Initial presentations and final outcomes of primary pyogenic liver abscess: a cross-sectional study

Early percutaneous catheter drainage in protecting against prolonged fever among patients with pyogenic liver abscess: a retrospective cohort study

BACKGROUND

Percutaneous catheter drainage (PCD) has been viewed as first-line treatment for pyogenic liver abscess (PLA), yet detailed guidance is lacking for best practice of PCD. This study investigated characteristics of patients with PLA who had received PCD, identified factors associated with prolonged fever, and aimed to evaluate the relationship between timing of PCD and clinical improvement.

METHODS

This was a retrospective study of patients with PLA who had undergone PCD over a 7-year period. PCD performed when the liquefaction degree of abscesses was less than 30% and/or within 1 week after fever onset was defined as early PCD. Patients were grouped and analysed based on the timing of PCD (early vs. delayed). Factors associated with prolonged fever were also analysed using univariate and multivariate logistic regression.

RESULTS

Among 231 patients with PLA, 81 treated with PCD were included in the study after exclusion. The size of abscesses ranged from 3.4 to 16 cm in diameter. Interestingly, the abscesses were predominantly multiloculated in this cohort (82.7%). The most common pathogen isolated from pus was Klebsiella pneumoniae (60.5%), followed by Escherichia coli (8.6%). The duration of fever was significantly shortened with early PCD as compared to delayed PCD intervention (p = .042). No statistical differences were found between the two groups with regard to catheter adjustment and salvage drainage. Maximum body temperature and diameter of abscess > 7.5 cm were found to be associated with prolonged fever while early PCD was inversely related to prolonged fever. Multivariate analysis suggested that early PCD treatment was an independent protective factor of prolonged fever (p = .030).

CONCLUSIONS

Large abscesses with loculation could be successfully treated with PCD, and early PCD protected patients with PLA from prolonged fever. Our findings suggest that early intervention should be provided if PCD is indicated in clinical practice.KEY MESSAGESLarge abscesses and multiloculated abscesses can be treated with percutaneous catheter drainage.Early percutaneous catheter drainage is identified as a protective factor of prolonged fever among patients with pyogenic liver abscesses.Early intervention should be provided if percutaneous catheter drainage is indicated for pyogenic liver abscesses.

Demographics, Radiological Findings, and Clinical Outcomes of Klebsiella pneumonia vs. Non-Klebsiella pneumoniae Pyogenic Liver Abscess: A Systematic Review and Meta-Analysis with Trial Sequential Analysis

Pyogenic liver abscess (PLA) is a common cause of hepatobiliary sepsis. Klebsiella pneumoniae (KP) is the most common organism causing PLA. Evidence is scarce on the demographics, radiological findings, and outcomes of KPPLA versus non-KPPLA (N-KPPLA). PubMed, Embase, The Cochrane Library, and Scopus were systematically searched until 14 May 2022 for studies comparing KPPLA and N-KPPLA. Exclusion criteria were single-arm studies. Primary outcomes were mortality (30-day/in-hospital) and metastatic complications. There were 16 studies, including 5127 patients (KPPLA n = 3305, N-KPPLA n = 1822). Patients with KPPLA were younger (mean difference: −2.04 years, p = 0.02). History of hepatobiliary disease (Odds ratio (OR) 0.30, 95% CI: 0.20, 0.46) and malignancy (OR 0.26, 95% CI: 0.16, 0.42) were less common in KPPLA. KPPLA was associated with lower incidence of multiple abscesses (OR 0.52, 95% CI: 0.35, 0.76, p < 0.001) and bilobar abscesses (OR 0.60, 95% CI: 0.49, 0.74, p < 0.001). KPPLA has higher overall metastatic complications (KPPLA 9.7% vs. N-KPPLA 4.8%, OR 3.16, 95% CI: 2.00, 4.99, p < 0.001), but lower mortality (KPPLA 3.9% vs. N-KPPLA 7.6%, OR 0.51, 95% CI: 0.34, 0.78, p < 0.001). Trial sequential analysis showed conclusive evidence that KPPLA has lower mortality than N-KPPLA. In conclusion, KPPLA has lower mortality than N-KPPLA.

