Changes in the Pathogenesis and Detection Of lntrahepatic Abscess
Stephen Silver, MD*, Cleveland, Ohio Alan Weinstein, MD+, Cleveland, Ohio Avram Cooperman, MD, FACS’, Cleveland, Ohio
Intrahepatic abscess may be associated with considerable morbidity and mortality [l-3]. Since the detailed study of liver abscesses by Ochsner [2] in 1938, the pathogenesis and therapy of this condition have changed significantly [4,5]. Intrahepatic abscesses formerly affected young adults, were most commonly caused by amebae, or were frequently a complication of acute appendicitis. Today, these abscesses usually develop in elderly patients, are produced by bacteria, and are related to biliary disease, intraabdominal trauma, neoplasms, and bacteremia [6]. The new diagnostic technics, such as liver scanning, angiography, and computed axial tomography are thought to permit earlier detection and treatment of liver abscesses. To determine whether the clinical aspects of this disease have changed in one institution and whether the use of the new diagnostic technics is associated with earlier diagnosis and treatment, we reviewed our experience during the past 23 years. Material and Methods The records of all patients with a diagnosis of hepatic abscess at The Cleveland Clinic Foundation from 1952 through 1975 were reviewed. The diagnosis was established during life in 22 patients and at autopsy in 1 patient. Three patients were excluded from the study because the liver abscess appeared to be an incidental autopsy finding and did not contribute to the clinical course of the patient. The series consisted of 14 men and 8 women, aged 19 to 77 years (mean 50). The mean age for men was 47 years and for From the Department of General Surgery* and the Department of Infectious Diseasest, the Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, Ohio. Reprint requests should be addressed to Avram M. Cooperman, MD, Department of General Surgery, Cleveland Clinic, 9500 Euclid Avenue, Cleveland. Ohio 44106.
608
women 57 years. Four of the 22 patients died of the disease during or after surgery, for a mortality rate of 18.2 per cent. In six patients, the intrahepatic abscess developed after intraabdominal surgery; the types of operation were gastrectomy for carcinoma, surgery for common bile duct stricture, surgery for gunshot wound of the liver, right hemicolectomy, colecystectomy and choledochojejunostomy, and hepatico-duodenostomy for common bile duct carcinoma. In six patients the liver abscess resulted from hematogenous dissemination of microorganisms from another primary focus of infection; five abscesses were caused by parasites. Five abscesses were classified “miscellaneous”; they included one abscess after percutaneous liver biopsy with subsequent bile peritonitis, one after perforation of the gallbladder, one from penetration of a gastric ulcer into the liver, and one with polycystic liver disease and an infected liver cyst. The cause of the other “miscellaneous” abscess was not known. Bacteriologic Studies
Cultures revealed bacterial species in 13 patients, parasites in 5 patients, and no microorganisms in 4 patients. The parasites were amebae in three patients and Echinococci in two. Three of the 13 patients with bacterial species had mixed flora; the bacteria included Aerobacter in 1 patient, Escherichia coli in 2 patients, Proteus in 1 patient, Pseudomonas in 1 patient, staphylococcus in 4 patients, and streptococcus in 7 patients. Fifteen of the abscesses were caused by a single microbial species; three were produced by more than one organism. The most frequently encountered bacterial species were streptococci, which were isolated in seven patients. Of these, four were alpha-hemolytie streptococci, one was a beta-hemolytic streptococcus, one was Streptococcus faecalis, and one was anaerobic streptococcus.
