1. LIVER ABSCESS Marc Richards Morning Report September 8th, 2009

2. CLASSIFICATIONS PYOGENIC Gram Positive Gram Negative Anaerobic (Polymicrobial) AMEBIC CANDIDA TB (rare)

3. EPIDEMIOLOGY Pyogenic Abscesses o Bacterial o Most common o M > F 3:1 Entamoeba o M > F 7:1 o 40-50 million amoeba infections/year worldwide o Age Extremes o Endemic Areas most susceptible o Country of origin or Travel

4. RISK FACTORS PYOGENIC DM Cancer Liver Transplant ENTAMOEBA Pregnancy Steroids Cancer Endemic area travel (short or long term) EtOH?

5. PATHOPHYS. PYOGENIC: o Peritonitis  To liver via portal circulation o Direct Spread o Biliary infections o Hematogenous Seeding o Look for bacteremia! o Sites: R lobe most common o Blood supply

6. PATHOPHYS. ENTAMOEBA: o Fecal-Oral transmission into GI Tract  To liver via portal circulation o Can also spread to other extraintestinal sites o Heart o Brain o Lungs

7. CLINICAL MANIFESTATIONS o SYMPTOMS o Fever (90%) o RUQ pain (50-75%) o Constitutional Sx o Diarrhea (<30%) o SIGNS o Hepatomegaly (50%) o RUQ tenderness o Jaundice o Acute abdomen (<7%)

8. WORKUP CBC (leukocytosis) LFTs AlkPhos elevated (67-90%) AST/ALT elevated (50%) TBili elevated (50%) Blood Cultures Bacteremia (50%) E Histolytica Ab Echinococcus Ab Imaging- US, CT, MRI Can not differentiate types of abscess

9. ULTRASOUND

10. CT/MRI Fluid Collection w/ surrounding stranding, edema, and inflammation

11. DIAGNOSTIC PROCEDURE *** IMAGING-GUIDED DRAINAGE *** ***SEND FOR CULTURE***

12. WHAT MAY GROW… POLYMICROBIAL (including anaerobes) GRAM NEGATIVES (think gut bugs) E. Histolytica Money is in the serum Ab (95%) Less yield with wet-mount of abscess or fecal microscopy (<20%) OTHERS Strep Milleri group S Aureus (chemoembo) S Pyogenes (chemoembo) Candida (s/p chemo) Klebsiella TB Burkholderia

13. TREATMENT TO DRAIN OR NOT TO DRAIN: <5cm, single abscess- needle aspiration or catheter >5cm- catheter Also: Surgery, ERCP Amoeba: drainage not usually required Exceptions: Verge of rupture Abx not working Imminent need to exclude other dx

14. TREATMENT-ABX Pyogenic: Gram Neg + Anaerobe cov. Unasyn Zosyn 3 rd gen Ceph (Rocephin) + Flagyl PCN Allergy: FQ + Flagyl, Carbapenem Course: 4-6 weeks IV duration depends on f/u imaging Suitable PO Abx: Augmentin OR FQ + Flagyl Amoeba : Flagyl 500-750mg TID 7-10days Then follow with lumenal antiamebic Usually Paromomycin TID 10d

15. PROGNOSIS & NATURAL HISTORY Mortality 2-12% Often due to comorbidities, not necessarily abscess itself

16. TAKE HOME MESSAGE Think Pyogenic (usually gram neg/anaerobe) or E.Histolytica Broad Spectrum Abx at first Image Image Image Imaging-Guided Culture +/- JP Drain Treat for 4-6 weeks MIAMI > FLORIDA STATE

17. REFERENCES eMedicine Current 2007 UpToDate Suki