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.

[Bacterial hepatobiliary infections : Pathogen spectrum, antimicrobial resistance and current treatment concepts]

Ascending cholangitis and pyogenic liver abscesses are acute febrile bacterial hepatobiliary diseases. Nowadays they frequently occur in patients with structural changes of the biliary system and are usually treated by a combination of interventional drainage procedures and antimicrobial therapy. While Gram-negative Enterobacterales were identified as major causes in the past, biliary tract interventions and antibiotic exposure have contributed to an increase in enterococcal species and extended spectrum beta-lactamase (ESBL)-producing Enterobacterales. When selecting an appropriate empirical treatment the treating internist must consider local and individual risk factors for antimicrobial resistance in addition to pharmacokinetic aspects and disease severity to reduce the likelihood of treatment failure.

Pyogenic Liver Abscess: Contemporary Trends in a Tertiary Institute

BACKGROUND

Pyogenic liver abscess (PLA) is an uncommon but potentially life-threatening condition. In recent years, advances in diagnostics and management have led to early diagnosis and treatment and decreased mortality. We present recent data from a large series of patients with PLA and examine the trends in the management of PLA over a period of 50 years.

METHODS

The medical records of all patients admitted to the Shaare Zedek Medical Center, Israel, between January 2011 and December 2021 with a primary or secondary diagnosis of PLA were reviewed retrospectively.

RESULTS

: Ninety-five patients with PLA were identified. Thirty-eight (40%) were female. The median patient age was 66 years (range 18-93). The diagnosis of PLA in all patients was confirmed with abdominal computed tomography (CT). In twenty patients (21.1%), PLA was not diagnosed by the initial abdominal US. Most abscesses were right-sided. Biliary tract origin was the most common underlying cause of PLA (n = 57, 60%), followed by cryptogenic etiology (n = 28, 30%). Escherichia coli, Klebsiella pneumoniae, and Streptococcus species were most commonly identified. The most common primary treatment modality was percutaneous drainage (PD), which was performed in 81 patients (85.3%). Fourteen patients (14.7%) were treated medically without intervention, and two patients (2.1%) were treated surgically following a failure of PD. Four patients died as a direct result of PLA.

CONCLUSIONS

Patients diagnosed with PLA are older, the male predominance is less pronounced, and the offending pathogens are likely to originate from the biliary tract. This study questions the utility of abdominal US as the initial diagnostic imaging in patients with suspected PLA (versus CT) and demonstrates improved outcomes for patients with PLA over the years.

LIVER ABSCESSES: A 10-YEAR VINNYTSYA UNIVERSITY STUDY

According to MEDLINE database there were about 1278 papers on liver abscess published in a period from 2001 to 2015. The aim of the study is to improve liver abscess treatment results comparing minimally invasive and traditional operative techniques. Materials and methods. 137 patients were included in the study and divided on two comparison groups. Traditional methods were used for the treatment of 66 participants of the control group (48.2 %). For 71 patients (51.8 %) of the general group the mini-invasive drainages were predominating. Results. Cholangiogenic causes of liver abscesses were found in 41 patients (29.93±3.91 %), cryptogenic ones – in 37 (27.01±3.79 %), haematogenous causes – in 29 (21.17±3.49 %), contact ones – in 16 (11.68±2.75 %), posttraumatic ones – in 11 (8.03±2.32 %) and purulent destruction of metastases – in 3 (2.19±1.25 %). Single abscesses occurred more often – in 117 (85.40±3.02 %), multiple once – in 20 (14.60±3.02 %). Mostly 3, 6 and 7 liver segments were damaged – 19 (13.88±2.95 %), 35 (25.55±3.73 %), 44 (32.12±3.99 %). In control group, the abscess drainage via laparotomy was performed on 58 patients (87.88±4.02 % of 66 ones) versus 21 (29.58±5.42 % of 71 ones) in general group. Percutaneous drainage was used in 8 (12.12±4.02 %) and in 44 (61.97±5.76 %) cases respectively. 6 or 8.45±3.30 % laparoscopic interventions were used only in the general group. Finally, mini-invasive drainages were applied in the greater part of general group - 50 (70.42±5.42 %) versus 8 ones (12.12±4.02 %) in control group. Conclusions. Minimally invasive liver abscess drainages showed a significant reduction of postoperative complications from 24.24±5.27 % in the control group to 12.66±3.95 % in the general group, shortening of hospital terms from 14.6±1 in control to 5.2±0.8 days and decreasing of mortality from 7.58±3.26 % to 2.82±1.96 %.

