Risk factors and clinical outcomes for spontaneous rupture of pyogenic liver abscess

Beyond the Liver: A Unique Case of Pyogenic Liver Abscess Caused by Peptostreptococcus micros Penetrating the Chest Wall

Liver abscesses are uncommon pyogenic infections with diverse microbiology, often involving enteric gram-negative bacilli such as Escherichia coli and Klebsiella pneumoniae. Standard management includes antibiotic therapy and abscess drainage. We present a case of a 37-year-old male with chronic right upper quadrant abdominal pain, who was found to have an enlarging liver mass infiltrating the chest wall and right-side chest ribs, ultimately diagnosed as a large pyogenic liver abscess (PLA) extending into the chest wall. Notably, the abscess was attributed to Peptostreptococcus micros, a rarely isolated pathogen in liver abscesses. Despite initial unsuccessful percutaneous drainage, surgical intervention proved necessary for definitive treatment. This case underscores the diagnostic challenge posed by uncommon pathogens in liver abscesses and emphasizes the effectiveness of surgical drainage in managing refractory cases.

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.

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.

A complex presentation of an uncommon disease: Gas-forming pyogenic liver abscess complicated by septic pulmonary emboli and muscle abscesses, a case report and review of the literature

Background

Pyogenic liver abscess (PLA) is the most common type of visceral abscess. Its variable clinical presentation depends on patient demography, underlying conditions, causative pathogens as well as the size of the abscess. Most cases are secondary to enteric pathogens that cause focal liver disease. Gas-forming pyogenic liver abscess (GFPLA) is a rare subgroup of PLA characterized by the presence of gas within the abscess. The disease is associated with diabetes mellitus (DM) while Klebsiella penumoniae is the most frequently isolated pathogen. Despite appropriate evaluation and management, secondary complications are common with significant morbidity and mortality that necessitate prompt recognition and management.

Case presentation

We present a case of a 46-year-old gentleman from Bangladesh who presented to the emergency department with fever, chills, and right upper quadrant abdominal discomfort. Evaluation revealed elevated inflammatory markers with high blood glucose and a subdiaphragmatic lucency on a plain chest radiograph. The suspected underlying visceral infection was confirmed by abdominal ultrasonography and computed tomography which demonstrated an emphysematous abscess of 8 cm in diameter in the right liver lobe.Because of clinical instability, the patient was admitted to the medical intensive care unit (MICU) where he received appropriate supportive management with antimicrobials and percutaneous drainage of the abscess. Cultures collected from blood, the abscess, and urine grew a sensitive strain of Klebsiella pneumoniae. During his stay in the MICU, he complained of dyspnea. A CT pulmonary angiography was suggestive of septic emboli. A few days later, the patient started to complain of left gluteal pain and an US revealed a deep left gluteal abscess which required drainage. Cultures of the pus grew the same sensitive strain of Klebsiella pneumoniae. After receiving 6 weeks of parenteral antimicrobial therapy a repeated US revealed complete resolution of the abscess in the liver. Outpatient follow up showed favorable recovery.

Conclusion

Gas-forming pyogenic liver abscess (GFPLA) is a rare manifestation of pyogenic liver abscess that usually occurs in patients with poorly controlled DM. Despite appropriate evaluation, morbidity remains high therefore timely recognition and anticipation of complications is important.

Successful Medical Treatment for Peritonitis Resulting from a Large Pyogenic Liver Abscess Rupture

The rupture of a pyogenic liver abscess (PLA) with peritonitis is a rare occurrence but a surgical emergency with a high mortality rate in the case of gas-forming PLA. Rare cases of ruptured PLA that recovered completely with only medical treatment have been reported. This paper reports a case of a large PLA rupture with peritonitis. In this case, surgical intervention was too risky because of the patient's age and poor general condition. The patient recovered fully with appropriate antibiotic therapy and sufficient percutaneous drainage. Therefore, medical treatment may be considered an alternative option in cases of a ruptured large PLA with peritonitis if surgical intervention is too risky.

Spontaneous rupture of pyogenic liver abscess with subcapsular hemorrhage mimicking ruptured hepatocellular carcinoma: A case report

RATIONALE

Spontaneous rupture of PLA (pyogenic liver abscess) is an extremely rare and life-threatening event. Ruptured PLA is very difficult to distinguish from malignant HCC (hepatocellular cancer) rupture or cholangiocarcinoma rupture on CT (computed tomography) scan.