The American Journal of Surgery
Pathogenesis of lntrahepatic
Signs and Symptoms The common presenting symptom in 22 patients was fever. This was accompanied by right upper quadrant abdominal pain in 17 patients; 5 patients had either pleural effusions or empyema, and 3 had tender palpable abdominal masses. Only one patient had lost weight. A preoperative diagnosis of intrahepatic abscess was made in three of six patients in whom a technetium liver scan was performed. In seven patients, chest roentgenography revealed a subdiaphragmatic inflammatory process indicated by elevation of the diaphragm, pleural effusion, or an air-fluid level below the diaphragm. In two patients computerized axial tomography revealed an intrahepatic mass. Results of transhepatic cholangiography suggested abscess in two patients. Intrahepatic abscess was diagnosed only at the time of surgery in eight patients who underwent abdominal exploration for evaluation of fever of undetermined origin. Twenty patients were treated initially with antimicrobial or antiparasitic therapy, or both. In most cases, the choice of antibiotics was based on the clinical impression of the most probable cause of the infection (either bacterial or parasitic). When the results of Gram stains and cultures were available after surgery, specific antimicrobial therapy was instituted. In 20 patients, drainage of the abscess was required. In 12 patients, drainage was achieved by a transperitoneal approach; none of these required a second procedure. In two patients, an extraperitoneal approach was used with resolution of the abscess. Five patients underwent transthoracic drainage with extrapleural and extraperitoneal approaches; one of these patients later required a repeat drainage procedure. In one patient percutaneous placement of an end-hole Fogarty catheter, inserted by means of a trocar through computerized axial tomographic guidance, was used. This successful drainage with good results has been reported elsewhere [ 71. Comments
The clinical manifestations of intrahepatic abscess may be relatively specific, with hepatic tenderness, leukocytosis, and findings consistent with bacteremia strongly suggesting the diagnosis. However, it is not uncommon for the only clinical manifestations to be fever and malaise. Most of our patients had fever and right upper quadrant pain. However, these findings were frequently considered to be caused by other intraabdominal inflammatory processes such as cholecystitis and pancreatitis. Regardless of the
Volume 137, May 1979
Abscess
clinical presentation of intrahepatic abscess, the prognosis depends primarily on establishing an early diagnosis and instituting appropriate therapy EN. A significant incidence of streptococcal infections was noted in our patients. Because careful anaerobic bacteriologic study was not performed routinely at our hospital before 1971, it is possible that the incidence of anaerobic infections was grossly underestimated. Patterson et al [IO] suggested that the large incidence of “sterile” abscesses reported in earlier studies of intrahepatic abscess may be explained either by the failure of material to be cultured anaerobically or by the inadequacy of past methods of anaerobic bacteriology. Advances in such bacteriologic technics in recent years should result in more precise characterization of all isolated bacterial species and will permit early institution of more definitive antimicrobial therapy. From 1952 to 1963, four intrahepatic abscesses caused by parasites were noted in our institution. In another 11 year period, from 1964 to 1975, only one such infection was observed. From 1952 to 1963, the incidence of staphylococcal and streptococcal infections was identical. However, in the second 11 year period, an increasing incidence of mixed infections was noted, as well as infections due to aerobic gram-negative organisms such as E. coli, Pseudomonus, and Proteus. These changes in microbial etiology are consistent with the differences noted by others [11,12]. The increasing use of hepatic scanning has permitted earlier diagnosis of intrahepatic abscess, and when the scan is truly positive, it provides significant assistance to the surgeon in localizing the infection before surgical drainage. However, the scanning defect must be at least 2 cm in diameter to be detected, and a number of “positive” scans have terminated with negative laparotomies [13]. Computed axial tomography is perhaps an even more precise diagnostic method than isotopic liver scanning [ 141. The advantages of this technic are that it can detect the intrahepatic abscess and provide visual guidance for the placement of a percutaneous catheter for drainage. Such a procedure is particularly appropriate for the patient who is considered a poor surgical risk. The basic requirements for effective therapy of intrahepatic abscess are early diagnosis and drainage [13,15]. The timing of the operation is more important than the operative approach. We administer antibiotics preoperatively when the diagnosis is established or when the febrile course continues despite a negative work-up. The operative approach varies depending on the location of the abscess. Formerly,
609
Silver et al
