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| __NOTOC__
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| {{Liver abscess}}
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| {{CMG}};{{AE}}{{YK}}
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| ==Overview==
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| A liver [[abscess]] is a pus-filled mass inside or attached to the [[liver]]. Common causes are an abdominal infection such as [[appendicitis]] or [[diverticulitis]]. With treatment, the death rate is 10-30%.<ref name="MedlinePlus">{{cite web | url=http://www.nlm.nih.gov/medlineplus/ency/article/000261.htm | title='MedlinePlus Medical Encyclopedia: Pyogenic liver abscess'}}</ref>. 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]] in the majority of patients, but low specificity. [[E. coli]] is the most prevalent 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]] [[antibiotic]]s and percutaneous US- 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 is a relatively infrequent (1.7% according to Cho, D. et. al.), although possible, complication of [[percutaneous]] [[radiofrequency ablation]] of hepatic tumors.
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| ==Classification==
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| Liver abscess may be classified into 3 types based on etiology into [[pyogenic]], [[amoeba|amoebic]], and [[fungal]] liver abscess.
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| {{familytree/start}}
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| {{familytree | | | | | | | | | | | A01| | | | | | | | | | | |A01='''Liver abscess'''}}
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| {{familytree | | | | |,|-|-|-|-|-|-|+|-|-|-|-|-|-|.| }}
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| {{familytree | | | | B01 | | | | | B02 | | | | | B03 |B01='''[[Amoebic liver abscess]]'''|B02='''[[Pyogenic liver abscess]]'''|B03='''Fungal abscess'''}}
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| {{familytree | | | | |!| | | | | | |!| | | | | | |!| |}}
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| {{familytree | | | | C01 | | | | | C02 | | | | | C03 | C01=[[Entamoeba histolytica]]|C02=[[Bacteria]]|C03=[[Candida|Candida species]]}}
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| {{familytree | | | | | | | | | | | |!| | | | | | | | |}}
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| {{familytree | | | | |,|-|-|-|-|-|-|+|-|-|-|-|-|-|v|-|-|-|-|-|.| }}
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| {{familytree | | | | D01 | | | | | D02 | | | | | D03 | | | | D04 |D01=[[Gram-positive]] [[aerobes]]|D02=[[Gram-negative]] enterics|D03=[[Anaerobic]] organisms|D04=[[Acid fast|Acid fast bacilli]]}}
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| {{familytree | | | | |!| | | | | | |!| | | | | | |!| | | | | |!|}}
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| {{familytree | | | | E01 | | | | | E02 | | | | | E03 | | | | E04 | E01=[[Streptococcus|Streptococcus sp]] <br> ''[[Staphylococcus aureus]]'' / ''[[Staphylococcus epidermidis]]'' <br> ''[[Actinomyces|Actinomyces sp]] <br>[[Enterococcus|Enterococcus sp]] <br> ''[[Streptococcus milleri]]''|E02=''[[Escherichia coli]]'' <br> ''[[Salmonella typhi]]'' <br> ''[[Yersinia enterocolitica]]'' <br> ''[[Klebsiella|K.pneumonia]]'' <br> [[Pseudomonas|Pseudomonas sp]] <br> [[Proteus|Proteus sp]] <br> ''[[Eikenella corrodens]]'' <br> Others|E03=[[Bacteroides|Bacteroids sp]] <br> [[Fusobacterium]] <br> [[Anaerobic]]/ [[Microaerophilic]] [[streptococci]] <br> Other [[anaerobes]]|E04=''[[Mycobacterium tuberculosis]]''}}
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| {{familytree/end}}
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| ==Differential Diagnosis==
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| The differential Diagnosis of liver abscess include:<ref name="pmid15189463">{{cite journal| author=Lodhi S, Sarwari AR, Muzammil M, Salam A, Smego RA| title=Features distinguishing amoebic from pyogenic liver abscess: a review of 577 adult cases. | journal=Trop Med Int Health | year= 2004 | volume= 9 | issue= 6 | pages= 718-23 | pmid=15189463 | doi=10.1111/j.1365-3156.2004.01246.x | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=15189463 }} </ref><ref name="pmid5054724">{{cite journal| author=Barbour GL, Juniper K| title=A clinical comparison of amebic and pyogenic abscess of the liver in sixty-six patients. | journal=Am J Med | year= 1972 | volume= 53 | issue= 3 | pages= 323-34 | pmid=5054724 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=5054724 }} </ref><ref name="pmid3316923">{{cite journal| author=Barnes PF, De Cock KM, Reynolds TN, Ralls PW| title=A comparison of amebic and pyogenic abscess of the liver. | journal=Medicine (Baltimore) | year= 1987 | volume= 66 | issue= 6 | pages= 472-83 | pmid=3316923 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3316923 }} </ref><ref name="pmid3945889">{{cite journal| author=Conter RL, Pitt HA, Tompkins RK, Longmire WP| title=Differentiation of pyogenic from amebic hepatic abscesses. | journal=Surg Gynecol Obstet | year= 1986 | volume= 162 | issue= 2 | pages= 114-20 | pmid=3945889 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3945889 }} </ref><ref name="pmid9834333">{{cite journal| author=Lipsett PA, Huang CJ, Lillemoe KD, Cameron JL, Pitt HA| title=Fungal hepatic abscesses: Characterization and management. | journal=J Gastrointest Surg | year= 1997 | volume= 1 | issue= 1 | pages= 78-84 | pmid=9834333 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9834333 }} </ref><ref name="pmid3275982">{{cite journal| author=Pastakia B, Shawker TH, Thaler M, O'Leary T, Pizzo PA| title=Hepatosplenic candidiasis: wheels within wheels. | journal=Radiology | year= 1988 | volume= 166 | issue= 2 | pages= 417-21 | pmid=3275982 | doi=10.1148/radiology.166.2.3275982 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3275982 }} </ref><ref name="pmid11452064">{{cite journal| author=Mortelé KJ, Ros PR| title=Cystic focal liver lesions in the adult: differential CT and MR imaging features. | journal=Radiographics | year= 2001 | volume= 21 | issue= 4 | pages= 895-910 | pmid=11452064 | doi=10.1148/radiographics.21.4.g01jl16895 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=11452064 }} </ref><ref name="pmid7668917">{{cite journal| author=Suwan Z| title=Sonographic findings in hydatid disease of the liver: comparison with other imaging methods. | journal=Ann Trop Med Parasitol | year= 1995 | volume= 89 | issue= 3 | pages= 261-9 | pmid=7668917 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7668917 }} </ref><ref name="pmid3047423">{{cite journal| author=Esfahani F, Rooholamini SA, Vessal K| title=Ultrasonography of hepatic hydatid cysts: new diagnostic signs. | journal=J Ultrasound Med | year= 1988 | volume= 7 | issue= 8 | pages= 443-50 | pmid=3047423 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3047423 }} </ref><ref name="pmid7225721">{{cite journal| author=Niron EA, Ozer H| title=Ultrasound appearances of liver hydatid disease. | journal=Br J Radiol | year= 1981 | volume= 54 | issue= 640 | pages= 335-8 | pmid=7225721 | doi=10.1259/0007-1285-54-640-335 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7225721 }} </ref>