PATIENT CONCERNS

We describe the case of a 71-year-old man with fever, right upper abdominal pain, nausea with intermittent vomiting, and general fatigue. He had no medical or surgical history.

DIAGNOSIS

CT scan showed a hypodense mass in right hepatic lobe and MRI (magnetic resonance imaging) revealed a heterogenous mass of ∼6 cm in segment VI of the liver and heterogenous fluid in the subcapsular region. We made a tentative diagnosis of HCC rupture with subcapsular hemorrhage based on these findings.

INTERVENTION

After improving the patient's condition by administering empirical therapy consisting of intravenous antibiotics and fluids, we performed surgical exploration. Gross examination of the abdomen showed that almost the entire right hepatic lobe was hemorrhagic and affected by peritonitis. Therefore, we performed right hepatectomy. The intraoperative frozen biopsy revealed suspicious PLA with marked necrosis, neutrophil infiltration, and hemorrhagic rupture, although no malignant tissue or fungus was observed. The postoperative secondary pathology report confirmed the diagnosis of PLA with hemorrhagic rupture.

OUTCOMES

The patient was discharged 13 days after the operation. Follow-up CT was performed 5 months after discharge and revealed no abnormal findings.

LESSONS

A high index of suspicion is key to preventing misdiagnosis of ruptured PLA and improving prognosis. Furthermore, even if rupture of the PLA is initially localized, delayed peritonitis may occur during medical treatment. Therefore, vigilant monitoring is essential.

Ruptured Emphysematous Liver Abscess: An Unusual Presentation in Kochs

Gas forming liver abscess (GFLA) though rare is seen in diabetic patients. Rupture of such abscesses usually requires surgical intervention. These cases are associated with high morbidity and mortality due to sepsis. Tuberculous liver abscesses are more often silent in presentation. GFLA formed in the background of a tuberculous liver abscess is rare. We present a case of ruptured GFLA with underlying tuberculous pathology in a normoglycemic patient. The abscess was managed by image guided intervention. A brief case report along with review of literature is presented.

Sonographic findings of hepatic venous gas in association with spontaneous rupture of a Klebsiella pneumoniae liver abscess: a case report

Hepatic venous gas (HVG) is a very rare ultrasonic finding, and it is defined as abnormal accumulation of gas in the hepatic venous system. Various diseases can cause HVG, and femoral venous catheter is the most common cause. We, herein, present the case of a 79-year-old female patient with HVG that was caused by spontaneous rupture of a Klebsiella pneumoniae liver abscess. This was first found by bedside ultrasonography. On the basis of the blood culture results, imipenem-cilastatin and cefoperazone sulbactam were administered and the effect was acceptable. After 41 days of antibacterial and symptomatic treatment in the hospital, the patient had recovered well and was discharged. All of the previous reports on HVG have been summarized by thoroughly reviewing the previous published work. Overall, this is the first patient with HVG in association with spontaneous rupture of a K. pneumoniae liver abscess, and it might provide insights for future studies regarding the treatment of this disease.

Multiple septae as potential protective factors against spontaneous pyogenic liver abscess rupture: a propensity score matching analysis

PURPOSE

The symptoms of spontaneous rupture of a pyogenic liver abscess (PLA) are severe and often life-threatening. Multiple septae are important imaging features of PLA. However, the relationship between septation and abscess rupture is still under debate.

METHODS

Patients diagnosed with PLA from January 2011 to November 2019 in our hospital were included. We collected demographic, clinical, and computed tomography data. Univariate and multivariate analyses determined liver abscess rupture risk factors. The relationship between multiple septae and abscess rupture was evaluated by propensity score matching after matching other influencing factors.

RESULTS

A total of 583 patients of pyogenic liver abscesses were included in the study: 30 ruptured and 553 unruptured. Multivariate analysis revealed diabetes, single lesion, gas formation, left hepatic lobe location, and a diameter > 66.5 mm as independent risk factors for ruptures, while multiple septae were identified as a protective factor. After matching all the influencing factors (excluding multiple septae), multiple septae and abscess rupture maintain a negative relationship.