high morbidity and mortality rates were associated with a transperitoneal approach, but the use of antibiotics has lowered these rates. We prefer to drain most lesions through an anterolateral abdominal incision either intraperitoneally or extraperitoneally, thus allowing complete exploration of the anterior and posterior surfaces of the right and left hepatic lobes. When an obvious abscess is encountered, it is aspirated for Gram stain and culture and then drained. Drains, either Penrose or sumps, are placed in the cavity. How long these drains remain in the cavity is not known. When drainage has stopped we usually perform a sinugram with contrast material, and when the cavity is obliterated the catheters are removed. When the abscess is small and deep in the liver, accurate palpation and localization are difficult. To meet this problem, we use preoperative localization by needle aspiration, with computed tomographic or fluoroscopic guidance. The needle is left in place and methylene blue is injected to facilitate localization and drainage. Recently, Haaga et al [7] reported successful transhepatic aspiration and drainage of an abscess by a percutaneous approach. That an abscess cavity can be completely drained percutaneously was well documented in that report. We now advocate this approach for posterior hepatic or deep intrahepatic abscess that can be approached safely without entry into the colon or other hollow viscera. Summary
A comparison of two distinct 11 year time periods at our institution demonstrated a change not only in the cause of intrahepatic abscess but also in the procedures used to diagnose this condition. Signifi-
610
cant improvement in the methods of detection of intrahepatic abscess permits earlier diagnosis and therapy and thus a significantly improved prognosis. References 1. Layarchick J, Silva N, Nichols D, Washington J: Fyogenic liver abscess. Mayo Clinic Proc 46: 349, 1973. 2. Ochsner A, DeRakey M, Murray S: Pyogenic abscess of the liver. II. An analysis of forty-seven cases with review of the literature. Am J Surg 40: 292, 1936. Dstermiller W Jr, Carter R: Hepatic abscess. Arch Surg 94: 353, 1967. Lee J, Block G: The changing clinical pattern of hepatic abscess. Arch Surg 104: 465. 1972. Palmer E: The changing manifestations of pyogenic liver abscess. JAh4A 231: 192, 1975. Rubin Ft. Swartz M, Malt R: Hepatic abscess: changes in clinical bacteriologic and therapeutic aspects. Am J A-fed 57: 60 1, 1974. 7. Haaga J, Alfidi RJ. Cooperman AM, Havrilla T, Meaney TF, Dckner SA, Stiff P. Silver SC: Definitive treatment of a laroa pyogenic liver abscess with CT guidance. C/eve C/in 0 43: 85, 1976. a. Brodine W, Schwartz S: Pyogenic hepatic abscess. NYStafe Jh4edp 1657. 1973. 9. McFadyean A. Cang K, Wong C: Solitary pyogenic abscess of liver treated by closed aspiration and antibiotics. A report of 14 consecutivecases with recovery. BrJSurg41: 141, 1953. 10. Patterson D, Ozaran R. Galtz G, Miller A, Finegold S: Pyogenic liver abscess due to microaerophilic streptococci. Ann Surg 165: 362, 1967. 11. Price J, Joseph W, Mulder D: Diagnosis and treatment of intrahepatic abscess. Am Surg 33: 620, 1967. 12. Warren K, Hardy J: Pyogenic hepatic abscess. Arch Surg 97: 40, 1968. 13. Shingleton W, Taylor L, Pucher F: Radioisotope photoscan of liver in differential diagnosis of upper abdominal disease: review of 232 cases. Ann Surg 163: 665, 1966. 14. Haaga J, Alfidi R: Precise biopsy localization by computed tomography. &dio/ogy, in press. 15. Tetz E, Reeves L, Longerbeam J: Treatment of liver abscesses: a conservative surgical approach. Am J Surg 126: 263, 1963.
The American Journal 04 Sugary
Stephen Silver, MD*, Cleveland, Ohio Alan Weinstein, MD+, Cleveland, Ohio Avram Cooperman, MD, FACS’, Cleveland, Ohio
Intrahepatic abscess may be associated with considerable morbidity and mortality [l-3]. Since the detailed study of liver abscesses by Ochsner [2] in 1938, the pathogenesis and therapy of this condition have changed significantly [4,5]. Intrahepatic abscesses formerly affected young adults, were most commonly caused by amebae, or were frequently a complication of acute appendicitis. Today, these abscesses usually develop in elderly patients, are produced by bacteria, and are related to biliary disease, intraabdominal trauma, neoplasms, and bacteremia [6]. The new diagnostic technics, such as liver scanning, angiography, and computed axial tomography are thought to permit earlier detection and treatment of liver abscesses. To determine whether the clinical aspects of this disease have changed in one institution and whether the use of the new diagnostic technics is associated with earlier diagnosis and treatment, we reviewed our experience during the past 23 years. Material and Methods The records of all patients with a diagnosis of hepatic abscess at The Cleveland Clinic Foundation from 1952 through 1975 were reviewed. The diagnosis was established during life in 22 patients and at autopsy in 1 patient. Three patients were excluded from the study because the liver abscess appeared to be an incidental autopsy finding and did not contribute to the clinical course of the patient. The series consisted of 14 men and 8 women, aged 19 to 77 years (mean 50). The mean age for men was 47 years and for From the Department of General Surgery* and the Department of Infectious Diseasest, the Cleveland Clinic Foundation, 9500 Euclid Avenue, Cleveland, Ohio. Reprint requests should be addressed to Avram M. Cooperman, MD, Department of General Surgery, Cleveland Clinic, 9500 Euclid Avenue, Cleveland. Ohio 44106.
