection remains viable and curative in selected patients.

How a Simple Diabetic Ketoacidosis Was Actually a Deadly Liver Abscess

Pyogenic liver abscesses (PLA) are rare causes of infection in immunocompetent individuals in developed countries. In this report, we discuss a rare presentation and the risk factors associated with developing PLA. Our aim is to raise awareness about PLA developing in patients with uncommon risk factors, enabling early identification and appropriate treatment. The case involves a male patient who presented to the hospital with generalized weakness, was admitted for diabetic ketoacidosis (DKA), and incidentally had elevated liver enzymes that required further investigation. It is important to note that risk factors such as diabetes mellitus, proton pump inhibitors, and colon malignancies are very rare but have been reported in isolated cases as potential risks for developing PLA. Early diagnosis of PLA is crucial due to its high mortality rate, even with intervention.

The influence of early adoption of nonenhanced computed tomography on management of patients with pyogenic liver abscess

Background and Aim

A pyogenic liver abscess (PLA) is an infectious disease with high in-hospital mortality. It has no specific symptoms and is difficult to be diagnosed early in the emergency department. Ultrasound is commonly used to detect PLA lesions of PLA, but its sensitivity can be affected by lesion size, location, and clinician experience. Therefore, early diagnosis and prompt treatment (especially abscess drainage) are crucial for better patient outcomes and should be prioritized by clinical physicians.

Methods

We conducted a retrospective study to compare the effect of early and late (i.e., receiving CT scanning within 48 h and >48 h after admission) adoption of nonenhanced computed tomography (CT) scanning regarding the hospitalization days and interval between admission and drainage of patients with PLA.

Results

This study included 76 hospitalized patients with PLA in the Department of Digestive Disease of Xiamen Chang Gung Hospital in China who underwent CT examinations from 2014 to 2021. We conducted CT scans on 56 patients within 48 h of admission and on 20 patients more than 48 h after admission. The early CT group had a significantly shorter hospitalization length compared with the late CT group (15.0 days vs. 20.5 days; P = 0.035). Besides, the median time to initiate drainage after admission was also significantly shorter in the early CT group than in the late CT group (1.0 days vs. 4.5 days; P < 0.001).

Conclusion

Early CT scanning within 48 h of admission may aid in early PLA diagnosis and benefit disease recovery, as revealed by our findings.

Giant Klebsiella pneumoniae pyogenic liver abscess in the left liver lobe presenting with dyspepsia and vaginal discharge

Pyogenic liver abscess (PLA) commonly occurs in the right liver lobe, causing the typical symptoms of fever and right upper quadrant pain. Less than one-third of cases occur in the left lobe. We describe an unusual presentation of a giant left-sided PLA that was compressing the stomach and surrounding venous vasculature, causing the respective symptoms of gastro-oesophageal reflux and vaginal discharge from secondary pelvic congestion syndrome. CT revealed a solitary 14 cm×10 cm×10 cm multiloculated lesion, replacing most of the left liver lobe. It was successfully treated with intravenous antibiotics and percutaneous drainage, resulting in complete resolution at 1-year follow-up. This case explores the predisposing risk factor of diabetes in PLA and its association with Klebsiella pneumoniae, which was the offending pathogen in our patient. We also discuss the phenomenon of secondary pelvic venous congestion syndrome and compare similar cases of left-sided PLA, highlighting the different modes of presentation and treatment options.

Clinical efficacy of ulinastatin in the treatment of unliquefied pyogenic liver abscess complicated by septic shock: A randomized controlled trial

INTRODUCTION

This study determined the therapeutic effect of ulinastatin (UTI) on unliquefied pyogenic liver abscesses complicated by septic shock (UPLA-SS).

METHODS

This was a randomized controlled trial involving patients with UPLA-SS who underwent treatment at our hospital between March 2018 and March 2022. The patients were randomly divided into control (n = 51) and study groups (n = 48). Both groups received routine treatment, but the study group received UTI (200,000 units q8h for >3 days). Differences in liver function, inflammatory indices, and effectiveness between the two groups were recorded.