CONCLUSIONS

Multiple septae were identified as a potentially protective factor against spontaneous pyogenic liver abscess ruptures.

Outcomes of Gas-Forming Pyogenic Liver Abscess Are Comparable to Non-Gas-Forming Pyogenic Liver Abscess in the Era of Multi-Modal Care: A Propensity Score Matched Study

Background: Gas-forming pyogenic liver abscess (GFPLA) occurs in 7%-24% of all PLAs and has been associated traditionally with high mortality rates. Studies have suggested that the use of a proactive approach of prompt resuscitation, parenteral antibiotic agents, percutaneous drainage, and a dedicated multi-disciplinary team may improve clinical outcomes. Hence, we aim to investigate whether the clinical outcomes of PLA are determined by gas formation. Methods: This is a retrospective study of patients with PLA from 2007 to 2011. A 1:2 propensity score matching (PSM) analysis was performed using age, co-morbid diabetes mellitus, presence of septic shock, hemoglobin levels, international normalized ratio, creatinine, total bilirubin, positive blood culture and pus culture, and the size of abscess. Baseline demographics, clinical profile, and peri-operative data were compared. Results: There were 213 patients who had PLA: 41 (19.2%) patients had GFPLA and 172 (80.8%) patients had non-GFPLA. The PSM analysis resulted in a total of 108 patients (36 GFPLA and 72 non-GFPLA). Median duration of parenteral antibiotic agents was significantly lower in the GFPLA group (9.5 d vs. 14 d, p = 0.044), but median total duration of antibiotic use was comparable (GFPLA 39 d vs. non-GFPLA 37 d, p = 0.634). Median length of stay (days) did not differ significantly between GFPLA and non-GFPLA (14 vs. 15, p = 0.299). There were no statistically significant differences between GFLPA and non-GFLPA in the need for percutaneous drainage (26/36 (72.2%) vs. 47/72 (65.3%), respectively, p = 0.467) and in-hospital all-cause death (4/36 (11.1%) vs. 7 (9.7%), p = 0.822) Conclusions: Outcomes of GFPLA are comparable to those of non-GFPLA in the era of multi-modal care.

Ruptured liver abscess presenting as pneumoperitoneum caused by Klebsiella pneumoniae: a case report

Background

Spontaneous gas-forming pyogenic liver abscess (GFPLA) is a rare complication with a high fatality rate in spite of aggressive management. Clinical spectrum of GFPLA can mimic hollow viscus perforation as it usually accompanied by pneumoperitoneum and peritonitis. Up to now, GFPLA has not been well studied in Vietnam.

Case presentation

We reported here a case with pneumoperitoneum caused by ruptured liver abscess in a 41-year-old man with a history of treated duodenal ulcer and uncontrolled type II diabetes mellitus. He had an epigastric pain associated with a high fever. Patient was diagnosed peritonitis and pneumoperitoneum presumed to be secondary to perforation of a hollow viscus and subjected to emergency laparotomy. We did not find any gastrointestinal perforation. Surprisingly, we detected a 4 cm × 4 cm pus-containing abscess in the left liver lobe of the liver. The abscess was ruptured. Pus was running into abdominal cavity through one hole. The abscess and abdominal cavities were cleaned up and abscess and abdominal drainages were performed. K. pneumoniae was isolated from culture of the abscess. The histopathological examination of the abscess did not yield any evidence of malignancy. Blood glucose levels were controlled. Antibiotic therapy was used according to antibiogram. A reassessment chest X-ray showed no air-fluid level or subdiaphragmatic air by the hospital day 14. Patient eventually made a full recovery and was discharged home 23 days after the operation.

Conclusions

Ruptured GFPLA is a life-threatening complication. It is usually accompanied by peritonitis and pneumoperitoneum and can imitate hollow viscous perforation. In these cases, CT scan should be performed whenever it is possible to make a correct diagnosis. When the abscess has small size, partial hepatectomy might not be necessary and could be replaced by a careful cleaning and drainage of the abscess. Patient could show a good postoperative recovery following an appropriate antibiotic therapy.

Subtle mimicry in action

Acute abdomen may often prompt surgeons to send patients to the operating theatre directly, especially in unstable conditions. Nevertheless, if clinically allows, it would be ideal if surgeons can have a better grasp of the root cause before operating. This case illustrates the integration of meticulous history taking and analysis of simple imaging could have led to a different clinical approach.