608
women 57 years. Four of the 22 patients died of the disease during or after surgery, for a mortality rate of 18.2 per cent. In six patients, the intrahepatic abscess developed after intraabdominal surgery; the types of operation were gastrectomy for carcinoma, surgery for common bile duct stricture, surgery for gunshot wound of the liver, right hemicolectomy, colecystectomy and choledochojejunostomy, and hepatico-duodenostomy for common bile duct carcinoma. In six patients the liver abscess resulted from hematogenous dissemination of microorganisms from another primary focus of infection; five abscesses were caused by parasites. Five abscesses were classified “miscellaneous”; they included one abscess after percutaneous liver biopsy with subsequent bile peritonitis, one after perforation of the gallbladder, one from penetration of a gastric ulcer into the liver, and one with polycystic liver disease and an infected liver cyst. The cause of the other “miscellaneous” abscess was not known. Bacteriologic Studies
Cultures revealed bacterial species in 13 patients, parasites in 5 patients, and no microorganisms in 4 patients. The parasites were amebae in three patients and Echinococci in two. Three of the 13 patients with bacterial species had mixed flora; the bacteria included Aerobacter in 1 patient, Escherichia coli in 2 patients, Proteus in 1 patient, Pseudomonas in 1 patient, staphylococcus in 4 patients, and streptococcus in 7 patients. Fifteen of the abscesses were caused by a single microbial species; three were produced by more than one organism. The most frequently encountered bacterial species were streptococci, which were isolated in seven patients. Of these, four were alpha-hemolytie streptococci, one was a beta-hemolytic streptococcus, one was Streptococcus faecalis, and one was anaerobic streptococcus.
The American Journal of Surgery
Pathogenesis of lntrahepatic
Signs and Symptoms The common presenting symptom in 22 patients was fever. This was accompanied by right upper quadrant abdominal pain in 17 patients; 5 patients had either pleural effusions or empyema, and 3 had tender palpable abdominal masses. Only one patient had lost weight. A preoperative diagnosis of intrahepatic abscess was made in three of six patients in whom a technetium liver scan was performed. In seven patients, chest roentgenography revealed a subdiaphragmatic inflammatory process indicated by elevation of the diaphragm, pleural effusion, or an air-fluid level below the diaphragm. In two patients computerized axial tomography revealed an intrahepatic mass. Results of transhepatic cholangiography suggested abscess in two patients. Intrahepatic abscess was diagnosed only at the time of surgery in eight patients who underwent abdominal exploration for evaluation of fever of undetermined origin. Twenty patients were treated initially with antimicrobial or antiparasitic therapy, or both. In most cases, the choice of antibiotics was based on the clinical impression of the most probable cause of the infection (either bacterial or parasitic). When the results of Gram stains and cultures were available after surgery, specific antimicrobial therapy was instituted. In 20 patients, drainage of the abscess was required. In 12 patients, drainage was achieved by a transperitoneal approach; none of these required a second procedure. In two patients, an extraperitoneal approach was used with resolution of the abscess. Five patients underwent transthoracic drainage with extrapleural and extraperitoneal approaches; one of these patients later required a repeat drainage procedure. In one patient percutaneous placement of an end-hole Fogarty catheter, inserted by means of a trocar through computerized axial tomographic guidance, was used. This successful drainage with good results has been reported elsewhere [ 71. Comments
The clinical manifestations of intrahepatic abscess may be relatively specific, with hepatic tenderness, leukocytosis, and findings consistent with bacteremia strongly suggesting the diagnosis. However, it is not uncommon for the only clinical manifestations to be fever and malaise. Most of our patients had fever and right upper quadrant pain. However, these findings were frequently considered to be caused by other intraabdominal inflammatory processes such as cholecystitis and pancreatitis. Regardless of the
Volume 137, May 1979
Abscess
clinical presentation of intrahepatic abscess, the prognosis depends primarily on establishing an early diagnosis and instituting appropriate therapy EN. A significant incidence of streptococcal infections was noted in our patients. Because careful anaerobic bacteriologic study was not performed routinely at our hospital before 1971, it is possible that the incidence of anaerobic infections was grossly underestimated. Patterson et al [IO] suggested that the large incidence of “sterile” abscesses reported in earlier studies of intrahepatic abscess may be explained either by the failure of material to be cultured anaerobically or by the inadequacy of past methods of anaerobic bacteriology. Advances in such bacteriologic technics in recent years should result in more precise characterization of all isolated bacterial species and will permit early institution of more definitive antimicrobial therapy. From 1952 to 1963, four intrahepatic abscesses caused by parasites