Abscesses of the Liver: Surgical Considerations
TL;DR: The experiences in a series of 65 patients with liver abscesses seen at the University of Cincinnati Medical Center have been reviewed and studied to obtain a better understanding of the incidence, etiology, pathogenesis, diagnostic problems, effectiveness of therapy, morbidity, and mortality of this serious disease.
Abstract: The experiences in a series of 65 patients with liver abscesses seen at the University of Cincinnati Medical Center have been reviewed and studied to obtain a better understanding of the incidence, etiology, pathogenesis, diagnostic problems, effectiveness of therapy, morbidity, and mortality of this serious disease. This study has emphasized the fact that this disease is life-threatening and that the mortality of undiagnosed and undrained cases was 100%. In contrast, there was no mortality in all of the cases but one in which a diagnosis had been made and surgical drainage was instituted. During the past five years, our ability to diagnose and localize liver abscesses 2 cm or larger has been greatly enhanced by the use of radioactive isotope liver scanning techniques, aided more recently by hepatic arteriography. The benefits of these new techniques have been evident not only in a marked reduction in mortality but also in a greatly increased number of correctly diagnosed cases for which successful operations could be done.
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TL;DR: It is concluded that percutaneous drainage is an effective method for treatment of abdominal abscesses and is indicated when sectional imaging demonstrates an accessible unilocular lesion.
Abstract: We used computed tomography (CT) and ultrasonography for detection and localization of intra-abdominal abscesses. On the basis of these images, safe routes for diagnostic aspiration and percutaneous drainage were planned. Over these routes indwelling catheters were inserted to provide immediate decompression, evacuation, and continuous drainage until the abscess resolved. All patients received concomitant intravenous antibiotics. The treatment was used for 71 abscesses in 67 patients. Sixty-one abscesses (86 per cent) were satisfactorily drained. There were 11 complications (15 per cent). Six deaths were attributable to sepsis, three of which (4 per cent) were related to inadequate drainage. There was one recurrence (1 per cent) during a follow-up period ranging from one month to five years (means, 22.3 months). The mean duration of treatment was 20.2 days (range, five to 120 days). We conclude that percutaneous drainage is an effective method for treatment of abdominal abscesses and is indicated when sectional imaging demonstrates an accessible unilocular lesion.
333 citations
TL;DR: Although significant advances have been made in the diagnosis and localization of hepatic abscesses, improved methods of earlier recognition and localization will be necessary to achieve earlier diagnosis, more effective surgical treatment, and lower mortality in patients with other types of intra-abdominal abscesss.
Abstract: A study of 501 patients with 540 intra-abdominal abscesses seen on the surgical services of the University of Cincinnati Medical Center during the past twelve years was undertaken to define the incidence by type and anatomic location, the sources, the effectiveness of diagnosis and treatment, the extended periods of required hospitalization, and the causes of mortality. The results have emphasized the continuing incidence, clinical importance, complexity of bacterial etiology, and the obscure nature of the various types of intra-abdominal abscesses. The high mortality of patients with unrecognized and undrained pancreatic and retroperitoneal abscesses has been striking when compared to the marked reduction in mortality possible by earlier diagnosis and adequate surgical drainage. Although significant advances have been made in the diagnosis and localization of hepatic abscesses, improved methods of earlier recognition and localization will be necessary to achieve earlier diagnosis, more effective surgical treatment, and lower mortality in patients with other types of intra-abdominal abscesses, particularly those in the retroperitoneal and recessed intraperitoneal areas.
305 citations
TL;DR: A subgroup of patients with no or low-level elevations in bilirubin and alkaline phosphatase and most often single right-sided PLA who do not have a readily identifiable cause of PLA are identified, as having a particularly favorable prognosis.
301 citations
TL;DR: Clinical, bacteriologic and therapeutic aspects of 53 patients with hepatic abscess seen from 1961 to 1973 are reviewed, finding bacteria of bowel origin and other Enterobacteriaceae and anaerobes were the common etiologic agents.
181 citations
TL;DR: The role of anaerobic bacteria in the etiology of pyogenic liver abscess has not been fully recognized and the number of cases encountered in 11 years represents a large number.
Abstract: The role of anaerobic bacteria in the etiology of pyogenic liver abscess has not been fully recognized. In 11 years we have encountered 25 cases of anaerobic liver abscess, which represent...
143 citations
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TL;DR: The principal symptoms and signs of pyogenic hepatic abscess are fever, pain and tenderness over the hepatic area, liver enlargement, chills, and jaundice, and there is a leucocytosis with a proportionate increase in polymorphonuclear leucocytes.