RESULTS

Following treatment, the white blood cell count, and lactate, C-reactive protein, procalcitonin, tumor necrosis factor-α, and interleukin-6 levels were significantly decreased in all patients compared to the admission values (p < .05). The study group had a faster decline with respect to the above indices compared to the control group (p < .05). The study group length of intensive care unit stay, fever duration, and vasoactive drug maintenance time were all significantly shorter than the control group (p < .05). The total bilirubin, alanine aminotransferase, and aspartate aminotransferase levels were significantly lower in the study and control groups after treatment compared to before treatment (p < .05); however, the study group had a faster recovery of liver function than the control group (p < .05). The overall mortality rate was 14.14% (14/99); 10.41% of the study group patients died and 17.65% of the control group patients died, but there was no statistically significant difference between the two groups (p > .05).

CONCLUSION

UTI combined with conventional treatment significantly controlled the infection symptoms, improved organ function, and shortened the treatment time in patients with UPLA-SS.

Liver abscess due to Granulicatella adiacens in an immunocompetent patient: Case report

Pyogenic liver abscesses due to Granulicatella adiacens are infections associated with high mortality, mainly in immunocompromised patients. The main microorganisms associated with liver abscesses are Klebsiella pneumoniae, and Escherichia coli, though it may also be polymicrobial. However, case reports describing liver infection by Granulicatella adiacens are scarce. We present the case of an immunocompetent adult patient who presented 15 days of evolution consisting of quantified fever peaks associated with asthenia, adynamia, chills, jaundice and coluria. The initial clinical examination revealed a generalized icteric tint without abdominal pain, and blood pressure with a tendency to hypotension. Biliopancreatic confluent neoplasia, secondary cholangitis and sepsis of biliary origin were suspected, initiating fluid resuscitation and antibiotic therapy; blood cultures and complementary diagnostic studies were taken. Hepatobiliary ultrasound with evidence of an abscess of 73 x 62 mm in segment IV; the bile duct and pancreas were within normal limits. To better characterize the lesion evidenced in the liver, a contrast-enhanced computed tomography of the abdomen was performed. The patient completed antibiotic management with ciprofloxacin, vancomycin, and metronidazole in good condition and was successfully discharged. This is the first pyogenic liver abscess reported caused by Granulicatella adiacens in an immunocompetent patient, in whom early microbiological diagnosis in conjunction with targeted antibiotic treatment and percutaneous drainage of the lesion was decisive in the clinical outcome.

Diagnosing Infectious Hepatic Cysts in an Older Patient With Multiple Skin Masses: A Case Report

Among the most severe complications of hepatic cystic diseases is infectious hepatic cysts (IHCs). IHCs may appear mainly among immunocompromised hosts. However, older patients have a variety of immunological conditions. The detection of the factors suppressing immunity is essential for patients with IHCs. Herein, we present the case of an 86-year-old woman admitted to the emergency department with a fever. We suspected IHCs based on changes in abdominal ultrasound findings. After multiple follow-ups to determine the cause of the fever that was unresponsive to treatment, we discovered debris in the cyst that had not been present at the time of the initial presentation. The patient was subsequently treated with percutaneous transhepatic drainage and tazobactam/piperacillin. The investigation of the causes of immunosuppression clarified the multiple skin masses. The biopsy of the mass clarified diffuse large B cell lymphoma without lymph node swellings. Consecutive ultrasound can detect findings missed during the initial presentation and changes that occur within a short period. The detection of the causes of immunosuppression is essential even among older patients with IHCs for better care among older patients.

Clinical characteristics and management of 106 patients with pyogenic liver abscess in a traditional Chinese hospital

This is a retrospective study of clinical data from 106 patients with pyogenic liver abscess (PLA) treated in a traditional Chinese hospital during the eight years preceding this publication. We aimed to provide evidence to improve the diagnosis accuracy and the treatment strategies for PLAs. We collected records of patients treated at the Guangxing Hospital, which is affiliated to the Zhejiang Traditional Chinese University in Hangzhou, and we collected their general background information, laboratory and imaging features, and clinical manifestations and outcomes to perform a retrospective analysis. Diabetes mellitus (45.3%, 48/106), biliary calculi (36.8%, 39/106), and history of abdominal surgery (15.1%, 16/106) were the three most common PLA risk factors present in our cohort. Fever and chills (95.3%, 101/106), right upper quadrant pain/epigastric discomfort (68.9%, 73/106), nausea and vomiting (38.8%, 41/106), and cough and sputum (14.2%, 15/106) were the most common clinical manifestations of PLA. Most patients had the abscesses in the right liver lobe, and the most commonly found bacteria were Klebsiella pneumoniae (54.8%, 42/76), Escherichia coli (35.1%, 27/76), and Streptococcus pneumoniae (3.9%, 3/76). Liver Doppler ultrasound is a conventional and effective method to identify liver abscesses. Most patients were treated using a percutaneous puncture under B-ultrasound guidance. Most patients (n = 104 or 98.1%) were cured, one patient (0.9%) died, and one was discharged with multiple abscesses post treatment.