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| {| class="wikitable"
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| ! rowspan="3" |Disease
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| ! rowspan="3" |Causes
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| ! colspan="11" |symptoms
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| ! rowspan="3" |Lab Findings
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| ! rowspan="3" |Imaging Findings
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| ! rowspan="3" |Other Findings
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| |-
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| ! rowspan="2" | Fever
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| ! colspan="2" | Pain
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| ! rowspan="2" | cough
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| ! rowspan="2" | Hepatomegaly
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| ! rowspan="2" | Jaundice
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| ! rowspan="2" | Weight loss
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| ! rowspan="2" | Anorexia
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| ! rowspan="2" | Diarrhoea
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| or Dysentry
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| ! rowspan="2" | Nausea and
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| vomiting
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| ! rowspan="2" | Stool
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| |-
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| ! Abdominal pain
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| (right upper quadrant pain)
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| ! Pleuritic pain
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| |-
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| |Amoebic
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| liver abscess
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| |Entamoeba
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| histolytica
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| |✔✔✔
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| |✔✔✔
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| |✔/✘
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| |✔
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| |✔✔/✘
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| |✔
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| (late stages)
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| |✔
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| (late stages)
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| |✔
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| |✔
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| |✔
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| |Hypoalbuminemia
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| ✔
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| * Respond well to chemotherapy and rarely require drainage
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| * Marked male predominance
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| * More common in developing countries
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| * Sero-positive
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| * Right lobe is more frequently involved
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| |-
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| |Pyogenic liver abscess
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| |Bacteria
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| * Gram-positive aerobes
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| * Gram-negative enterics
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| * Anaerobic organisms
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| * Acid fast bacilli
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| |✔
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| |✔
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| |✔✔
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| |✔✔
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| |✔/✘
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| |✔✔✔
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| |✔
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| (acute loss)
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| |✔
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| |✔
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| |Pale/dark
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| |Hypoalbuminemia
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| ✔✔✔
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| * Abnormal pulmonary findings
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| * Diabetes mellitus increases the risk
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| * Medical-surgical approach is indicated
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| * More common in developed countries
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| * Culture positive and sero-negative
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| * Both lobes are commonly involved
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| |-
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| |Fungal liver abscess