Endogenous Endophthalmitis Associated with Pyogenic Liver Abscess Caused by Klebsiella pneumoniae

We report 2 cases of endogenous endophthalmitis associated with pyogenic liver abscess caused by Klebsiella pneumoniae. Case 1 involved a 70-year-old woman and case 2 involved a 50-year-old man who were admitted to our hospital with diagnoses of liver abscess and endogenous endophthalmitis, respectively. The liver abscess resolved with antibiotics and percutaneous transhepatic drainage in case 1 and with antibiotics alone in case 2. Even though both cases underwent ophthalmic surgery, they were discharged from our hospital without the recovery of their eyesight. An earlier diagnosis and treatment are needed to improve the prognosis of endophthalmitis.

Clinical characteristics and treatment outcomes in a cohort of patients with pyogenic and amoebic liver abscess

Background

We describe the clinical features of a cohort of patients with liver abscesses and investigate relationships between clinical, radiological and microbiological findings and mortality.

Methods

Retrospective review of pyogenic (PLA) or amoebic liver abscesses (ALA) diagnosed and treated at a major infectious diseases department in London over 9 years.

Results

One hundred forty-one patient records were identified; 132 (93.6%) had PLA and 9 (6.4%) ALA. No organism was identified in 38.6% (51/132); a single bacterial species was isolated in 47.0% (62/132) of PLA, ≥ 2 in 14.4% (19/132). There was weak evidence of variation in abscess size by type of microorganism, with streptococcal PLA typically larger (p = 0.03 for Streptococcus milleri group, p = 0.05 for non-milleri streptococci). Patients with ALA were younger (median 41, IQR 37–51 years) than those with PLA (median 68, IQR 50.5–78 years) (p = 0.003) and all were male (9/9, 100%, (p = 0.03)), with a history of recent travel in the majority (6/9, 66.7% (p = 0.003)). C-reactive protein was higher in ALA than in PLA (p = 0.06). In the entire cohort, loculation (HR = 2.51 (95% CI 1.00–6.32), p = 0.04) and baseline ALP (HR = 4.78 (95% CI 1.19–19.2) per log₁₀ increase, p = 0.03) were associated with mortality. 16S ribosomal RNA (rRNA) analysis was used in a subset of culture-negative cases and increased the diagnostic yield by 13%.

Conclusions

Clinical or radiological features cannot be used to distinguish between PLA and ALA, or help identify the bacterial cause of PLA. However, ALA is more common in young, male patients with a history of travel. 16S rRNA analysis of abscess fluid has a role in improving microbiological diagnosis in culture-negative cases.

Electronic supplementary material

The online version of this article (10.1186/s12879-019-4127-8) contains supplementary material, which is available to authorized users.

Pyogenic liver abscesses due to Escherichia coli are still related to worse outcomes

BACKGROUND

In western countries, there has been a gradual shift from Escherichia coli to Klebsiella pneumoniae as an emerging pathogen isolated from pyogenic liver abscesses (PLA).

AIMS

To compare outcomes between patients with Escherichia coli liver abscesses and non-Escherichia coli liver abscesses in terms of mortality.