Successful hepatic resection for invasive Klebsiella pneumoniae large multiloculated liver abscesses with percutaneous drainage failure: A case report

Background

Invasive Klebsiella-associated liver abscesses can progress rapidly and cause severe metastatic infections such as meningitis and hydrocephalus, which are associated with high morbidity and mortality. In patients with large multiloculated liver abscesses after failure of percutaneous drainage, rapid diagnosis of the abscess followed by hepatic resection is necessary for early recovery and to prevent severe secondary metastatic complications.

Case presentation

An 84-year-old woman with a large liver abscess and in septic shock was transferred to our hospital. Abdominal CT showed multiloculated liver abscesses 15 cm in diameter in the right lobe of the liver. We first performed percutaneous liver abscess drainage. The patient was managed in the intensive care unit, as well as treated with intravenous administration of meropenem followed by cefozopran according to the antibiogram. Klebsiella pneumoniae with invasive infection was confirmed by a string test in an isolated colony of K. pneumoniae; the K1 serotype with the rmpA and magA genes was determined by polymerase chain reaction and Sanger sequencing. Additional percutaneous liver abscess drainage was performed due to initial inadequate drainage. Although the abscess had shrunk to a diameter of 8 cm after drainage in 4 weeks, the patient recovered from sepsis, but still had low-grade fever (occasionally 38°C) and continued to have symptoms of chronic inflammation with persistent hyper mucus discharge from the liver abscess. Surgical resection was chosen to prevent prolonged hospitalization and ensure early recovery. A right posterior sectionectomy of the liver, including liver abscess, was performed. The post-operative course was uneventful, with no complications, and she was discharged after 18 days. There were no signs of abscess recurrence 1 year after surgery.

Conclusion

We present a case of successful hepatic resection after percutaneous drainage failure in a patient with invasive K. pneumoniae multiloculated liver abscess.

Role of liver biopsy in management of liver diseases without hepatic nodules following end of the interferon era: experience of a tertiary referral center

Liver biopsy (LB) is the cornerstone in the management of patients with liver diseases. However, a lot of queries had emerged about its role following the end of the interferon era. The aim of this study was to re-evaluate the current role of LB in the diagnosis of liver diseases. All patients who had underwent LB at the Department of Hepatology, National Liver Institute, from January 2015 through December 2018 were recruited. Indications for LB, pathology reports and medical records of all cases were retrieved, reviewed and statistically analyzed. A total of 275 liver biopsies were collected, 191 males and 84 females with mean age 41.22 ± 13.36 years. Etiological diagnosis made by histopathological evaluation was 48 drug-induced liver injury (DILI), 42 nonalcoholic fatty liver disease (NAFLD), 34 chronic hepatitis B, or C with cholestasis, 29 autoimmune hepatitis, 34 primary sclerosing cholangitis, 13 primary biliary cholangitis, 7 autoimmune overlap syndrome, 13 active bilharziasis and 10 Wilson's disease. Minor number of cases was diagnosed by different other etiologies. Initial diagnosis was made by liver biopsy and confirmed by clinical response and laboratory findings. Liver biopsy is still considered as the gold standard diagnostic measure of different liver diseases representing an integral component of management decisions in hepatology.

MICROBIOLOGICAL ANALYSIS OF ABDOMINAL CAVITY EXUDATE, BLOOD AND AFFECTED TISSUES SAMPLES FROM PATIENTS WITH INTRA-ABDOMINAL ABSCESSES IN COMPLICATED INFECTION OF ABDOMINAL CAVITY

OBJECTIVE

The aim: To conduct an analysis of the results of a microbiological examination of biological samples taken from patients with intra-abdominal abscesses.

PATIENTS AND METHODS

Materials and methods: Material for microbiological examination was collected from 60 patients during surgery and transported to laboratory at the same day. Isolation and identification of microbial pure cultures were performed by standard microbiological methods. Statistical analysis was performed using Statistica software.