were noted in our institution. In another 11 year period, from 1964 to 1975, only one such infection was observed. From 1952 to 1963, the incidence of staphylococcal and streptococcal infections was identical. However, in the second 11 year period, an increasing incidence of mixed infections was noted, as well as infections due to aerobic gram-negative organisms such as E. coli, Pseudomonus, and Proteus. These changes in microbial etiology are consistent with the differences noted by others [11,12]. The increasing use of hepatic scanning has permitted earlier diagnosis of intrahepatic abscess, and when the scan is truly positive, it provides significant assistance to the surgeon in localizing the infection before surgical drainage. However, the scanning defect must be at least 2 cm in diameter to be detected, and a number of “positive” scans have terminated with negative laparotomies [13]. Computed axial tomography is perhaps an even more precise diagnostic method than isotopic liver scanning [ 141. The advantages of this technic are that it can detect the intrahepatic abscess and provide visual guidance for the placement of a percutaneous catheter for drainage. Such a procedure is particularly appropriate for the patient who is considered a poor surgical risk. The basic requirements for effective therapy of intrahepatic abscess are early diagnosis and drainage [13,15]. The timing of the operation is more important than the operative approach. We administer antibiotics preoperatively when the diagnosis is established or when the febrile course continues despite a negative work-up. The operative approach varies depending on the location of the abscess. Formerly,
609
Silver et al
high morbidity and mortality rates were associated with a transperitoneal approach, but the use of antibiotics has lowered these rates. We prefer to drain most lesions through an anterolateral abdominal incision either intraperitoneally or extraperitoneally, thus allowing complete exploration of the anterior and posterior surfaces of the right and left hepatic lobes. When an obvious abscess is encountered, it is aspirated for Gram stain and culture and then drained. Drains, either Penrose or sumps, are placed in the cavity. How long these drains remain in the cavity is not known. When drainage has stopped we usually perform a sinugram with contrast material, and when the cavity is obliterated the catheters are removed. When the abscess is small and deep in the liver, accurate palpation and localization are difficult. To meet this problem, we use preoperative localization by needle aspiration, with computed tomographic or fluoroscopic guidance. The needle is left in place and methylene blue is injected to facilitate localization and drainage. Recently, Haaga et al [7] reported successful transhepatic aspiration and drainage of an abscess by a percutaneous approach. That an abscess cavity can be completely drained percutaneously was well documented in that report. We now advocate this approach for posterior hepatic or deep intrahepatic abscess that can be approached safely without entry into the colon or other hollow viscera. Summary
A comparison of two distinct 11 year time periods at our institution demonstrated a change not only in the cause of intrahepatic abscess but also in the procedures used to diagnose this condition. Signifi-
610
cant improvement in the methods of detection of intrahepatic abscess permits earlier diagnosis and therapy and thus a significantly improved prognosis. References 1. Layarchick J, Silva N, Nichols D, Washington J: Fyogenic liver abscess. Mayo Clinic Proc 46: 349, 1973. 2. Ochsner A, DeRakey M, Murray S: Pyogenic abscess of the liver. II. An analysis of forty-seven cases with review of the literature. Am J Surg 40: 292, 1936. Dstermiller W Jr, Carter R: Hepatic abscess. Arch Surg 94: 353, 1967. Lee J, Block G: The changing clinical pattern of hepatic abscess. Arch Surg 104: 465. 1972. Palmer E: The changing manifestations of pyogenic liver abscess. JAh4A 231: 192, 1975. Rubin Ft. Swartz M, Malt R: Hepatic abscess: changes in clinical bacteriologic and therapeutic aspects. Am J A-fed 57: 60 1, 1974. 7. Haaga J, Alfidi RJ. Cooperman AM, Havrilla T, Meaney TF, Dckner SA, Stiff P. Silver SC: Definitive treatment of a laroa pyogenic liver abscess with CT guidance. C/eve C/in 0 43: 85, 1976. a. Brodine W, Schwartz S: Pyogenic hepatic abscess. NYStafe Jh4edp 1657. 1973. 9. McFadyean A. Cang K, Wong C: Solitary pyogenic abscess of liver treated by closed aspiration and antibiotics. A report of 14 consecutivecases with recovery. BrJSurg41: 141, 1953. 10. Patterson D, Ozaran R. Galtz G, Miller A, Finegold S: Pyogenic liver abscess due to microaerophilic streptococci. Ann Surg 165: 362, 1967. 11. Price J, Joseph W, Mulder D: Diagnosis and treatment of intrahepatic abscess. Am Surg 33: 620, 1967. 12. Warren K, Hardy J: Pyogenic hepatic abscess. Arch Surg 97: 40, 1968. 13. Shingleton W, Taylor L, Pucher F: Radioisotope photoscan of liver in differential diagnosis of upper abdominal disease: review of 232 cases. Ann Surg 163: 665, 1966. 14. Haaga J, Alfidi R: Precise biopsy localization by computed tomography. &dio/ogy, in press. 15. Tetz E, Reeves L, Longerbeam J: Treatment of liver abscesses: a conservative surgical approach. Am J Surg 126: 263, 1963.
The American Journal 04 Sugary