METHODS

One hundred nine-three consecutive hospital admissions of Pyogenic liver abscesses were analyzed, mean age 66.9 years old (± 13.6), 112 men (58%). The sample was divided into two groups: E. coli liver abscesses and non-E. coli liver abscesses. The etiologic, clinical, and microbiologic characteristics; therapeutic options; and outcomes, in terms of morbidity and mortality, between E. coli and non-E. coli liver abscesses were compared. In-hospital mortality, as outcome variable, was analyzed in a multivariate analysis.

RESULTS

Fifty-seven episodes of PLA (29.5%) corresponded to E. coli infections, and 136 (70.5%) to non-E. coli infections. Patients with E. coli PLA were more likely to have jaundice, polymicrobial isolation (57.1% vs 21.6%, p < 0.001), biliary origin (71.9% vs 39%, p < 0.001), and septic shock (38.6% vs 12.5%, p < 0.001). Antibiotic therapy alone, without percutaneous drainage, was less common in the E. coli PLA group (5.3% vs 18.4%, p = 0.018). These patients also showed a higher mortality (28.1% vs 11%, p = 0.003). In multivariate analysis, E. coli isolation PLA adjusted remained as an independent factor of mortality (OR 2.6, 95%CI 1.04-6.56, p = 0.041).

CONCLUSIONS

E. coli liver abscess may preclude a worse outcome than other microbiological agents, including the development of septic shock and mortality. Aggressive management must be considered.

Recurrent retroperitoneal abscess after biliary tract surgery in an elderly patient: a minimally invasive nonsurgical approach and its consequences: a case report

Introduction

Hepatic abscess can be defined as an encapsulated collection of suppurative material within the liver parenchyma. Hepatic abscess can be distinguished as pyogenic, amebic, or fungal. Biliary tract disease remains the most common cause of hepatic abscess today, and the most common complications range from pleural effusion, empyema, and bronchohepatic fistula to subphrenic abscess and rupture into the peritoneal cavity, stomach, colon, vena cava, or kidney. A large abscess compressing the inferior vena cava and the hepatic veins may result in Budd-Chiari syndrome. In this report, we present a rare case of hepatic abscess with an unusual evolution that was treated with a noninvasive approach.

Case presentation

A 79-year-old Caucasian woman underwent endoscopic bile stone extraction and laparoscopic cholecystectomy. Six months later, a hepatic abscess in association with bilateral effusion was diagnosed. The prompt imaging-guided drainage solved the case. Three years later, she came to our attention complaining of dull, diffuse abdominal pain and high body temperature (38 °C). A retroperitoneal abscess was diagnosed that was spreading to the right lateral wall of the abdomen and extending across the muscular wall to the subcutaneous layer. The fluid collection also involved the right pleural cavity, forming an empyema. Also in this case, an imaging-guided drainage was performed, and the patient’s clinical picture resolved in a few days. The retroperitoneal abscess recurred 14 months later, and it was dealt with using the same treatment. Three months from the last follow-up, the patient came back to our attention with an evident swelling of her right lumbar region. Computed tomography revealed a right inferior lumbar hernia comprising adipose tissue and the right kidney. A surgical intervention was recommended to the patient, but, owing to her poor general health, she refused any invasive approach.

Conclusions

Retroperitoneal abscess is an uncommon complication of biliary tract surgery and represents a potential cause of death, especially in those patients with multiple diseases. Prompt drainage is crucial to the treatment. Failure in eliminating the primary infective focus could bring complications and, in general, a weakness of lumbar muscular wall, even resulting in a rare case of lumbar hernia.

The geriatric nutritional risk index independently predicts adverse outcomes in patients with pyogenic liver abscess

Background

Geriatric nutritional risk index (GNRI) is a simple and useful nutritional marker for predictor of adverse outcomes in patients undergoing a variety of conditions. This study explored the relationship between GNRI and adverse outcomes of Pyogenic Liver Abscess (PLA) patients and assessed GNRI predictive value.