RESULTS

Results: Analyzing the microbiological research results indicated importance of the sample collecting time (first or repeated surgery). In pa¬tient's blood taken during first surgery it was found a statistically significant predominance of no growth of microflora. In abdominal cav¬ity exudates anaerobic cultures increased statistically significantly in repeated surgery. It was noted that in samples taken during first sur¬gery mixed pathogens were represented mainly by facultative anaerobic cocci, then in repeated surgery anaerobic microorganisms were predominant. Examination of liver abscess content found that monoculture was isolated in 85.7 %. Blood and affected tissue samples in such patients were sterile. Investigation of samples from patients with multiple abdominal cavity abscesses revealed anaerobic microorganisms in 16.7 %. Blood samples of that patients in 40 % were sterile.

CONCLUSION

Conclusions: An analysis showed that in appendicular abscesses content gram-negatives were predominant. Gram-positive bacteria dominated in paravesical abscesses with 65 % isolates from gallbladder and 66.7 % from the affected tissue samples. In liver abscesses gram-positive cocci were isolated in 57.1 %. In multiple abdominal abscesses due to bowel perforation rod-shaped microflora was predominant (76 %) and represented by either obligate aerobes or obligate and facultative anaerobes.

Clinical and CT comparative study of invasive and non-invasive Klebsiella pneumoniae liver abscesses

AIM

To investigate the clinical and CT features of invasive and non-invasive Klebsiella pneumoniae liver abscesses (KPLA).

MATERIALS AND METHODS

Fifty-one patients with KPLA diagnosis including 26 invasive and 25 non-invasive KPLA cases were analysed retrospectively. All patients underwent routine abdominal unenhanced and three-phase enhanced CT examinations. The CT images were assessed by two experienced radiologists by examining location, number, size, septa, texture, gas in the pus cavity, portal phlebitis, thrombophlebitis, and abnormal perfusion during the arterial phase. Statistical differences for continuous characteristics were analysed with independent samples t-test or Wilcoxon's test, while the chi-square test or Fisher's exact test was used for categorical variables. A logistic regression analysis was performed to determine the independent related factors of invasive KPLA and receiver operating characteristic (ROC) curves were used for assessment.

RESULTS

Age and type 2 diabetes were significantly different between the patients with invasive and non-invasive KPLA. In addition, patients with invasive KPLA had lower levels of platelet and total protein (p<0.05) and higher total bilirubin compared to patients with non-invasive KPLA. Throughout the regression analysis, total bilirubin, platelets, and total protein demonstrated an area under the ROC curves of 0.717, 0.745, and 0.728, respectively.

CONCLUSION

Invasive KPLA occurs predominantly in younger patients with type 2 diabetes. Laboratory tests revealed low platelet and total protein levels and high total bilirubin levels. If the patient with KPLA exhibits hepatic venous thrombophlebitis with no abnormal enhancement around the abscess in the arterial phase of enhanced CT, it indicates that the abscess has invaded.

Epidemiology, Clinical Features, and Outcome of Liver Abscess: A Single-Center Experience

Introduction Liver abscesses are rare, but whenever they occur, it is predominantly among males over 60 years of age. The paradigm in the treatment has changed, and percutaneous drainage is now the initial treatment for drainage of the abscesses. Open surgery is reserved for patients with septated abscesses and those greater than 5 cm. Objective  To study the etiological, clinical, pathological, and demographic characteristics of individuals with liver abscesses and to evaluate the outcome associated with different treatment strategies. Methods This clinico-epidemiological study was carried out at a tertiary care hospital in Jodhpur. One hundred patients with liver abscesses were studied. Patients were assigned to three groups: Group 1 - medical management alone (in non-aspirable uncomplicated abscess), Group 2 - USG-guided needle aspiration or pigtail percutaneous catheter drainage plus medical management (in unruptured aspirable abscess), Group 3 - open surgical drainage plus medical management (In ruptured abscesses). Of the total patients, 36% were treated with medical therapy alone, 45% with USG-guided needle aspiration, 10% with USG-guided percutaneous catheter drainage, and 9% with open surgical drainage. Results In our study, fever and hepatomegaly were the commonest presentations, observed in 91% and 62% of cases, respectively. Escherichia coli (E.coli) was the predominant organism cultured in 28 (43.75%) patients followed by Klebsiella growing in 24 (37.50%) patients. The right lobe was affected more (83%) than the left lobe and in the majority (83%), a solitary abscess was present. The mean age of liver abscess presentation was 40.72 years, with a 5.67:1 male-to-female ratio. Alcohol consumption was reported by 33% of patients, the majority of whom were men. Serum bilirubin was elevated in 56% of liver abscess patients, while it was normal in 44%. The mean serum bilirubin was 2.08 mg/dl. The mean value in group 1, group 2, and group 3 was 1.44 mg/dl, 2.23 mg/dl, and 2.57 mg/dl, respectively. Liver abscesses were identified in 76% of patients with right lobes; 83% had solitary liver abscesses and 17% had numerous abscesses. Abscess culture showed E. coli in 21 (32.81%) and Klebsiella in 17 (26.56%) patients. Conclusion Right-sided solitary pyogenic liver abscess caused by E.coli is the most common liver abscess, with fever and hepatomegaly as the most common presentation. Non-aspirable liver abscesses, regardless of aetiology, can be successfully treated by medical therapy alone. Needle aspiration or catheter drainage is standard for liver abscesses. Thus, needle aspiration has replaced the surgical exploration of liver abscesses.

