Liver abscess

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Abscess Main Page

Liver abscess Main Page




Pyogenic liver abscess
Amoebic liver abscess

Differential Diagnosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Yamuna Kondapally, M.B.B.S[2]; Aravind Kuchkuntla, M.B.B.S[3]

Synonyms and keywords: Hepatic abscess


Liver abscess is a pus-filled cavity inside or attached to the liver. Common causes are an abdominal infection such as appendicitis or diverticulitis. With treatment the prognosis of liver abscess is poor with a mortality rate is 10-30%.[1]. Biliary tract disease is the most common cause but no cause identified in the majority of patients. There are nonspecific clinical findings hence a high degree of suspicion required for diagnosis. There are most often single, rather than multiple foci. Hyperbilirubinemia and elevated alkaline phosphatase are seen in the majority of patients, but it has a low specificity. E. coli is the most common causative organism, followed by Klebsiella, Streptococcus, and Bacteroides species. Rare cause is bowel perforation following foreign body ingestion. Therapy for solitary liver abscess from causes other than bowel perforation is intravenous antibiotics and percutaneous ultrasonography or CT-guided drainage. Therapy for liver abscess caused by bowel perforation or foreign body is open surgical drainage. Amoebic liver abscess occurs in 94% of cases of amebiasis. Liver abscess can be caused rarely as complication of percutaneous radiofrequency ablation for hepatic tumors.


The following are the list of potential sources for infection that can lead to the formation of liver abscess:

The following is a list of organisms that can cause liver abscess with the most common cause is E. coli followed by Klebsiella, Streptococcus, and Bacteroides species:

Liver abscess
Amoebic liver abscess
Pyogenic liver abscess
Fungal abscess
Entamoeba histolytica
Candida species
Gram-positive aerobes
Gram-negative enterics
Anaerobic organisms
Acid fast bacilli
Streptococcus sp
Staphylococcus aureus / Staphylococcus epidermidis
Actinomyces sp
Enterococcus sp
Streptococcus milleri
Escherichia coli
Salmonella typhi
Yersinia enterocolitica
Pseudomonas sp
Proteus sp
Eikenella corrodens
Bacteroids sp
Anaerobic/ Microaerophilic streptococci
Other anaerobes
Mycobacterium tuberculosis


Liver abscess can be classified based on the etiology into :

Differential Diagnosis

Pyogenic liver abscess must be differentiated from:[2][3][4][5][6][7][8][9][10][11]

Disease Causes Signs and symptoms Lab Findings Imaging Findings Other Findings
Fever Pain cough Hepatomegaly Jaundice Weight loss Anorexia Diarrhoea

or Dysentry

Nausea and


Abdominal pain

(right upper quadrant pain)

Pleuritic pain
Amoebic liver abscess Entamoeba histolytica ✔✔✔ ✔✔✔ ✔/✘ ✔✔/✘

(late stages)

(late stages)



  • Respond well to chemotherapy and rarely require drainage
  • Marked male predominance
  • More common in developing countries
  • Sero-positive
  • Right lobe is more frequently involved
Pyogenic liver abscess Bacteria ✔✔ ✔✔ ✔/✘ ✔✔✔

(acute loss)

Pale/dark Hypoalbuminemia


Cluster sign
  • CT scan shows cluster sign
  • Aggregation of multiple low attenuation liver lesions in a localized area to form a solitary larger abscess cavity
  • Abnormal pulmonary findings
  • Diabetes mellitus increases the risk
  • Medical-surgical approach is indicated
  • More common in developed countries
  • Culture positive and sero-negative
  • Both lobes are commonly involved
Fungal liver abscess Candida species
Aspergillus species
✔/✘ CT and USG findings with four patterns of presentation:
  • Wheel-within-a-wheel pattern
  • Bull’s-eye configuration pattern
  • Uniformly hypoechoic nodule
  • Echogenic foci with variable degrees of posterior acoustic shadowing
Echinococcal (hydatid) cyst Echinococcus granulosus

(Obstructive jaundice)

Histology: Hydatid cyst with three layers

a.The outer pericyst, which corresponds with compressed and fibrosed liver tissue

b.The endocyst, an inner germinal layer

c.The ectocyst, a thin, translucent interleaved membrane

  • Cystic to solid-appearing pseudotumors
  • Water lily sign
  • Calcifications seen peripherally
  • Blood or liquid from the ruptured cyst may be coughed up
  • Pruritis

(Hepatocellular carcinoma/Metastasis)


✔✔ ✔✔ Pale/Chalky Other symptoms:


  1. "'MedlinePlus Medical Encyclopedia: Pyogenic liver abscess'".
  2. Lodhi S, Sarwari AR, Muzammil M, Salam A, Smego RA (2004). "Features distinguishing amoebic from pyogenic liver abscess: a review of 577 adult cases". Trop Med Int Health. 9 (6): 718–23. doi:10.1111/j.1365-3156.2004.01246.x. PMID 15189463.
  3. Barbour GL, Juniper K (1972). "A clinical comparison of amebic and pyogenic abscess of the liver in sixty-six patients". Am J Med. 53 (3): 323–34. PMID 5054724.
  4. Barnes PF, De Cock KM, Reynolds TN, Ralls PW (1987). "A comparison of amebic and pyogenic abscess of the liver". Medicine (Baltimore). 66 (6): 472–83. PMID 3316923.
  5. Conter RL, Pitt HA, Tompkins RK, Longmire WP (1986). "Differentiation of pyogenic from amebic hepatic abscesses". Surg Gynecol Obstet. 162 (2): 114–20. PMID 3945889.
  6. Lipsett PA, Huang CJ, Lillemoe KD, Cameron JL, Pitt HA (1997). "Fungal hepatic abscesses: Characterization and management". J Gastrointest Surg. 1 (1): 78–84. PMID 9834333.
  7. Pastakia B, Shawker TH, Thaler M, O'Leary T, Pizzo PA (1988). "Hepatosplenic candidiasis: wheels within wheels". Radiology. 166 (2): 417–21. doi:10.1148/radiology.166.2.3275982. PMID 3275982.
  8. Mortelé KJ, Ros PR (2001). "Cystic focal liver lesions in the adult: differential CT and MR imaging features". Radiographics. 21 (4): 895–910. doi:10.1148/radiographics.21.4.g01jl16895. PMID 11452064.
  9. Suwan Z (1995). "Sonographic findings in hydatid disease of the liver: comparison with other imaging methods". Ann Trop Med Parasitol. 89 (3): 261–9. PMID 7668917.
  10. Esfahani F, Rooholamini SA, Vessal K (1988). "Ultrasonography of hepatic hydatid cysts: new diagnostic signs". J Ultrasound Med. 7 (8): 443–50. PMID 3047423.
  11. Niron EA, Ozer H (1981). "Ultrasound appearances of liver hydatid disease". Br J Radiol. 54 (640): 335–8. doi:10.1259/0007-1285-54-640-335. PMID 7225721.