Methods

This was one retrospective study involving 240 PLA patients. According to one GNRI cutoff value of 90, the patients were divided into two groups. Besides, demographic, laboratory, adverse outcomes were compared between the two groups. Multivariate logistic regression analyses and receiver-operating characteristic (ROC) curve analysis were performed.

Results

Compared with high GNRI patients, those with low GNRI had a higher risk of mortality (13.4% vs. 2.0%, P = 0.002), metastatic infection (17.7% vs. 8.2%, P = 0.050), acute hepatic failure (6.8% vs. 1.0%, P = 0.036), acute respiratory failure (7.4% vs. 1.0%, P = 0.024), upper gastrointestinal (UGI) bleeding (11.9% vs. 2.1%, P = 0.006) and empyema (20.1% vs. 10.2%, P = 0.047). Multivariate logistic regression analysis demonstrated GNRI (< 90) as one independent factor in death prediction (odds ratio (OR) = 5.36, 95% of confidence interval (CI) = 1.17–24.48), and adverse outcomes (OR = 2.04, 95% CI = 1.05–3.98). GNRI had the largest area under receiver operating characteristic (ROC) curve than albumin, BMI, platelet, prothrombin time and hemoglobin in death prediction (area under ROC curves (AUC) = 0.771, cutoff value = 79.45, P < 0.01) and all adverse outcomes (AUC = 0.656, cutoff value = 87.43, P < 0.01).

Conclusions

Lower levels of GNRI are an independent risk factor for poor PLA prognosis. Physicians should consider GNRI for PLA outcomes and consider more careful resuscitation and timely and appropriate treatment, especially in those with GNRI< 87.43.

Low T3 Syndrome as a Predictor of Poor Prognosis in Patients With Pyogenic Liver Abscess

Aim: There is an association between the low triiodothyronine (T3) state and the poor prognosis for severe acute conditions. However, the correlation between thyroid dysfunction and pyogenic liver abscess (PLA) is unclear. This study aims to figure out how low T3 syndrome is related to the poor prognosis in PLA patients as well as estimate the serum T3 predictive value. Methods: The study consecutively enrolled 240 PLA patients in total with a 3 month followed-up period, and defined low T3 syndrome as low T3 level together with non-thyroid disease. Researchers implemented multivariate logistic regression analyses, univariate analysis, as well as receiver-operating characteristic (ROC) curve analysis. Results: Patients with low T3 syndrome had a higher mortality rate (14.3 vs. 2.0%), acute hepatic failure (6.8 vs. 1.0%), and septic shock (12.1 vs. 3.0%) than patients with normal levels of T3 (all P < 0.05). Low T3 syndrome served as an independent predictor of death [odds ratio (OR) = 5.03, 95% of confidence interval (CI) = 1.09-23.05], and all adverse outcomes [odds ratio (OR) = 3.63, 95% of confidence interval (CI) = 1.84-7.17] following the adjustment of potential confounders in the logistic model. T3 had the largest area under the ROC curve (AUC) than T4, FT3, FT4, and TSH in death prediction (AUC = 0.901, cut-off value = 0.70 nmol/L, P < 0.01), and all adverse outcomes (AUC = 0.743, cutoff value = 0.83 nmol/L, P < 0.01). Conclusions: It seems that low T3 syndrome can predict the prognosis of PLA in clinical practice in future.

HEPATECTOMY FOR PYOGENIC LIVER ABSCESS TREATMENT: EXCEPTION APPROACH?

BACKGROUND

Percutaneous drainage for pyogenic liver abscess has been considered the gold-standard approach for the treatment on almost of the cases. However, when percutaneous drainage fails or even in some especial situations, as multiloculate abscess, lobe or segment surgical resection can solve infectious clinical condition.

AIM

To report a series of patients who underwent hepatectomy for pyogenic liver abscess performed by a single surgical team.