Multiple Hepatic Abscesses Secondary to Streptococcus anginosus Infection: A Case Report and Review of the Literature

Hepatic abscesses are rare and generally present as solitary lesions in immunocompromised patients. The development of multiple hepatic abscesses in an immunocompetent patient is relatively uncommon. We report a rare case of a 73-year-old woman who presented with fever and right upper quadrant abdominal tenderness. Laboratory findings were significant for leukocytosis, transaminitis, and elevated inflammatory markers. Peripheral blood culture grew Streptococcus anginosus. Computed tomography of the abdomen and pelvis (CT A/P) revealed multiple hypoattenuating ill-defined cystic lesions in the liver consistent with abscesses formation; this was confirmed by magnetic resonance cholangiopancreatography (MRCP). The patient underwent appropriate treatment with antibiotics. Upon a three-week follow-up, the patient’s symptoms subsided, and her laboratory parameters normalized. Although Streptococcus anginosus is a normal gastrointestinal flora, it has the potential to form abscesses. Our report indicates the importance of considering Streptococcus anginosus in the differential diagnosis. Management includes four to six weeks of antibiotic therapy together with drainage of larger abscesses.

Emergence of K1 ST23 and K2 ST65 hypervirulent klebsiella pneumoniae as true pathogens with specific virulence genes in cryptogenic pyogenic liver abscesses Shiraz Iran

Hypervirulent Klebsiella pneumoniae (hvKp) pathotype is emerging worldwide in pyogenic liver abscesses (PLAs). However, the role of virulence factors in pathogenicity remains unclear. On the other hand, the epidemiology of PLAs in Iran is unknown. From July 2020 to April 2022, bacterial species were isolated and identified from the drainage samples of 54 patients with PLAs. K. pneumoniae as the most common pathogen of pyogenic liver abscesses was identified in 20 (37%) of the 54 patients. We analyzed the clinical and microbiological characteristics of K. pneumoniae-related pyogenic liver abscesses. Antibiotic susceptibility testes and string test were performed. 16S rRNA, antibiotic resistance, and virulence genes were determined by polymerase chain reaction amplification. Clonal relatedness of isolates was identified by multilocus sequence typing. Virulence levels were assessed in the Galleria mellonella larval infection model. Four hvKp isolates (K1/K2) were found to be responsible for cryptogenic PLAs, and 16 classical K. pneumoniae isolates (non-K1/K2) were associated with non-cryptogenic PLAs. Three capsular serotype K1 strains belonged to sequence type 23 (ST23) and one K2 strain to ST65. Meanwhile, the non-K1/K2 strains belonged to other STs. ST231 was the most common strain among the classical K. pneumoniae strains. Compared with the non-K1/K2 strains, capsular serotypes K1/K2 strains were less resistant to antibiotics, had positive string test results, and had more virulence genes. In Galleria mellonella, a concentration of 10⁶ colony-forming units of the K1 hvKp strain resulted in 100% death at 24 hours, confirming the higher virulence of the hvKp strain compared with cKp. K. pneumoniae isolates represented that the acquisition of any plasmid or chromosomal virulence genes contributes to pathogenicity and high prevalence in PLAs. Meanwhile, hvKp isolates with a specific genetic background were detected in cryptogenic PLAs.

Occurrence of spontaneous fistulas detected by contrast filling during computed tomography-guided percutaneous drainage placement of splenic and perisplenic fluid collections

BACKGROUND

Fistulas are serious complications of splenic and perisplenic fluid accumulations, which are often difficult to detect by routine imaging methods.

