Clinical presentation and diagnosis
The most common presenting symptoms include pyrexia and rigours associated with right upper quadrant pain, general malaise and anorexia. Examination may reveal tender hepatomegaly. A pleural effusion may be present. Occasionally, hypotension and cardiovascular collapse may be the presenting symptoms.
Liver function tests may show hyperbilirubinemia and raised alkaline phosphatase and transaminase levels. Blood cultures are frequently positive. A leucocytosis
is usually evident. Radiological investigations include ultrasound or CT scan of the abdomen to determine the size, characteristics, number and anatomical location of the liver abscesses. A chest X-ray may show an elevated hemidiaphragm or a pleural effusion. Further tests such as an ERCP or a colonoscopy may be required to determine the cause of pyogenic liver abscesses.
Therapeutic principles include symptomatic measures, appropriate antibiotic therapy and drainage of the liver abscess. In addition the diagnosis and eradication of the underlying cause is essential. Symptomatic measures include a regimen of analgesics and attention to adequate nutrition and hydration.
Antimicrobial therapy is dependent on the underlying cause. Biliary or enteric causes involve microbial cover against Gram-negative and anaerobic organisms.
Haematogenous causes usually include antibiotic cover against the staphylococcus organisms.
Administration of antibiotics is usually prolonged over several weeks to eradicate infection and avoid recurrence.
Drainage of the abscess may be achieved by percutaneous drainage under ultrasound control or by repeated percutaneous aspiration. Open surgical drainage is now rarely indicated.
Frequent clinical, biochemical, microbial and radiological follow-up is required to assess progress and detect relapses.