METHODS

Eleven patients were operated with ages ranging from 45-73 years (mean and median 66 years). There were eight men and three women. The etiologies were: idiopathic (n=4), biliary (n=2), radiofrequency (n=2), direct extension (n=1), portal (n=1), and arterial (n=1). The mean lesion diameter was 9.27 cm (6-20 cm).

RESULTS

The mean operation length was 180 min (120-300). The mean intra-operative blood loss was 448 ml (50-1500). Surgical approaches were: right hepatectomy (n=4), left hepatectomy (n=3), left lateral sectioniectomy (n=1), right posterior sectioniectomy (n=2), resection of S8 (n=1), and S1 (n=1). Postoperative morbidity rate was 30%, while mortality was null. Median hospital stay was 18 days (5-45). The median follow-up period was 49 months (13-78). There was single lesion recurrence.

CONCLUSION

Hepatectomy can be done as exception approach for pyogenic hepatic abscess treatment; it is a good therapeutic option in special situations.

Liver abscess due to Fusobacterium species detected on ultrasonography: a case report

An oral infection harboring Fusobacterium species can gain entrance to the liver via hematogenous spread in the form of septic embolus, and can thereby cause abscesses. Such spread, described as Lemierre syndrome, is life threatening. We present such a case history of a man in his mid-40s, who presented with infection and Fusobacterium liver abscess with an acute fulminant disease course. The initial diagnosis was arrived at by ultrasound imaging and blood investigations. He was treated with antibiotics, ultrasound-guided liver abscess drainage, and extraction of the infected molar tooth. He was discharged 6 weeks after admission. To date, there have been no reports describing the ultrasound images of a Fusobacterium liver abscess in detail. Hence, we herein present the ultrasound images of a Fusobacterium liver abscess.

Neutrophil-to-lymphocyte ratio as a feasible prognostic marker for pyogenic liver abscess in the emergency department

PURPOSE

The neutrophil-to-lymphocyte ratio (NLR) is an effective predictor of mortality in patients with for various conditions. To date, there are no previous studies on NLR as a prognostic marker for pyogenic liver abscess (PLA), especially on admission to the emergency department (ED).

METHODS

From January 2013 to December 2015, 102 patients diagnosed with PLA in the ED were included. Clinico-radiological and laboratory results, including NLR, were evaluated as variables. NLR was calculated as absolute neutrophil count/absolute lymphocyte count. To evaluate the prognosis of PLA, data on hospital mortality, intensive care unit (ICU) admission, and development of septic shock were obtained. Multivariate logistic regression analyses and receiver-operating characteristic (ROC) curve analysis were performed.

RESULTS

Among 102 patients, 10 (9.8%) died, 14 (13.7%) were admitted to the ICU, and 15 (14.7%) developed septic shock during hospitalization. Multivariate logistic regression analysis revealed NLR as an independent factor in predicting death [odds ratio (OR), 1.4; p = 0.020], ICU admission (OR, 1.4; p = 0.021), and development of septic shock (OR, 1.6; p = 0.041). NLR showed an excellent predictive performance for death (areas under the ROC curves [AUC], 0.941; cut-off value, 19.7; p < 0.001), ICU admission (AUC, 0.946; cut-off value, 16.9; p < 0.001), and development of septic shock (AUC, 0.927; cut-off value, 16.9; p < 0.001).

CONCLUSION

NLR was positively associated with poor prognosis of PLA; elevated NLR could predictor of high risk of death, ICU admission, and development of septic shock. Emergency physicians should consider NLR for the prognosis of PLA and early aggressive treatment, especially in patients with NLR > 16.9.

Pyogenic liver abscesses: a contemporary analysis of management strategies at a tertiary institution

BACKGROUND

Despite equivocal evidence, non-surgical management for pyogenic liver abscess (PLA) has become the standard of care at most institutions with surgery relegated to salvage therapy for those who fail less invasive means. The aim of this study was to describe the outcomes of a step-up approach to PLA management.