A rare case of massive pericardial effusion due to spontaneous rupture of Streptococcus anginosus group liver abscess

Purulent pericardial effusion is a rare and life-threatening complication of pyogenic liver abscess if not diagnosed and intervened early. Due to its nonspecific presentation, diagnosis of pyogenic liver abscess is challenging. Herein, we discuss the case of a 31-year-old healthy male that presented with acute chest tightness for one day in the setting of spontaneous rupture of pyogenic liver abscess and developed transdiaphragmatic extension of purulent pericardial effusion. The abscess resolved with antibiotic therapy (beta-lactam), ultrasound-guided aspiration, and pericardial window. Culture of pericardial fluid yielded the Streptococcus anginosus group. He was subsequently discharged following clinical resolution and normalization of liver function tests after 15 days of treatment. Follow-up ultrasonography revealed that the liver abscess and pericardial effusion were resolved in 8 weeks post treatment and intervention.

Peritoneal GATA6+ macrophages function as a portal for Staphylococcus aureus dissemination

Essentially all Staphylococcus aureus (S. aureus) bacteria that gain access to the circulation are plucked out of the bloodstream by the intravascular macrophages of the liver - the Kupffer cells. It is also thought that these bacteria are disseminated via the bloodstream to other organs. Our data show that S. aureus inside Kupffer cells grew and escaped across the mesothelium into the peritoneal cavity and immediately infected GATA-binding factor 6-positive (GATA6+) peritoneal cavity macrophages. These macrophages provided a haven for S. aureus, thereby delaying the neutrophilic response in the peritoneum by 48 hours and allowing dissemination to various peritoneal and retroperitoneal organs including the kidneys. In mice deficient in GATA6+ peritoneal macrophages, neutrophils infiltrated more robustly and reduced S. aureus dissemination. Antibiotics administered i.v. did not prevent dissemination into the peritoneum or to the kidneys, whereas peritoneal administration of vancomycin (particularly liposomal vancomycin with optimized intracellular penetrance capacity) reduced kidney infection and mortality, even when administered 24 hours after infection. These data indicate that GATA6+ macrophages within the peritoneal cavity are a conduit of dissemination for i.v. S. aureus, and changing the route of antibiotic delivery could provide a more effective treatment for patients with peritonitis-associated bacterial sepsis.

Effect of diabetes mellitus on short-term prognosis of 227 pyogenic liver abscess patients after hospitalization

BACKGROUND

Pyogenic liver abscess (PLA) is an inflammatory disease with increasing incidence. When it occurs with diabetes mellitus (DM), the risk of recurrence and mortality may increase. However, the effect of DM on the short-term prognosis of PLA patients after hospitalization remained unknown.

METHODS

Two hundred twenty-seven PLA patients who received treatment at the First Affiliated Hospital of Xi'an Jiaotong University from January 2011 to January 2018 were retrospectively enrolled. They were divided into two groups as the DM group (n = 61) and the Non-DM group (n = 166). In the DM group, HbA1C level < 7% was considered to be good-control of glycaemia (n = 23). The clinical characteristics and overall short-term survival were analyzed.

RESULTS

The proportion of PLA patients with DM was 26.87%. In the DM group, there was a higher incidence of hypertension and Candida spp. infection. Conservative administration and percutaneous drainage were mainly used in patients with good- (60.87%) and poor-control (60.53%) of glycaemia, respectively. During follow-up, 24 (10.57%) died due to uncontrolled systemic infections and other serious complications. Compared with PLA patients without DM, patients in the DM group had significantly increased 6-month mortality rate after discharge (Log-Rank test, P = 0.021). Poor-control of glycaemia did not reduce the six-month survival, while the recurrence rate of PLA within 3 months showed an almost 3-fold increase (13.16% vs. 4.35%). Further multivariate analyses found that DM was the only independent risk factor for the PLA six-month survival (odds ratio [OR]: 3.019, 95% confidence interval [CI]: 1.138-8.010, P = 0.026). However, the blood glucose level had no significant effect on the short-term survival of PLA patients with DM (Log-Rank test, P = 0.218).