PURPOSE

To evaluate the occurrence of spontaneous fistulas detectable during computed tomography-guided percutaneous drainage placement (CTGDP) with contrast filling of splenic or perisplenic fluid collections and to assess characteristics in comparison with perihepatic or peripancreatic fluid accumulations, also being treated with CTGDP.

MATERIAL AND METHODS

In 127 CTGDP-procedures, pre-interventional CTs conducted with intravenous contrast agent were compared to post-interventional CTs including contrast filling of the drain to identify spontaneous fistulas. Patient and case characteristics were evaluated, and therapeutic consequences of fistula identification were analyzed.

RESULTS

A total of 43 perisplenic, 40 peripancreatic, and 44 perihepatic drains were evaluated; 13 (30.2%) perisplenic, 7 (17.5%) peripancreatic, and 10 (22.7%) perihepatic fistulas were observed. Concerning the frequency of fistulas, no significant difference was found between the patient groups (P = 0.39). All fistulas were solely proven in CT scans including contrast filling of the drain. Seven fistulas (23.3%) required additional interventions. Perihepatic drains were significantly more often associated with recent surgery (P < 0.001). The mean size of peripancreatic drains was significantly greater (11.8 ± 3.9 F; P < 0.001) than in perihepatic or perisplenic fluid collections.

CONCLUSION

Spontaneous fistulas detected during CTGDP of splenic or perisplenic fluid collections are common. Post-interventional contrast filling of the drain drastically improves the detection rate of perisplenic, peripancreatic and perihepatic fistulas simultaneously initiating appropriate follow-up interventions.

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.

Prophylactic Use of Antibiotics for Postsurgical Infection in c-TACE and DEB-TACE High-Risk Patients: A Case-Control Study

Objectives

According to recent reports, prophylactic use of antibiotics is not always required in conventional transarterial chemoembolization (c-TACE). However, clinical evidence of prophylactic antibiotics in drug-eluting beads transarterial chemoembolization (DEB-TACE) to prevent postsurgical infection is limited. This study is aimed to evaluate the correlation between the preoperative prophylactic application of antibiotics and postoperative infection in c-TACE or DEB-TACE, especially in a population with a high risk for postsurgical infection.

Methods

In this retrospective study, TACE patients diagnosed with hepatic carcinoma (between January 2019 and May 2021) were examined. The case group was given 1.5 g cefuroxime sodium 0.5-1 hour before TACE, while there was no intervention in the control group. The outcomes analyzed were leukocyte count >9.5 × 109/L on the second day after the operation and the diagnosis of infection within one month after the operation. We applied univariate, multivariate logistic regression, trend analysis, and subgroup analysis to find potential risk factors and the necessity of prophylactic antibiotics.

Results

Among 142 eligible cases, 72 received antibiotics while 70 were kept as control, 113 cases were treated with c-TACE, and 29 were treated with DEB-TACE. Multivariate analysis showed that the increase in white blood cell count after the operation was related to diabetes (OR 5.112, 95% CI 1.229-21.264, p = 0.025). The occurrence of postoperative infection was negatively correlated with preoperative albumin value (＜25 g/L) (OR 153.118, 95% CI 1.631-14372.331, p = 0.030). Trend analysis showed that the risk of postoperative infection increased with a decrease in serum albumin level (P < 0.05). Subgroup analysis showed that there were no significant differences in the incidence of increased leukocyte count and postoperative infection between the prophylactic and nonprophylactic treatment groups, in the case of diabetes, preoperative albumin levels, and operation mode (P > 0.1).

Conclusions

Prophylactic antibiotic treatment before the c-TACE or DEB-TACE had no significant correlation with postoperative leukocyte increase and postoperative infection. Diabetes history and serum albumin levels were the prominent risk factors associated with an increase in postoperative leukocyte count and postoperative infection. Future large-scale studies and randomized-controlled trials are required to confirm and validate this association.

Large retrospective study analysing predictive factors of primary treatment failure, recurrence and death in pyogenic liver abscesses

PURPOSE

Pyogenic liver abscess (PLA) is a severe disease, which unfavourable evolution remains frequent. Our objective was to assess predictive factors of unfavourable outcome in patients with PLA.

METHODS

We conducted a retrospective study in a French tertiary care centre. All patients admitted for PLA between 2010 and 2018 were included. Unfavourable course was defined as the occurrence of a primary treatment failure (PTF), recurrence of PLA after an initial cure, or death within 3 months after diagnosis. Hazard ratios (95% CI) were calculated with multivariable Cox proportional hazard models.