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| |Candida species
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| |✔
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| |✔
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| |✔/✘
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| |✔
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| |✔
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| |✔
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| |✔
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| |✔
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| |✔
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| |✔
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| |CT and Us findings with four patterns of presentation:
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| * Wheel-within-a-wheel pattern
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| * Bull’s-eye configuration pattern
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| * Uniformly hypoechoic nodule
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| * echogenic foci with variable degrees of posterior acoustic shadowing
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| * Less common
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| * Pure fungal abscess or associated with pyogenic abscess
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| * Candida and Aspergillus are commonly found in the culture of aspirated pus
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| * Associated with underlying malignancy or DM
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| |-
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| |Echinococcal (hydatid) cyst
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| |Echinococcus granulosus
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| |✔
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| |✔
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|
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| |✔
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| (Obstructive jaundice)
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| |✔
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| |✔
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| |Histology: Hydatid cyst with three layers
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| a.The outer pericyst, which corresponds with compressed and fibrosed liver tissue
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| b.The endocyst, an inner germinal layer
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| c.The ectocyst, a thin, translucent interleaved membrane
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| |Ultrasound:
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| * Cystic to solid-appearing pseudotumors
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| * Water lily sign
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| * Calcifications seen peripherally
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| *
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| * Blood or liquid from the ruptured cyst may be coughed up
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| * Pruritis
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| |-
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| |Malignancy
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| (Hepatocellular carcinoma/Metastasis)
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| *Hepatitis B and C
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| *Aflatoxins
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| *Alcohol
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| *Heamochromatosis
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| *Alpha 1 antitrypsin deficiency
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| *Non alcoholic fatty liver disease
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| |✔
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| (uncommon)
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| |✔
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| |✔
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| |Other symptoms:
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| * Splenomegaly
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| * Variceal bleeding
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| * Ascites
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| * Spider nevi
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| * Asterixis
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| |-
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| |Hepatocellular adenoma
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| |-
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| |Cholangiocarcinoma
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| |-
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| |Hemangioma
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| |-
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| |Focal nodular hyperplasia
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| |-
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| |Nodular regenerative hyperplasia
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| |-
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| |Simple hepatic cyst
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| |-
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| |Biliary cystadenoma or cystadenocarcinoma
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| |-
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| |Polycystic liver disease
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| |}
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| ==Treatment==
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| ==References==
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| {{reflist|2}}
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| {{WH}}
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| {{WS}}
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| [[Category:Gastroenterology]]
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| [[Category:Infectious disease]]
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| [[Category:Mature chapter]]
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| [[Category:Disease]]
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