CONCLUSIONS

In PLA patients, DM aggravated short-term mortality and blood glucose levels should be well controlled.

Prognostic nomogram for the combination therapy of percutaneous catheter drainage and antibiotics in pyogenic liver abscess patients

PURPOSE

To identify the predictors for recovery of pyogenic liver abscess (PLA) patients treated with percutaneous catheter drainage (PCD) and antibiotics, and then develop an effective nomogram to predict the recovery time.

MATERIALS AND METHODS

The retrospective study included consecutive PLA patients treated with PCD and antibiotics. We defined the overall recovery time (ORT) as the time from the PCD procedure to the time of clinical success or failure. Based on the ORT, its predictors were identified with univariate and multivariate analyses. Then, a nomogram was developed to predict the ORT, and was internally validated by using Harrell's c statistic.

RESULTS

A total of 116 patients and 142 PCD procedures with a median ORT of 15.0±10.6 days were included. Gas-formation (GF; HR: 0.486 [95% CI 0.312-0.757]; P = 0.001), diabetes mellitus (DM; HR: 0.455 [95% CI 0.303-0.682]; P<0.001), and preinterventional septic shock (PSS; HR: 0.276 [95% CI 0.158-0.483]; P < 0.001) were identified as predictors for the ORT of combination therapy after univariate and multivariate analyses, which indicated a significantly longer ORT than those patients without. The prognostic analyses demonstrated that the more predictors (GF, DM, and PSS) a patient exhibited, the longer ORT for the combination therapy. A nomogram was developed to predict the ORT and revealed high accuracy, with Harrell's c statistic of 0.73.

CONCLUSION

GF, DM, and PSS were predictors for the recovery of PLA patients treated with PCD and antibiotics. The nomogram was effective in predicting the ORT of combination therapy.

Ruptured Pyogenic Liver Abscess with Pneumoperitoneum 19 Years After Pancreatoduodenectomy

BACKGROUND Rupture of a pyogenic liver abscess is rare but serious complication. In patients after pancreatoduodenectomy, there are some conditions causing the development of liver abscesses (e.g., chronic reflux-cholangitis, efferent jejunal loop stasis, stenosis of the biliary anastomosis, and pancreatogenic diabetes). However, the number of published cases of liver abscess after pancreatoduodenectomy is small. CASE REPORT A 42-year-old male was admitted with severe abdominal pain, fever, and jaundice. Nineteen years previously, he had undergone pancreatoduodenectomy and cholecystectomy for chronic pancreatitis with obstructive jaundice. Two years later, diabetes mellitus was diagnosed, with subsequent insulin treatment. At admission, symptoms of peritonitis were present. Plain abdominal radiography showed free gas under the right hemidiaphragm and heterogeneous liver shade with small gas-fluid levels. The rupture of a liver abscess was suspected. Laparotomy with adhesiolysis, debridement of the liver abscess cavity, and abdominal drainage were performed. The postoperative period was complicated by sepsis, right lower lobe pneumonia, and two-sided pleural effusions, on the background of insulin-dependent diabetes and malnutrition. The patient was discharged on the 40th day and the subdiaphragmatic drains were removed on the 114th day. Sixteen months after surgery, the patient's condition was satisfactory. Magnetic resonance imaging and echography showed the absence of biliary hypertension. The liver tissue had healed completely. CONCLUSIONS A unique case of ruptured liver abscess after pancreatoduodenectomy is presented. To the best of our knowledge, this is the first published case with such a long time interval (19 years) between pancreatoduodenectomy and the formation of a pyogenic liver abscess.

A cohort study of age and sex specific risk of pyogenic liver abscess incidence in patients with type 2 diabetes mellitus