METHODS

A retrospective chart review was conducted at a single institution for patients diagnosed with PLA over a 10-year period. Demographic, radiologic, microbiological, treatment, and outcomes data were collected and analyzed.

RESULTS

64 patients with PLA were identified. Initial treatment included antibiotics alone (n = 9), percutaneous drainage (PD) (n = 54), and surgery (n = 1). Surgery was ultimately required in 8 patients while 50 were cured with PD and 4 with antibiotics alone. Two (3%) patients died. Overall, PD carried an 85% success rate.

CONCLUSION

PLA patients should be initially treated non-operatively, barring indications for emergent surgery or inaccessibility for PD. Surgery can be reserved for failure of PD.

Klebsiella Pneumoniae Liver Abscess: A Case Series of Six Asian Patients

BACKGROUND Liver abscesses represent a serious infection of hepatic parenchyma and are associated with significant morbidity and mortality. The emergence of a new hypervirulent variant of Klebsiella pneumoniae, which can cause serious infections in the Asian population, is under investigation. We report a case series of six Asian patients hospitalized at our institution from January 2013 to November 2015 for liver abscess due to Klebsiella pneumoniae. CASE REPORT Charts of six Asian patients were retrospectively reviewed. Four patients were male and two were female. The mean age was 53 years (range: 35-64 years). All patients had no known past medical history of immunodeficiency. Three patients had multiple liver abscesses at the time of initial presentation. In five patients, the source of entry of the pathogenic microorganism was unknown and in one patient the suspected source of entry was the gastrointestinal tract. In three patients there was also concomitant Klebsiella pneumoniae bacteremia. The mean duration of antibiotic treatment was seven weeks and the mean duration of hospital stay was 13.5 days. CONCLUSIONS Liver abscess should always be included in the differential diagnosis in cases of sepsis without obvious source and/or in the clinical scenarios of fever, abdominal pain, and liver lesions.

Primary benign liver lesions

Benign focal liver lesions can origin from all kind of liver cells: hepatocytes, mesenchymal and cholangiocellular line. Their features at imaging may sometimes pose difficulties in differential diagnosis with malignant primary and secondary lesions. In particular, the use of MDCT and MRI with extracellular and hepatobiliary Contrast Agents may non invasively help in correct interpretation and definition of hepatocellular or mesenchymal and inflammatory nature, allowing to choose the best treatment option. The peculiarities of main benign liver lesions at US, CT and MRI are described, with special attention to differential diagnosis and diagnostic clues.

Fusobacterial liver abscess: a case report and review of the literature

Background

Fusobacteriae are facultative anaerobic gram-negative bacilli which cause a range of invasive infections, amongst which pyogenic liver abscesses are rare. We describe a case of Fusobacterium nucleatum liver abscess and review the relevant literature.

Case presentation

A 51-year-old lady presented with a 4-day history of abdominal pain, diarrhoea, fever, rigors, and lethargy. Imaging revealed an abscess which was drained. Cultures of the blood and abscess aspirate grew Fusobacterium nucleatum and Prevotella pleuritidis respectively. She achieved full recovery following treatment.

A MEDLINE search was undertaken using free-text and Medical Subject Headings (MeSH), keywords “Fusobacterium” and “Liver abscess”. Non-English language reports and cases without confirmed growth of Fusobacterium species were excluded. Additional cases were identified by surveying the references of each report and by using the same keywords in a web-based search.

Forty-eight cases were identified, 41 in men. The median age was 42.5, with an interquartile range of 33. F. nucleatum and F. necrophorum were in involved in 22 cases each, and 4 cases were not further speciated. Among cases of F. nucleatum liver abscess, nine were attributed to periodontal disease, four to lower gastrointestinal tract disease, one to Lemierre’s Syndrome, and eight were considered cryptogenic. All patients treated made a full recovery. Antimicrobial treatment duration ranged from 2 weeks to 6 months with a median of 6 weeks.