Abstract: 1. 1. An analysis is presented of 830 cases of pyogenic hepatic abscess collected from the world literature and a presentation of 47 additional cases is made. 2. 2. During the ten-year period, 1928–1937 inclusive, there were 186 cases of abscess of the liver admitted to Charity Hospital and Touro Infirmary in New Orleans. Of this number, 139 (74.7 per cent) were amebic abscesses and 47 (25.2 per cent) were pyogenic. During this same period there were 540,776 total admissions to the Charity Hospital, among which there were 160 (0.029 per cent) abscesses of the liver, and 1,152 patients diagnosed as having liver disease, of which 10.2 per cent were amebic abscesses and 3.6 per cent were pyogenic abscesses. The sex incidence of pyogenic hepatic abscess reveals a preponderance of occurrence in the male, 67.4 per cent in the collected series and 70.2 per cent in the authors'. This is probably explained by the fact that the etiologic agents occur more frequently in the male. The greatest age incidence is from the third to the fifth decades. There is no significant racial predisposition. 3. 3. Pyogenic liver abscess is primarily a complication of an intra-abdominal suppurative process with the antecedent lesions in the portal area. Of these lesions, suppurative appendicitis is the most frequent. Appendicitis was the etiologic agent in 34.2 per cent of the collected cases and 10.6 per cent of the authors' cases. This discrepancy is due to the fact that the majority of reports in the literature represented primarily the author's interest in pylephlebitis and liver abscess as complications of appendicitis. Pyogenic liver abscess can be caused also by direct extension from contiguous suppurative processes, trauma, and by transportation of microorganisms through the hepatic artery from distant foci. There is a relatively large group (59.5 per cent) of the authors' series termed “cryptogenic,” idiopathic, or primary pyogenic hepatic abscess in which the antecedent lesion could not be determined. 4. 4. The most frequently found organisms in pyogenic hepatic abscess are B. coli, streptococci, and staphylococci. 5. 5. Pyogenic hepatic abscess may be multiple or single, and usually involves the right lobe. The abscesses were single in 28.8 per cent, multiple in 71.1 per cent, and involved the right lobe alone in 41.8 per cent of the collected cases. In the authors' forty-seven cases these incidences were 54.5 per cent, 45.4 per cent, and 68.1 per cent, respectively. 6. 6. The principal symptoms and signs of pyogenic hepatic abscess are fever, pain and tenderness over the hepatic area, liver enlargement, chills, and jaundice. Characteristically, there is a leucocytosis with a proportionate increase in polymorphonuclear leucocytes. The characteristic roentgenologic changes are elevation and immobility of the diaphragm, usually the right. The diagnosis was positive in 82.1 per cent of 28 cases in the authors' series in which roentgenologic studies were made. 7. 7. The prognosis in pyogenic hepatic abscess depends upon: (1) the multiplicity of the lesions; (2) the presence or absence of complications; and (3) the type of drainage instituted. Whereas of the twenty-four cases in the authors' series with single abscess of the liver nine (37.5 per cent) died, of the twenty cases with multiple abscesses, nineteen (95 per cent) died. The mortality rate was 90.9 per cent in those cases with complications and 36 per cent in the cases without complications. The total mortality rate was 79.6 per cent in the collected cases and 72.3 per cent in the authors' series. Whereas in those cases not operated upon the mortality rate was 100 per cent in both series, in the cases in which operation was performed the mortality was 50.9 per cent in the collected series and 64.8 per cent in the authors' series. 8. 8. The complications of pyogenic hepatic abscess are usually the result of rupture or direct extension into one of the adjacent viscera. 9. 9. The treatment of pyogenic hepatic abscess may be divided into: (1) prophylactic and (2) surgical. Prophylaxis is particularly applicable to multiple hepatic abscesses which are preceded by appendicitis and pylephlebitis, because once the development has proceeded to the stage of multiple abscess formation, surgical therapy offers only the slightest hope. The treatment of solitary pyogenic hepatic abscess consists of incision and drainage. 10. 10. The employment of that type of drainage which completely avoids the slightest possibility of contamination of the peritoneal or pleural cavity is of paramount importance. The results obtained in the authors' series of cases clearly demonstrate this fact. Of the twenty-two cases in which the transperitoneal approach was employed for the institution of drainage, there were sixteen deaths (72.7 per cent). The transpleural method of drainage was used in nine cases with six deaths (66.6 per cent). In contrast to these high mortality rates is the 33.3 per cent mortality obtained in six cases in which the extraserous approach was used.
312 citations
131 citations
TL;DR: There are patients who undoubtedly develop hepatic abscesses associated with cholangitis, but never come to operation or autopsy, and in whom the diagnosis is missed, according to Ochsner, 1 and Rothenberg and Linder 2.
Abstract: THIS STUDY is a review of the records of 20 patients in whom the diagnosis of pyogenic hepatic abscess was made at the Lahey Clinic in the years 1923 to 1966. In all patients the diagnosis of pus in the liver has been made at operation or at autopsy. Despite this we agree with Ochsner, 1 and Rothenberg and Linder 2 that there are patients who undoubtedly develop hepatic abscesses associated with cholangitis, but never come to operation or autopsy, and in whom the diagnosis is missed. Our current practice is to culture the bile at operation, and by the results of the sensitivity tests choose the antibiotic to be administered for any suspected postoperative cholangitis. This makes the definite diagnosis of small multiple abscesses even more difficult. All cases of amebic abscesses have been excluded from this review. Etiology Incidence.— The age of the patients at the time of
128 citations
TL;DR: Radioisotopic hepatic photoscanning was of limited value in detection of diffuse disease, but it was useful in guiding needle biopsy for metastases and in localizing intra- and parahepatic abscesses.
Abstract: To assess the value, sensitivity, and reliability of radioisotopic hepatic photoscanning, results of 380 liver scans performed on 357 patients were compared with final diagnosis and results of liver function tests on these patients. An attempt was made to determine whether new informaion was obtained or that from conventional methods merely duplicated. Abnormal scans indicating localized disease were highly reliable, with less than 2.5% false positives. Normal scans did not exclude focal disease, but scans were more sensitive than any other method available in its detection. The alkaline phosphatase, almost as sensitive in detection of localized disease, yielded false positives twice as often. Scanning was of limited value in detection of diffuse disease. It was useful in guiding needle biopsy for metastases and in localizing intra- and parahepatic abscesses.
83 citations