To investigate the age-sex-specific incidence and relative risk of pyogenic liver abscess (PLA) in patients with type 2 diabetes mellitus (T2DM), and to assess the joint effects of T2DM and other clinical risk factors for PLA on PLA incidence. We used a population-based cohort design with Taiwan's National Health Insurance claim data. Study subjects included 613,921 T2DM patients and 614,613 controls identified in 2000 and were followed to the end of 2010. Cox regression model was employed to calculate the hazard ratio (HR) and 95% confidence interval (CI) of PLA in relation to T2DM. Over an 11-year follow-up, 5336 T2DM and 1850 controls were admitted for PLA, representing a cumulative incidence of 0.87% and 0.30%, respectively. T2DM was significantly associated with increased hazard of PLA (HR, 2.88; 95% CI, 2.73-3.04). We also found that age and gender may significantly modify the relationship between T2DM and PLA, with a higher HR noted in males patients and those aged <45 years. Biliary tract diseases (HR, 8.60; 95% CI, 7.87-9.40) and liver cirrhosis (HR, 7.52; 95% CI, 6.58-8.59) may add substantially additional risk to the incidence of PLA in T2DM patients. The increased risk of PLA in T2DM was greater in male and younger patients. Careful management of biliary tract diseases and liver cirrhosis may also help reduce the incidence of PLA in T2DM patients.

Computed tomography-guided catheter drainage with ozone in management of pyogenic liver abscess

Purpose

To compare the treatment efficacy of percutaneous catheter drainage alone to catheter drainage combined with ozone in the management of pyogenic liver abscess (PLA).

Material and methods

This prospective study included 85 patients diagnosed with PLA. All patients were randomly divided into two groups: catheter drainage alone (Group I); catheter drainage combined with ozone (Group II). Drainage was considered successful when: 1) the abscess cavities were completely drained, and 2) clinical symptoms were resolved. Kruskall-Wallis nonparametric test was used to compare the success rates, length of stay (LOS), and need of further surgery. A value of p < 0.05 was considered significant for all statistical analyses.

Results

In all the patients' percutaneous catheters were placed successfully under the guidance of computed tomography. All of the patients in Group I (43; 50.6%) were treated with percutaneous catheter drainage alone, while the patients in Group II (42; 49.4%) were treated with PCD combined with ozone. The success rates of Group I and II were 81% and 94%, respectively (p < 0.05). The duration of fever as well as LOS was longer for Group I when compared with Group II (p < 0.05).

Conclusions

Catheter drainage combined with ozone is an effective and safe treatment in PLA.

The Value of Ozone in CT-Guided Drainage of Multiloculated Pyogenic Liver Abscesses: A Randomized Controlled Study

OBJECTIVE

This study was designed to compare the effects of catheter drainage alone and combined with ozone in the management of multiloculated pyogenic liver abscess (PLA).

METHODS

The prospective study included 60 patients diagnosed with multiloculated PLA. All patients were randomly divided into two groups: catheter drainage alone (group I) and catheter drainage combined with ozone (group II). Drainage was considered successful when (1) the abscess cavity was drained and (2) clinical symptoms were resolved. Kruskal-Wallis nonparametric test was used to compare the success rates, length of stay (LOS), and need for further surgery of the two groups. P < 0.05 indicates significant difference.

RESULTS

All patients' catheters were successfully placed under CT guidance. Group I was treated with catheters alone and group II was treated with catheters and ozone. The success rates of groups I and II were 86% and 96%, respectively (P < 0.05). And compared with group II, the duration of fever in group I was longer (P < 0.05), and the LOS was also longer (P < 0.05).

CONCLUSION

Catheter drainage combined with ozone is an effective and safe treatment in multiloculated PLA. The Clinical Registration Number is ChiCTR1800014865.

Posttraumatic venous gas in the liver - a case report and review of the current literature

Background

There are numerous causes of hepatic gas formation that range from serious pathologies to incidental findings, including mesenteric infarction, liver abscess, inflammatory bowel disease or minimally invasive hepatic interventions.

Case presentation

We report a case of a 50-year-old man who was admitted to the emergency room after a car accident. The clinical examination and further diagnostics revealed a craniocerebral injury with a fracture of the skull, concomitant soft tissue lesions and subarachnoidal bleeding. Furthermore, a blunt thoracic trauma with hemopneumothorax due to rib fractures was treated with a chest tube. No obvious abdominal pathology was seen. While in the operating theatre for the surgical revision of the cranial soft tissue lesions, a femoral venous catheter was inserted without any complications. A routine ultrasound of the abdomen six hours after the trauma revealed unclear hepatic gas formation. A contrast-enhanced computer tomography (CT) scan of the abdomen was performed, and the gas formation was found to be localized within the left hepatic vein. Afterwards, there was no specific treatment of the hepatic venous gas formation, as no alterations of liver function or liver enzymes were seen. The further course of the patient was uneventful regarding the gas formation in the liver, and another ultrasound two days later revealed no further gas in the liver.