RESULTS

302 patients were included among which 91 (30.1%) patients had an unfavourable outcome because of PTF, recurrence or death in 55 (18.2%), 28 (9.2%) and 32 (10.6%) patients, respectively. Hepatic metastases (HR 2.08; 95% CI 1.04-4.15), a nosocomial infection (2.25; 1.14-4.42), portal thrombosis (2.12; 1.14-3.93), and the isolation of Enterococcus spp. (2.18; 1.22- 3.90) were independently associated with PTF. Ischemic cholangitis (6.30; 2.70-14.70) and the isolation of Streptococcus spp. (3.72; 1.36-10.16) were associated with the risk of recurrence. Charlson comorbidity index (HR 1.30 per one point; 95% CI 1.15-1.46; p < 0.001), portal thrombosis (3.53; 1.65-7.56) and the presence of multi-drug-resistant organisms (3.81; 1.73-8.40) were associated with mortality within 3 months following PLA diagnosis. PLA drainage was the only factor associated with a lower mortality (0.14; 0.06-0.34).

CONCLUSION

Identification of specific risk factors may help to improve the management of PLA and to elaborate targeted recommendations according to patient's and disease's characteristics.

Large Solitary Pyogenic Liver Abscesses: A Review of Their Management at a Tertiary Care Hospital

Background and objective

Liver abscesses are one of the common surgical diseases to be treated as an emergency in any tertiary care hospital in India. The formation of abscesses in the liver is still a major problem and associated with significant morbidity in developing countries. We come across all types of liver abscesses, such as amoebic (most common), pyogenic, mixed, and occasionally fungal. There have been several studies on the percutaneous modality of treatment for pyogenic liver abscesses. Most of the studies suggest that percutaneous catheter drainage (PCD) offers a better approach than aspirations for treating pyogenic liver abscesses. However, a few recent studies suggest that percutaneous aspiration leads to equally good results when compared to percutaneous drainage. In this study, we aimed to review the management of solitary large pyogenic liver abscesses and to assess the effectiveness of ultrasonography (USG)-guided aspiration in the procedure. 

Methods

A retrospective study was carried out at the Department of General Surgery of our institute. In this study, a total of 27 patients treated for solitary pyogenic liver abscess were included. All patients with a large liver abscess greater than 5 cm without the features of frank peritonitis were included. These patients were followed up regularly for six months.

Results

The single-attempt USG-guided aspiration was successful in 70.3% of patients. Repeat USG-guided aspiration was performed in 18.5% of patients. In 7.4% of patients, a USG-guided percutaneous pigtail catheter was placed. And only 3.7% of cases required exploratory laparotomy. 

Conclusion

Based on our findings, USG-guided aspiration is a fairly efficient method for treating a large solitary pyogenic abscess with acceptable results, shorter hospital stays, and minimal complications.

The “Black Pattern”, a Simplified Ultrasound Approach to Non-Traumatic Abdominal Emergencies

Background: A key issue in abdominal US is the assessment of fluid, which is usually anechoic, thus appearing “black”. Our approach focuses on searching for fluid in non-traumatic patients, providing a new, simplified method for point-of-care US (POCUS). Objective: Fluid assessment is based on a three-step analysis that we can thus summarize. 1. Look for black where it should not be. This means searching for effusions or collections. 2. Check if black is too much. This means evaluating anatomical landmarks where fluid should normally be present but may be abnormally abundant. 3. Look for black that is not clearly black. This means evaluating fluid aspects, whether wholly anechoic or not (suggesting heterogeneous or corpusculated fluid). Discussion: Using this simple method focused on US fluid presence and appearance should help clinicians to make a timely diagnosis. Although our simplified, systematic algorithm of POCUS may identify abnormalities; this usually entails a second-level imaging. An accurate knowledge of the physio–pathological and anatomical ultrasound bases remains essential in applying this algorithm. Conclusion: The black pattern approach in non -traumatic emergencies may be applied to a broad spectrum of abnormalities. It may represent a valuable aid for emergency physicians, especially if inexperienced, involved in a variety of non-traumatic scenarios. It may also be a simple and effective teaching aid for US beginners.