Conclusion

Fusobacterium nucleatum is an uncommon cause of liver abscess generally associated with good clinical outcomes with contemporary medical and surgical care.

Pyogenic liver abscess: current status and predictive factors for recurrence and mortality of first episodes

BACKGROUND

In times of modern surgery, transplantation and percutaneous techniques, pyogenic liver abscess (PLA) has essentially become a problem of biliary or iatrogenic origin. In the current scenario, diagnostic approach, clinical behavior and therapeutic outcomes have not been profoundly studied. This study analyzes the clinical and microbiological features, diagnostic methods, therapeutic management and predictive factors for recurrence and mortality of first episodes of PLA.

METHODS

A retrospective single-center study was conducted including 142 patients admitted to the Hospital Italiano de Buenos Aires, between 2005 and 2015 with first episodes of PLA.

RESULTS

Prevailing identifiable causes were biliary diseases (47.9%) followed by non-biliary percutaneous procedures (NBIPLA, 15.5%). Seventeen patients (12%) were liver recipients. Eleven patients (7.8%) died and 18 patients (13.7%) had recurrence in the first year of follow up. The isolation of multiresistant organisms (p = 0.041) and a history of cholangitis (p < 0.001) were independent risk factors for recurrence. Mortality was associated with serum bilirubin >5 mg/dL (p = 0.022) and bilateral involvement (p = 0.014) in the multivariate analysis.

CONCLUSION

NBPLA and PLA after transplantation may be increasing among the population of PLA in referral centers. History of cholangitis is a strong predictor for recurrence. Mortality is associated to hiperbilirrubinemia and anatomical distribution of the lesions.

The Evolving Nature of Hepatic Abscess: A Review

Hepatic abscess (HA) remains a serious and often difficult to diagnose problem. HAs can be divided into three main categories based on the underlying conditions: infectious, malignant, and iatrogenic. Infectious abscesses include those secondary to direct extension from local infection, systemic bacteremia, and intra-abdominal infections that seed the portal system. However, over the years, the etiologies and risks factors for HA have continued to evolve. Prompt recognition is important for instituting effective management and obtaining good outcomes.

Intraabdominal Infections in Older Adults

Intraabdominal infections represent a diagnostic and therapeutic challenge in the elderly population. Atypical presentations, diagnostic delays, additional comorbidities, and decreased physiologic reserve contribute to high morbidity and mortality, particularly among frail patients undergoing emergency abdominal surgery. While many infections are the result of age-related inflammatory, mechanical, or obstructive processes, infectious complications of feeding tubes are also common. The pillars of treatment are source control of the infection and judicious use of antibiotics. A patient-centered approach considering the invasiveness, risk, and efficacy of a procedure for achieving the desired outcomes is recommended. Structured communication and time-limited trials help ensure goal-concordant treatment.

Veno-venous extracorporeal membrane oxygenation (ECMO) for acute respiratory failure caused by liver abscess

Liver abscess remains a life-threatening disease, particularly when it results in systemic organ failure necessitating intensive care. Only few cases of respiratory failure caused by liver abscess and treated with veno-venous extracorporeal membrane oxygenation (ECMO) have been reported. Here we present a case of liver abscess with rapid progression of multiple organ dysfunction, including severe acute respiratory failure on admission to the intensive care unit (ICU). Upon admission, we immediately initiated artificial organ support systems, including ventilator, continuous renal replacement therapy, and cardiovascular drug infusion for septic multiple organ failure and source control. Despite this initial management, respiratory failure deteriorated and V-V ECMO was introduced. The case developed abdominal compartment syndrome, for which we performed a bedside decompressive laparotomy in the ICU. The case gradually recovered from multiple organ failure and was discharged from the ICU on day 22 and from the hospital on day 53. Since liver abscess is potentially lethal and respiratory failure on admission is an additional risk factor of mortality, V-V ECMO may serve as an adjunctive choice of artificial organ support for cases of severe acute respiratory failure caused by liver abscess.