Conclusions

The placement of a femoral venous catheter is a risk factor for gas formation in liver veins. No further treatment is needed in cases with stable liver function. To rule out serious pathologies, diagnostic findings (e.g., ultrasound, CT), clinical history and underlying diseases need to be analyzed carefully after the detection of intrahepatic gas formation. With contrast-enhanced CT, the localization of the gas and its potential causes might be detectable.

Gas-forming pyogenic liver abscess: A world review

BACKGROUNDS/AIMS

Gas-forming pyogenic liver abscess (GFPLA) has an incidence of up to 30% of all pyogenic liver abscesses (PLA). GFPLA has higher mortality compared to non-GFPLA. Mere presence of gas within abscess may not determine clinical outcome. Hence it is important to study biologic characteristics that make GFPLA a distinct clinical entity. The aim of this study was to conduct a world review on GFPLA.

METHODS

We conducted literature searches in PubMed using the following MeSH terms: "gas forming" AND "Liver abscess, pyogenic", "gas" AND "Liver abscess, pyogenic", "gas" AND "Liver abscess", "gas forming" AND "Liver abscess". Thirteen case series including 313 GFPLA patients were included. Age, gender, diabetes mellitus (DM), bacteriology, underlying etiology, symptoms, investigations, operative indications, and mortality rates were tabulated.

RESULTS

GFPLA is often cryptogenic. There was no difference in age, gender, or symptomatology between GFPLA and non-GFPLA patients. DM was more common in patients with GFPLA compared to that in non-GFPLA patients (mean: 83.5% vs. 38.3%). Klebsiella pneumoniae is the most common causative pathogen. GFPLA has higher mortality compared to non-GFPLA (mean: 30.3% vs. 9%).

CONCLUSIONS

GFPLA is associated with DM and monomicrobial Klebsiella pneumoniae infection. GFPLA has high mortality. It needs to be recognized as a distinct clinical entity.

Ruptured Gas-forming Pyogenic Liver Abscess into the Peritoneal Cavity Treated Successfully with Medical Treatment

Gas-forming pyogenic liver abscess (GFPLA) is very rare and has a very high mortality in case of rupture into the abdominal cavity, which usually require surgical treatment. We experienced a case of a ruptured GFPLA due to Klebsiella pneumoniae complicated with peritonitis and sepsis in a 68-year-old diabetic woman. Immediate and aggressive medical treatments including intravenous antibiotics, percutaneous drainage, and continuous renal replacement therapy dramatically improved the liver abscess, peritonitis, and metabolic problems. We report an unusual case of a ruptured GFPLA without surgical management, treated successfully with only medical treatment.

A rare case of pericarditis and pleural empyema secondary to transdiaphragmatic extension of pyogenic liver abscess

BACKGROUND

Transdiaphragmatic extension of pyogenic liver abscess is the rarest cause of pericarditis and pleural empyema. It is a rapidly progressive and highly lethal infection with mortality rates reaching 100% if left untreated. However, the transmission route, treatment methods and prognosis have not been well studied.

CASE PRESENTATION

A 65-year-old male patient presented with a fever, dyspnea, and right upper quadrant abdominal pain. Computed tomography of the chest and abdomen showed huge liver abscess without full liquefaction in the left lobe, large amount of left pleural effusion, and mild pericardial effusion, and the patient was treated with parenteral antibiotics and pigtail insertion at the left pleura. However, four days later, cardiac tamponade was developed and surgical drainage of the abscess and pericardium was performed. Klebsiella pneumonia was isolated from pleural empyema. Twenty-five days after surgery, the patient was discharged without any complications.

CONCLUSIONS

Herein, we report a rare case of pleural empyema and pericarditis in that resulted from the extension of huge pyogenic liver abscess. Early surgical treatment may have prevented progression of the pericarditis to the more dismal purulent pericarditis. We also review pertinent English literature on pericarditis as a complication of PLA.