Emphysematous Liver Abscess and Disseminated Hypervirulent Klebsiella pneumoniae Infection in a Patient from Southern India

The pyogenic liver abscess is usually polymicrobial and is seen as a complication of biliary disease or peritonitis. Over the past three decades, monomicrobial liver abscess caused by Klebsiella pneumoniae is being increasingly reported from South East Asian countries like Taiwan and Korea. It is a community-acquired infection caused by a distinct strain, hypervirulent K. pneumoniae, different from classical strain related to the healthcare-associated Klebsiella infections. Diabetes mellitus is a significant risk factor. Reports of the disseminated infection due to hypervirulent Klebsiella are very few in Indian literature. We report the successful management of a diabetic patient with emphysematous liver abscess, brain abscess, and meningitis caused by hypervirulent K. pneumoniae infection.

Endogenous Endophthalmitis-The Clinical Significance of the Primary Source of Infection

Endophthalmitis is a severe form of ocular inflammation. The source of pathogens in endogenous endophthalmitis is located inside the body, and infection spreads hematogenously. Although rare, endogenous endophthalmitis is a very serious condition, as this type of inflammation is very devastating for ocular tissues. Prognosis is very poor, and the patients are often in a serious general condition, so they require special care and an individual approach in the treatment process. Thanks to the knowledge of the risks associated with infections of individual tissues and organs as well as potential pathogens and the clinical picture, it is possible to make a correct diagnosis faster and implement the correct treatment. In the case of endogenous endophthalmitis, reaction time is absolutely crucial for prognosis. In this review, we focus primarily on the importance of the primary source of infection for the course of the disease and prognosis.

Sonographic Detection of Hepatic Abscesses

Hepatic abscesses are masses or lesions within the liver as a response to an infection manifesting into the liver. Hepatic abscess can be a result of other abdominal diseases, such as any biliary tract disease or appendicitis. Because of its inconsistent characteristics in many imaging modalities, its appearance can be mistaken for other pathologies like liver metastasis. With the use of one or more imaging modalities and an imaging-guided biopsy of the targeted lesion, hepatic abscess can be confirmed. The case presents multiple hepatic abscesses throughout the liver with similar imaging characteristics as that of metastasis. Computed tomography (CT), sonography, magnetic resonance imaging, and a biopsy were performed to successfully diagnose the hepatic abscesses.

Juxta-papillary duodenal diverticula are associated with pyogenic liver abscesses: a case control study

BACKGROUND

Juxta-papillary duodenal diverticulum (JPDD) has been associated with obstructive jaundice and ascending cholangitis. Potential mechanisms include periampullary colonization of pathogenic bacteria and mechanical obstruction. However, the relation of JPDD with pyogenic liver abscess (PLA) has not been reported. Moreover, approximately one third of patients with PLA have no identifiable risk factors and are labelled as "cryptogenic". We hypothesized that JPDD is an unidentified risk factor for cryptogenic PLA and the aim of this study was to examine this association.

METHODS

We conducted a retrospective chart review to identify cases of PLA (n = 66) and compare those to matched controls (n = 66). 66 patients met the study inclusion criteria of a diagnosis of PLA using computerized tomography (CT) imaging and either positive culture or confirmed resolution after antibiotic therapy. Patients with diagnoses of amebic liver abscess, traumatic liver abscess, post cholecystectomy liver abscess, concurrent acute cholecystitis, and hepatobiliary malignancy were excluded. Controls were identified from a radiology database and matched one-to-one with the cases by age and sex. Demographic and clinical data was extracted from electronic medical records. CT scan images of all cases and controls were reviewed by a single expert radiologist to identify the presence of JPDD. Statistical tests including Chi-square and t-test with multiple logistic regression were used to examine the group differences in JPDD and other factors.

RESULTS

Among 132 study samples, 13.6% (9/66) of the cases were found to have JPDD, compared to 3.0% (2/66) among controls (p = 0.03). This corresponded to an odds ratio (OR) of 5.05 [OR 5.05; CI 1.05-24.4] on multiple logistic regression analysis. In addition, 1/3rd of PLA cases with JPDD had no other traditional risk factors (cryptogenic PLA). However, a statistically significant association of JPDD with cryptogenic PLA could not be established possibly because of a small number of cases. We found significantly high rate of diabetes mellitus (DM) (42.4%; n = 28/66) among cases compared to controls (21.2%; n = 14/66; p = 0.01).

CONCLUSION

We found a significant association between JPDD and PLA. We need studies with larger sample sizes to confirm this relationship and to explore if JPDD could be related to cryptogenic liver abscesses.