Distribution of common pathogens in patients with pyogenic liver abscess in China: a meta-analysis

Pyogenic liver abscess (PLA) is a potentially life-threatening disease in many parts of the world, especially in Asia. The aim of this study was to quantify the proportion of common pathogens in patients with PLA in China, using a meta-analysis method based on systematic review of published studies. Several electronic databases were searched to identify the studies reporting the pathogens of PLA. We performed a meta-analysis to calculate the pooled proportion of pathogens and subgroup analysis among the included studies using R 3.1.1 software. In total, 183 studies were included in our final analysis, Klebsiella spp (54 %), Escherichia spp (29 %), Enterobacter spp (9 %), Proteus spp (6 %) and Pseudomonas spp (5 %) comprised the major gram-negative bacteria. Gram-positive bacteria mainly included Staphylococcus spp (13 %), Streptococcus spp (8 %) and Enterococcus spp (7 %). The distribution of pathogens in PLA patients were different in different economic regions in China. The proportion of Klebsiella spp had an upward tendency in recent years compared to other pathogens. In addition, the proportion of common pathogens in PLA patients with diabetes mellitus (DM) were carried out indicating that the dominant pathogens were Klebsiella spp (66 %), Escherichia spp (21 %) and Enterobacter spp (11 %). This meta-analysis showed that the main pathogens of PLA were Klebsiella spp, Escherichia spp, Staphylococcus spp, and Enterobacter spp in China. To ensure a precise estimate of the epidemiology of the pathogens, further large-scale or even a population-based study is needed.

Abdominal wall abscess secondary to spontaneous rupture of pyogenic liver abscess

INTRODUCTION

Pyogenic liver abscess is a rare cause of hospitalization, related to a mortality rate ranging between 15% and 19%. Treatment of choice is represented by image-guided percutaneous drainage in combination with antibiotic therapy but, in some selected cases, surgical treatment is necessary. In extremely rare cases, spontaneous rupture of liver abscess may occur, free in the peritoneal cavity or in neighboring organs, an event which is generally considered a surgical emergency.

PRESENTATION OF CASE

A 95-years-old woman was hospitalized with fever, upper abdominal pain, mild dyspepsia and massive swelling of the anterior abdominal wall. Computed tomography revealed an oval mass located in the abdominal wall of 12cm×14cm×7cm, in continuity with an abscess of the left hepatic lobe. Because Proteus mirabilis was detected in both the liver abscess and the abdominal wall abscess, the patient was diagnosed with a ruptured pyogenic liver abscess. After spontaneous drainage to the exterior of the hepato-parietal abscess, she was successfully treated with antibiotics alone.

CONCLUSION

Pyogenic liver abscess is a serious and life-threatening illness. Abscess rupture might occur. Many authors consider this complication a surgical emergency, but the site of abscess rupture changes the clinical history of the disease: in case of free rupture into the peritoneum, emergency surgery is mandatory, while a rupture localized in neighboring tissues or organs can be successfully treated by a combination of systemic antibiotics and fine needle aspiration and/or percutaneous drainage of the abscess.

Inferior vena caval thrombosis complicating pyogenic liver abscess after pancreatoduodenectomy: a case report

Pyogenic liver abscess (PLA) complicated by inferior vena caval (IVC) thrombosis is rare but life-threatening. We experienced a case of PLA complicated by an IVC thrombus close to the right atrium after pancreatoduodenectomy. A 75-year-old man had undergone pancreatoduodenectomy with modified-Child reconstruction for pancreatic cancer 3 years prior, and no recurrence was noted on follow-up. He was admitted to our hospital owing to fever and general fatigue. PLA and septic shock were diagnosed, and conservative therapy with antibiotics was initiated. His general condition gradually improved, but a thrombus in the middle hepatic vein and IVC was noted on follow-up computed tomography on hospital day 8. Although anticoagulant therapy using heparin was started, the thrombus size increase and extended to the right atrium. Considering the risk of pulmonary embolism, we planned a surgical intervention with a cardiovascular surgeon to remove the thrombus. During surgery, we made an incision in the right atrium and removed the thrombus using extracorporeal circulation. After removal, we dissected the middle hepatic vein using an automated suturing device to prevent the thrombus from extending into the IVC. The patient was discharged 10 weeks after surgery. Eighteen months post-intervention, there was no recurrence of either PLA or thrombi. Our experience suggests that physicians should consider the existence of a middle hepatic vein and IVC thrombi when examining PLA patients and that surgical intervention can be applied successfully in such cases.